From the 2021 HVPAA National Conference
Christopher Tsoutsoulas (University of Toronto), Joseph Choi
Despite guidelines recommending against routine screening and treatment of asymptomatic bacteriuria (ASB), it continues to be commonly performed for eldery patients presenting to the emergency department (ED). We examined practices among emergency physicians (EPs) regarding the use of urine studies in the workup of elderly patients presenting to the ED with non-specific symptoms.
We performed a chart review and a survey of EPs. The chart review was conducted at 2 academic EDs and included patients > 65 years old presenting with chief complaints of weakness, falls, or confusion between March and July 2019. We excluded patients with any systemic inflammatory response syndrome (SIRS) criteria, had focal neurological deficits, or had a Glasgow Coma Scale Score < 14 to include only patients without signs of infection and who were able to provide a reliable history. The rate of documentation of urinary symptoms and the rate of urine studies performed were analyzed.
The survey contained 5 cases based on clinical scenarios from the 2019 guidelines on ASB from the Infectious Diseases Society of America. As per guidelines, these cases would not warrant screening for, nor treatment of, ASB. We asked EPs if they would have ordered a urinalysis, and if they would have prescribed antibiotics and/or sent a culture if one was sent prior to assessment and had a positive result.
The chart review included 31 patients that met our inclusion criteria. 74% of these patients had a urinalysis performed. Of those patients, 52% had a subsequent urine culture. Only 35% of EPs documented whether lower urinary symptoms were present, and only 18% of those patients (6% overall) endorsed having symptoms.
The survey had 46 EP respondents (53% response rate). A urinalysis was ordered by 26% to 84% of EPs. Of those who would not have ordered a urinalysis, 32-50% would have acted on a positive result by sending a urine culture, and 9-18% would have prescribed antibiotics.
Many elderly patients presenting to the ED have urine studies as part of their diagnostic workup despite not having urinary symptoms or signs of infection. Furthermore, our survey suggests that a positive result may sway a clinician to order more downstream tests and treatment even if their pre-test suspicion of a urinary tract infection was low. Clinical Implications: More research is needed to explore the rationale for this behaviour, which may lead to targeted quality improvement initiatives to reduce this practice.