Uti???? Do u check for them in Sicu?

[europeman]

Our unit doesn't believe in UTI causing fever/sepsis unless it ascends because of an obstruction. They never check urine cultures or wbcs. Mind u most these patients in our Sicu are on big guns already for intraabdominal sepsis and abx don't follow a zip code.... But the point remains....

Can u really get a straight forward bladder infection (non ascending) if u have a functioning foley and descent urine output??? I mean it's a flowing system!

I have seen plenty of patients with high WBC and lots of colonies in urine who have pristine kidneys and bladder on ct (say when they were imaged for another reason).

Funny... I can't find any GOOD evidence one way or another.

Thoughts?

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[jdh71]

Our unit doesn't believe in UTI causing fever/sepsis unless it ascends because of an obstruction. They never check urine cultures or wbcs. Mind u most these patients in our Sicu are on big guns already for intraabdominal sepsis and abx don't follow a zip code.... But the point remains....

Can u really get a straight forward bladder infection (non ascending) if u have a functioning foley and descent urine output??? I mean it's a flowing system!

I have seen plenty of patients with high WBC and lots of colonies in urine who have pristine kidneys and bladder on ct (say when they were imaged for another reason).

Funny... I can't find any GOOD evidence one way or another.

Thoughts?

Checking urine cultures as a routine is stupid in the ICU. I would probably still check in a case of a fever that didn't go away for some time - w/u of the FUO. But as a routine, no. Bladder infections don't cause fever anyway. Not in adults.

 

[Hernandez]

I'm going to anecdotally disagree with jdh just a tad.

My hospital has an annoying habit of checking ua on damn near everyone who walks into the hospital, and I've seen several cases of sepsis where the only culture positive was the urine with no evidence of pylo.

I personally check them on admission for sepsis, unless they can give me a good history of no dysuria in an otherwise ambulatory pt. Now if we're talking chronic foley PTs, we have a large MRDD population that frequently show up with sepsis with concordant blood/urine cultures from that with an otherwise normal ct abd. But without chronic foley or bladder dysfunction or disability, it's unusual.

 

[jdh71]

I'm going to anecdotally disagree with jdh just a tad.

My hospital has an annoying habit of checking ua on damn near everyone who walks into the hospital, and I've seen several cases of sepsis where the only culture positive was the urine with no evidence of pylo.

I personally check them on admission for sepsis, unless they can give me a good history of no dysuria in an otherwise ambulatory pt. Now if we're talking chronic foley PTs, we have a large MRDD population that frequently show up with sepsis with concordant blood/urine cultures from that with an otherwise normal ct abd. But without chronic foley or bladder dysfunction or disability, it's unusual.

Oh, I totally agree you check for UTI on admission to the unit if the patient is septic, especially nursing home patients. But I thought the OP was talking about the patient in the unit who has a per routine foley in and spikes a fever while in the unit. I don't go after the urine unless I'm getting frustrated about source.

 

[Hernandez]

Oh, I totally agree you check for UTI on admission to the unit if the patient is septic, especially nursing home patients. But I thought the OP was talking about the patient in the unit who has a per routine foley in and spikes a fever while in the unit. I don't go after the urine unless I'm getting frustrated about source.

I was a little unclear what he meant, I kinda thought he asked in general as well. But in the pt who's been there a while, if I remember my numbers correctly, virtually everyone who has a foley for 30 days will have bactiuria, so no I don't go looking unless I have a reason to look.

 

[cpants]

Bacteriuria develops at a rate of 5-10% per day in catheterized patients. UTI can obviously cause sepsis, even in the absence of obstruction, but it should be a diagnosis of exclusion in anyone who has had a catheter in for more than a few days (ie. most SICU patients). It's more dangerous to check the urine than to ignore it, because the tendency is to stop looking when you get positive cultures, and you might be missing something else. You might deescalate antibiotics based on false sensitivities. If a SICU patient is getting shocky, UTI should be pretty much last on your list of possible causes.

That said, don't ignore the GU tract on your scans. Have seen a few consults (from medicine) lately who had been sitting in septic shock for a couple of days with obstructing stones on their admission CT scans. Also keep ureteral/bladder injury on your differential for postop patients. They can get pretty sick, pretty fast, and urine cx might actually help you in those cases, but again will be diagnosed radiologically first.

 

[DrDawg]

I only check UA's. Urine cultures often result in inappropriate abx use. Pyuria without significant RBC would prompt repeat UA, and urine clx. Most of my patients aren't on big gun antibiotics.

 

[europeman]

How Come virtually everyone in my Sicu on big guns and yours none? Sicu or are u in a trauma Icu?

Regarding ascending infections I agree of course. But what about uti causing severe sepsis on a patient without an obstruction or in absence of ct which shows pyelonephritis?


European

 

[Hernandez]

But what about uti causing severe sepsis on a patient without an obstruction or in absence of ct which shows pyelonephritis?


European

It happens

 

[europeman]

Really? I'm a surgical chief and I have yet to see this


European

 

[Hernandez]

Really? I'm a surgical chief and I have yet to see this

European

I'm a pulm-cc chief and see it not infrequently. Mainly in the really old

 

[europeman]

In micu patients or Sicu patients?


European

 

[Hernandez]

Micu.

 

[cpants]

How Come virtually everyone in my Sicu on big guns and yours none? Sicu or are u in a trauma Icu?

Regarding ascending infections I agree of course. But what about uti causing severe sepsis on a patient without an obstruction or in absence of ct which shows pyelonephritis?


European

Really? I'm a surgical chief and I have yet to see this


European

Happens all the time. Ask anyone from the MICU world. Pyelonephritis is not diagnosed on CT scan. The SICU is a different animal with different differentials. In the SICU, UTI is a diagnosis of exclusion for sepsis source.

 

[europeman]

in 2012... pyelonephritis, to my understanding, CAT SCAN is most certainly a main modality to diagnosed/confirm in the evaluation of patients suspected of pyelonephritis.

am I wrong?

i'm not a medine doctor, but as a surgeon I am often consulted for patients with severe sepsis / septic shock with abominal pain who are sometimes found to have pyelo based on CT. Hard to make sense of a positive urine in lots of these peeps

Anyway, obviously the world of patients in the MICU and SICU and Trauma ICU and Transplant ICU have their differences.

Here is my question... patients admitted to these units for OTHER problems.... how often do they "Catch" a uti while having a functioning foley in place?

I just don't get it. I find it very unusual that patients will randomely get a urinary tract infection with a foley which is actively draining whatever is coming out. I find it harder to believe that, in the absence of there being an obstruction, patients mounting a significant fever or WBC from SOLEY a hospital acquired infection as a result of their foley catheter still being in place.

Virtually all patients in an ICU at one week will have grossly dirty urines in the foley bags.

Diagnosis of exclusion? hmm.