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Case #14 Confusion

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Anaesthetics and Critical Care

Obstetrics Gynaecology

Trauma and Orthopaedics

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Urology

Version Jan 2023

An 83-year-old male with a long term catheter is admitted to hospital with fever, delirium with an AMTS of 5 (He knows the month, the year, the PM and monarch and WW2) and loin and suprapubic discomfort. He has a clinical frailty score of 6. He lives at home with his wife and he has carers twice a day. The WCC is 15 and CRP is 67. His urine is concentrated. Clinically he is dry. His CXR is clear and there are no respiratory symptoms.

1. What test result would you like and how would you treat

The clinical picture fits with an upper urinary tract infection. A catheter sample of urine shows protein ++, Leucocytes ++ and nitrites++. You send a sample for culture.

What is the correct management

IV fluids preferably Crystalloid to replace the deficit
Obtain a urine sample from the sampling port of the catheter using an aseptic technique (in line with the NICE guideline on healthcare-associated infection) and send for culture and susceptibility testing.
Consider removing or changing the catheter before treating the infection if it has been in place for more than 7 days. Catheters should be removed rather than changed where possible
Antibiotics e.g. stat dose of Gentamicin 5 mg/kg and then Co-Amoxiclav 625 mg TDS PO for 7 days

Do all patients with this condition need admission or hospital referral

Refer people with catheter-associated UTI to the hospital if they have a severe systemic infection (any of the high-risk criteria from the NICE guideline on sepsis).

4. How useful is urine dip in asymptomatic patients with a catheter

Generally unhelpful. The only time that it might be useful is in pregnant patients. In older patients with catheters, the dipstick can appear positive but treatment only advised when there are symptoms or signs of UTI.

5. What other patients may need hospital referral

Those who are significantly dehydrated or unable to take oral fluids and medicines
Pregnant
Higher risk of developing complications (for example, people with known or suspected structural or functional abnormality of the genitourinary tract or underlying disease [such as diabetes or immunosuppression]
Those with recurrent catheter-associated UTIs.

6. What other antibiotics may be used here

Co-Amoxiclav 625 mg three times a day for 7 days
Ciprofloxacin 500 mg twice a day for 7 days
Levofloxacin 500 mg once a day for 7 days
Trimethoprim (only if culture results available and susceptible) 200 mg twice a day for 14 days

7. Question

Answer

8. Question

Answer

9. Question

Answer

10. Question

Answer

References

Draft Guidance from NICE

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. The official launch will be at the end of 2018. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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