LIN Sessions – The Geriatric ED

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Ian L., Dr -

Getting a baseline urine culture when a patient is over 70 or in an aged care facility is valuable .
The baseline urine would have information on wbc count per high powered field the predominant organisms eg Ecoli and their count and sensitivities .
If asymptomatic there is no treatment .
It is worth getting baseline temperature .
In Clinical Infectious diseases Jan 2009 pgs 149-171 Head Keith et al describe the effects of the blunting of the immune system on infectious diseases presentation in the elderly and note a 1.1 degree C fevers above" baseline " is a fever together with one reading of 37.8 or several readings of 37.2 C .
Other" baseline " vitals such as Appearance and Alertness Blood pressure sitting and standing pulse rate respiratory rate and pulse Oximeter PO2 are worth recording in long term care facilities by the General Practitioner and Primary Care Team .
In Australia Medication reviews Medicare Refunded can performed on all patients on PolyPharmacy with regard to Cholinergic and other Adverse Effects Risks but balancing benefits with harms to reduce the incidence of emergency room visits
The classic theorised benefits are a blood pressure of 120-130/80 to reduce stroke and maximising medications and salt restriction and graded
exercise for Reduced ejection fracture heart failure .
Extensive Training in preventing or ameliorating the Behavioural and Psychological Symptoms of Dementia non- Pharmacologically so as to avoid Chemical Restraint as much as possible is a large area now getting extra support in Australia from Government Grants .

Elizabeth G., MD -

Dr. Ian, thanks for your thoughts. A baseline urine culture on every older ED patient is not recommended in the US, even in patients at long term care facilities. Here a recent statement by the Society of Post-acute and Long-term Care Medicine: "Don’t obtain urine tests until clinical criteria are met. Clinical uncertainty surrounding asymptomatic bacteriuria (ASB) and/or pyuria is the major driver for overtreatment of Urinary Tract Infections (UTI) in PALTC, (Nace). Colonization (a positive bacterial culture without signs or symptoms of a localized UTI) is a common problem in PALTC facilities that contributes to the over-use of antibiotic therapy in this setting, leading to an increased risk of diarrhea or other adverse drug events, resistant organisms, and infection due to Clostridioides difficile. An additional concern is that the finding of asymptomatic bacteriuria may lead to an erroneous assumption that a UTI is the cause of an acute change of status, hence failing to detect or delaying the timely detection of 5 signs and symptoms likely indicative of uncomplicated cystitis. These include dysuria, and one or more of the following: frequency, urgency, supra-pubic pain or gross hematuria. In the presence of dysuria and one or more sign/symptom, collection of a urine culture is indicated."

Also, here a recent reference including an algorithm on when to test and treat for UTI by colleague Dr. Chris Carpenter

Ian L., Dr -

Comparing urinary test results when a patient is asymptomatic to when they are symptomaic is the idea here .
So in the patients cognitively impaired the hypothesis is with a urine infection the wbc per high powered field increases say from 5 asymptomatic to 15 symptomatic .
Nitrates on urine dipstick become positive in some cases .RBC" appear ."
The bacterial colony count increases from 10-3 to 10-5.
With recurrent UTI a prior urinem/c/s may help with sensitivities and choosing the most likely antibiotic to work assuming sensitivity does not change over a six month time period.
The aim is to obtain baseline tests when patient is stable - from ability to count back from 20-1 to rise in basal temperature of 1.1 C to help focus on a diagnosis .
There will be times when a UTI is present but also there is another pathological state eg Cellulitis Hyponatremia and Diverticulitis

Ian L., Dr -

For Infections that are altering patients baseline status but the patient is still hemodynamically stable and the diagnosis is still not certain some recommend
IV ceftriaxone 1-2G IV or even IM .
This can be given in a more rural area far from hospital and futher tests .
What is your belief as regards Empirical Antibiotic and other Supportive therapy in the isolated setting or when transfer late at night would be very unsettling for an elderly person in an aged care residential facility ?

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