Diagnosing UTI

[diddyman]

What should I expect from the GP when tackling a possible urine infection?

At the moment I take a urine sample to the surgery when I suspect that something is odd. They do a dip test and if the result is positive they send the sample away to be cultured.

This happened last Friday and a doctor telephoned to say that the dip test did show 'something'. The culture was arranged. But the GP wanted to know what the symptoms were before he would give antibiotics. I find this difficult because mum has advanced dementia and doesn't respond to questions.

Outcome is usually that doctors from the surgery don't prescribe antibiotics and in the hope that things get better (often things clear up by themselves).

This time the culture showed up a bug.

What could be described as 'best practice' when dealing with suspected UTI's in people with advanced dementia? Doctors seem very reliant on symptoms - which puts me under pressure to spot them and communicate them effectively (not always easy).

 

[Beate]

Best practice should be to prescribe antibiotics straight away if a UTI is so much as suspected! They do need treating quickly and can often be suspected by smelly urine and the person acting out of sorts. I've had my GP surgery give antibiotics simply by me describing the symptoms though they did want me to produce a urine sample for testing. Sending it away to the lab can take 5 days though and treatment shouldn't have to wait that long.

 

[lemonjuice]

For me, generally different abnormal behaviour was always a sign. 'Problems down there' definitely affect 'problems up there' in the brain.
So any extra obsessional behaviour or anything which is not part and parcel of their normal abnormal behaviour (if you see what I mean) was often an indication of a uti. Could you ask at your surgery for some stand-by dip sticks as this is such a common problem?
Of course after a while ABs do stop working and Drs are so cautious these days, but the sooner the infection is cleared up the better and eventually ABs always stop working for most dementia sufferers anyway. It just helps their QoL in between that inevitable date.

And of course one always queries whether it's 'just another new stage', but after a while one gets very good at spotting the difference.

 

[diddyman]

For me, generally different abnormal behaviour was always a sign. 'Problems down there' definitely affect 'problems up there' in the brain.
So any extra obsessional behaviour or anything which is not part and parcel of their normal abnormal behaviour (if you see what I mean) was often an indication of a uti. Could you ask at your surgery for some stand-by dip sticks as this is such a common problem?
Of course after a while ABs do stop working and Drs are so cautious these days, but the sooner the infection is cleared up the better and eventually ABs always stop working for most dementia sufferers anyway. It just helps their QoL in between that inevitable date.

And of course one always queries whether it's 'just another new stage', but after a while one gets very good at spotting the difference.

LemonJ, it's not identifying a possible UTI that is my dilemma, but how I should expect the GP's surgery to react. They seem very reluctant to give antibiotics unless I exaggerate the symptoms.

And people with advanced dementia as you know cannot be diagnosed very easily......Question: "Does she have pain when she urinates?"....How would I know.

At the moment I have to wait until the results from the culture come through. Is this 4-5 day delay in treating a UTI putting her in danger? Should the surgery 'best practice' be to give antibiotics when the dip test shows positive.....rather than base the decision on symptoms that cannot be obtained as you would in a person without advanced dementia?

 

[mitz]

Hi,

My Mum gets a lot of UTIs. Either me or district nurses take sample to GP for dip test. If positive the doc prescribes antibiotics straight away. They're usually antibiotics mum has had before. But absolutely - as soon as a pwd is diagnosed with a uti antibiotics must be started that very day! The culture that goes to the lab will tell the doc exactly which organism has caused the uti and tells the doc if person needs a particular kind of antibiotic. I have never been asked to describe symptoms in order to inform drs treatment for uti. In my experience everything doc needs for diagnosis is in the urine.

 

[Carolyn B]

I might be missing the point here, but.. I think there is more than one type of infection that causes UTI and so different types of anti biotics. I was told common practice was if one type doesn' seem to shift it then they try another. Without testing, depends on the GP and the patient. Could be wrong but that was my understanding. So possibly the GP is trying to establish exactly what it is.

 

[lemonjuice]

I might be missing the point here, but.. I think there is more than one type of infection that causes UTI and so different types of anti biotics. I was told common practice was if one type doesn' seem to shift it then they try another. Without testing, depends on the GP and the patient. Could be wrong but that was my understanding. So possibly the GP is trying to establish exactly what it is.

I think you may have a reason why some GPs are reluctant to prescribe them straight off.

We have friends who have a disabled son and I know they say often 'broad-spectrum; antibiotics are completely ineffective now, as he's had so many courses and so they always have to test for the particulars of any infection to target the antibiotics more accurately.

These days with many people and infections becoming A-B -resistant I can understand why Drs are being more cautious. problem is, as many of us here recognise many PWD do suffer multiple events of infections. and as I see it, so it shortens their life! Their lives may not be that great and may not need extending just for the sake of it. Their QoL has to be the priority and being symptom-free would seem to more important. IMHO.

 

[LynneMcV]

With my husband I generally just needed to phone up and say I suspected a UTI (I could tell by his increasingly challenging behaviour and state of mind and the GP trusted my judgement as my husband's full time carer).

The GP would quickly prescribe an antibiotic to start taking immediately (one which he knew worked well for most male UTIs) - in the meantime I would drop a urine sample off as soon as I could. If things hadn't improved by the end of the course of antibiotics I would contact the GP again, by which time he would have the results of the urine test to hand, enabling him to know if a different antibiotic was needed - or just a longer course.

In 99% of the cases we didn't need a longer course or to change to a different antibiotic. The prompt action resolved the problem quickly.

 

[Carolyn B]

With my husband I generally just needed to phone up and say I suspected a UTI (I could tell by his increasingly challenging behaviour and state of mind and the GP trusted my judgement as my husband's full time carer).

The GP would quickly prescribe an antibiotic to start taking immediately (one which he knew worked well for most male UTIs) - in the meantime I would drop a urine sample off as soon as I could. If things hadn't improved by the end of the course of antibiotics I would contact the GP again, by which time he would have the results of the urine test to hand, enabling him to know if a different antibiotic was needed - or just a longer course.

In 99% of the cases we didn't need a longer course or to change to a different antibiotic. The prompt action resolved the problem quickly.

Wow that's really efficent. I can't be bothered repeating my tale of woe. But the urine sample I had, with difficulty, obtained he didn't even test Prescribed her anti-biotics for a chest infection. In the end she didn't have either infections. Another GP told me to complain. I didn' have the energy.

 

[diddyman]

Thanks for all the replies. Which seem to confirm that there is no 'Best Practice' when dealing with suspected UTI's in PWD.

It seems to be what the carer can arrange with their doctor.....if the carer is assertive then I suspect the doctor will follow their lead (we all want an easy life).

My doctors surgery are very much led by symptoms when using anti-biotics. Problem is that those symptoms rely on me as the main carer to identify them and to assertively relay that information to the GP (I've never been good at that).

There is something in the 'theory' that unless the patient is in obvious discomfort (bed bound, peeing blood) then my GP is reluctant to prescribe AB's, because what's the point?....they have dementia and prolonging life isn't necessarily in their best interest (or the families).....but quality of life (pain free) is important. I just wish sometimes the GP's would be honest with me.

When I dropped off the urine sample the lady at reception (untrained probably) described a process to me:

Should the urine dip test show positive then a general AB will be prescribed and that would be reviewed when the culture came through in 4-5 days.

It didn't happen like that. The Urine dip test was posiitive (although I don't know how positive). The GP didn't prescribe AB's (although they said they would give me a prescription to use over the weekend should symptoms get worse). I declined the prescription and said I would telephone '111' should she become bed bound or start peeing blood (scary).

I almost get the feeling that they treat UTI's differently in dementia patients to 'normal' people.....almost a 'light touch' medical care because of the dementia....because what's the point in prolonging life.

But I suppose it could just be that they don't want to over-prescribe AB's.

Although what the receptionist said has me thinking....I guess I need to discuss things with the surgery manager.

 

[Moggymad]

Hi @diddyman i think you need to get back in touch with the GP & get the prescription your mum needs. To wait until things worsen to peeing blood is in my opinion neglect & can result in kidney infection or even urosepsis if not properly treated. My mums previous doc used to prescribe AB whilst awaiting hospital test. The new GP (mum now in a care home) will not prescibe until results are back. If you have ever suffered with a UTI you will know how urgently you need relief from those symptoms. I know from my own mum she is unable to express where her pain is so it is all about observation. Please follow this up, speak to another GP if necessary.

 

[Amy in the US]

I'm sorry to be blunt (due to time constraints, not a lack of interest in a longer post) but I would begin antibiotics now. UTIs are a major problem in the elderly and dementia populations and I wouldn't want things to worsen to the point of needing hospitalization or IV antibiotics or a major systemic infection. The usual rules do not apply in UTIs in dementia patients. I would also get a culture started ASAP. Best wishes and hope this can get cleared up quickly.

 

[diddyman]

........ My mums previous doc used to prescribe AB whilst awaiting hospital test. The new GP (mum now in a care home) will not prescibe until results are back........

Moggymad, so you are in the same boat as me. Your mum's doctor at the care home won't prescribe AB's straight away. How do you tackle it?

I find it difficult to argue with a doctor (several doctors in fact because most of the doctors at the surgery seem to think the same) that they need to be more pro-active in the use of AB's as a preventative for patients with dementia.

BTW she did get the AB's eventually. The urine sample went to the surgery on Friday. It was dip tested and came back positive. I had a conversation with the GP who wanted to know her symptoms, but he didn't want to prescribe AB's immediately - because I didn't describe symptoms that were severe enough - so the 'plan' was to wait for symptoms to get more indicative of a UTI (a bit scary with the weekend coming up but I felt I could deal with it). The urine sample was sent to be cultured. On Tuesday the GP telephoned me to say the culture showed a bug and that she needed AB. She started the course that same day. She has finished the course. She seems OK (less sleepy now).

I did 'suggest' to the GP during our Friday conversation that prescribing AB's to patients like my mother - at the cost of a few pounds - could prevent her being hospitalised where the cost would be many thousands of pounds. But it's not the way they think. They seem to concentrate on the symptoms and let someone else pay for treatment should things escalate due to a lack of early intervention. I think the new rules on AB may be influencing their decisions.

Thanks for all the advice anyway.

I was hoping that there was a 'best practice' to follow regarding UTI's and AB's......but there doesn't appear to be one. I guess I must get more imaginative in describing mum's symptoms....."Doctor, her leg has just fallen off, is that a sign of a UTI?"

 

[diddyman]

.......... I would begin antibiotics now. UTIs are a major problem in the elderly and dementia populations and I wouldn't want things to worsen to the point of needing hospitalization or IV antibiotics or a major systemic infection. The usual rules do not apply in UTIs in dementia patients. I would also get a culture started ASAP. Best wishes and hope this can get cleared up quickly.

Amy, I agree with you 100% but I expect things are slightly different in the US to Blighty. We don't pay for our medical care directly so we cannot 'demand' (not a good choice of words...sorry) medical treatment. We can try to put pressure on the doctor ....but I don't like doing that. It's a failing of our system...people who shout the loudest seem to get the best treatment. People who 'make do' get ignored. But I guess that's life in general and is a universal truth.

Didn't someone in high office over there write his own medical report for a job? As I say, you do things differently over there.

 

[Moggymad]

@diddyman, I have just found these GP guidelines for prescribing antibiotics, here is the link. The section on UTI's may interest you. Luckily it's not too far in as it's a massive document!
https://www.england.nhs.uk/south/wp...6/PHE-Primary-Care-Guidance-for-Gateway-2.pdf

Thanks @Carmar that is very useful & does clarify a few things with my mum.
@diddyman I am pleased & relieved that your mum got the antibiotics in the end & that she appears ok now. Has the doc or nurse suggested retesting a week after the antibiotics have finished? That is usually recommended to make sure the infection has cleared. In answer to your question, unlike previously when I was my mums carer, I now don't usually have to get involved with this as the care home are quite assertive in getting AB, after all they are dealing with the consequences & with 40+ residents mostly ladies all with dementia, they have to be 'on the ball' with it. The tests usually come back pretty quickly here but they have had to ring 111 if weekend/BH delays things for too long & symptoms worsen. I have spoken to GP about the AB they kept prescribing which mum has resistance to so infection kept coming back. A different one is currently being prescribed instead.
I know it's not easy but GP should listen to any concerns you may have, after all you know her better than anyone else & continuing to speak up in her best interests in the end will give you more confidence. Best wishes.

 

[diddyman]

@diddyman, I have just found these GP guidelines for prescribing antibiotics, here is the link. The section on UTI's may interest you. Luckily it's not too far in as it's a massive document!

Carmar, thanks for your kind words and for finding the link.

 

[diddyman]

Thanks @Carmar that is very useful & does clarify a few things with my mum.
@diddyman I am pleased & relieved that your mum got the antibiotics in the end & that she appears ok now. Has the doc or nurse suggested retesting a week after the antibiotics have finished? That is usually recommended to make sure the infection has cleared. In answer to your question, unlike previously when I was my mums carer, I now don't usually have to get involved with this as the care home are quite assertive in getting AB, after all they are dealing with the consequences & with 40+ residents mostly ladies all with dementia, they have to be 'on the ball' with it. The tests usually come back pretty quickly here but they have had to ring 111 if weekend/BH delays things for too long & symptoms worsen. I have spoken to GP about the AB they kept prescribing which mum has resistance to so infection kept coming back. A different one is currently being prescribed instead.
I know it's not easy but GP should listen to any concerns you may have, after all you know her better than anyone else & continuing to speak up in her best interests in the end will give you more confidence. Best wishes.

Thanks Moggymad, glad to know that your mother is being looked after properly.

I think you are correct about retesting when the AB's have finished to make sure that the bug has been defeated. And I specifically asked the GP this when he prescribed the AB's and he said that it wasn't necessary. I also checked that the AB was suitable for fighting the bug and he said it was....I did this because mum cannot take big tablets and requires an AB suspension & Amoxicillin seems to be the only one readily available.

 

[diddyman]

@diddyman, I have just found these GP guidelines for prescribing antibiotics, here is the link. The section on UTI's may interest you. Luckily it's not too far in as it's a massive document!

Carmar, I noticed in the document that to help prevent UTI's they recommend hydration and cranberry products. But I think there was a report last week or so that Cranberry juice isn't any good for preventing UTI's (although it's obviously useful as hydration). I guess information changes as more research is done and even though this information is only 4 years old it may have be slightly out of date. But it was jolly interesting...although I didn't understand that much of it.

I think it sort of suggested that AB's should be given if the dip test shows certain key indicators. But personally I find dip sticks very confusing and the cheap ones I have used in the past next to useless. I think the paper confirms that I need to discuss this with the surgery manager.