“I have a result here which shows a urine which is growing an E.coli resistant to all oral antibiotics. Should I admit the patient to hospital for IV antibiotics?”
I get a call along these sort of lines every week or two from GPs.
Hold on a minute….
I now have a fairly routine set of questions lined up in order to filter out those patients that really do need immediate attention.
- Why was the urine sample taken in the first place? This is an interesting question which often provokes all sorts of interesting answers. In a good proportion of cases, it turns out that the patient was not actually symptomatic in the first place…
- When was the urine taken? Sometimes a week or more has passed since the urine sample was taken. Time to take another one.. It is surprising how often two urine samples taken a week apart in an untreated patient can produce different results. (Nothing to do with laboratory error.)
- Is the patient still symptomatic? Even if the patient was symptomatic when the urine was taken, is the patient still symptomatic? The indications for treating asymptomatic bacteruria are few and far between.
- Has the patient got an indwelling catheter in situ? This also changes things. Patients with catheters in situ generally do grow micro-organisms in their urine, but in the majority of cases this does not mean very much, unless the patient is genuinely unwell with systemic symptoms.
If after the above questions have been asked, the patient still requires treatment (the minority), then I have a look to see if there are any antibiotics that may be strictly resistant according to “national standards” but still retain in-vitro activity. e.g. showing a zone size of 17mm when the breakpoint is 18mm. Unless the patient is desperately sick, such oral options are worth a trial, as urinary concentration of many antibiotics means that such a result may well translate into in-vivo susceptibility.
Using the above measures it is usually possible to whittle down the number of patients who actually need IV antibiotics/Inpatient care.
It is often just a case of treating the patient, not the laboratory result. No complex evidence based medicine, no exotic antibiotics, just simple common sense stewardship…..