db_pavnp Posted April 1, 2014 Share Posted April 1, 2014 I am curious to hear from ER providers what your facility's general strategy is for UAs and clean catches. Is your ED too busy for clean catches and they are obtained after the fact if a culture is to be ordered on a patient with a dirty catch in lab? Do your labs refuse to culture at a certain level of epi contamination? Do you order cultures on dirty catches and force them through because the patient is too hard to collect clean from? Thank-you for participating. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 1, 2014 Moderator Share Posted April 1, 2014 our e.d. reflexively cultures all pediatric urines and any adult urine with greater than or = 10 wbc/HPF or + nitrite. sure, we get a lot of cultures that are nl flora Link to comment Share on other sites More sharing options...
db_pavnp Posted April 1, 2014 Author Share Posted April 1, 2014 No clean catches? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 1, 2014 Moderator Share Posted April 1, 2014 No clean catches? everone is instructed in how to do one. not everyone does it right. we do lots of cath urines also if the answer is really important(febrile baby, etc). wee bags are worthless unless 100% normal. better in boys than girls. Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 2, 2014 Moderator Share Posted April 2, 2014 I am left stammering at the OP post Really too busy for a clean catch? come on now, that is like saying I was too busy to listen to their heart and lungs.... one thing that does bug me is getting cultures on healthy reproductive age females with classic s/s and no red flags..... just treat them, forget the culture My pet peeve is the clean catch on guys that come in with dysuria - I can not say how many times i have explained to nursing staff (who is allowed to order this through triage) ORDER a dirty and clean on a male to save the urethral swab.... But just seems to fall on deaf (death) ears.... Link to comment Share on other sites More sharing options...
Guest Paula Posted April 2, 2014 Share Posted April 2, 2014 Funny clean catch story: Female patient comes in with dysuria. She is instructed how to use the towelettes, produce the specimen and place the cup in the door in the wall. Lab tech retrieves a cup with towelette in it and no urine to be found. She thought cleansing the area "caught the urine". Link to comment Share on other sites More sharing options...
db_pavnp Posted April 2, 2014 Author Share Posted April 2, 2014 I am left stammering at the OP post Really too busy for a clean catch? come on now, that is like saying I was too busy to listen to their heart and lungs.... This is kinda what I am curious about, but I am trying not to lead with what I am seeing... Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 2, 2014 Moderator Share Posted April 2, 2014 This is kinda what I am curious about, but I am trying not to lead with what I am seeing... simply demand urine is collected and done right..... settle for nothing less If the nurses say it is impossible then start writing for straight caths (this will freek the nurses out as they are likely to lazy to get a clean catch and a straight cath is a HUGE amount more work) BTW don't let them straight cath someone that doesn't need it - it is just a threat.... Link to comment Share on other sites More sharing options...
skyblu Posted April 3, 2014 Share Posted April 3, 2014 I don't understand the question. What time is involved in collecting a clean catch? most patients do the clean catch themselves. If they are too debilitated/demented/young to be able to do it, then we straight-cath. Ventana, I order cx for female uncomplicated not for my own decision making, but for further. I've had many patients who came in with repeat UTIs and don't remember what antibiotic they took. Looking at a previous/recent culture gives me a better guess as to what pattern of resistance her particular bug might present. I don't wait for the cx to treat, though, in those cases. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted April 3, 2014 Moderator Share Posted April 3, 2014 I'm with ventana in that I don't culture much at all- certainly not healthy, reproductive-age females on an initial visit. I culture if they're getting admitted (or transferred to pediatric facility for inpt care), or if the healthy reproductive-age female returns more than two times for the same dysuria/UTI-type complaint. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 3, 2014 Share Posted April 3, 2014 In a private clinical setting where care didn't cost the patient anything (covered by employing gov't. agency) I cultured not due to concern about resistance but more to know what to use if pyelo were to develop (which did occur not infrequently). I routinely used Macrobid due to resistance with Cipro/TMP-SMX. Don't know what it was about this particular population that seemed to cause an increased incidence of pyelo. Link to comment Share on other sites More sharing options...
db_pavnp Posted April 3, 2014 Author Share Posted April 3, 2014 I don't understand the question. What time is involved in collecting a clean catch? Maybe I should have asked it differently. What do your ERs intentionally collect dirty catches on? What do you do when you get a UA back that has massive epi contamination? Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 4, 2014 Moderator Share Posted April 4, 2014 Ventana, I order cx for female uncomplicated not for my own decision making, but for further. I've had many patients who came in with repeat UTIs and don't remember what antibiotic they took. Looking at a previous/recent culture gives me a better guess as to what pattern of resistance her particular bug might present. Just a question to you - ever see how much they charge for that little U/A C+S? It is BIG bucks! $100's of dollars.... I have not looked in the past 1-2 years at the guidelines, but they used to clearly state that you were perfectly okay to treat the typical UTI in the healthy reproductive age female with bactrim is your local sensitivities were > 80% - a simple call to your lab will get you this answer.... It fast, cheaper, easier, better more efficient medicine.... As for prior pathogens - E.coli #1, followed by a few others - no real need for a culture on initial presentation..... Link to comment Share on other sites More sharing options...
skyblu Posted April 4, 2014 Share Posted April 4, 2014 Our antibiogram steers us away from Bactrim, so Macrobid is my first choice. I want to clarify I don't order a C&S on every single UTI. Just the ones who tell me they've had them before (and not just once five years ago), and also on pregnant women. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 4, 2014 Share Posted April 4, 2014 ^^^ Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 4, 2014 Moderator Share Posted April 4, 2014 Our antibiogram steers us away from Bactrim, so Macrobid is my first choice. I want to clarify I don't order a C&S on every single UTI. Just the ones who tell me they've had them before (and not just once five years ago), and also on pregnant women. yup, my practice as well. cultures on old/sick/kids/diabetics. I also try to save bactrim for mrsa and use macrobid, a quinolone, or vantin. Link to comment Share on other sites More sharing options...
LoRezSkyline Posted April 7, 2014 Share Posted April 7, 2014 My pet peeve is the clean catch on guys that come in with dysuria - I can not say how many times i have explained to nursing staff (who is allowed to order this through triage) ORDER a dirty and clean on a male to save the urethral swab.... But just seems to fall on deaf (death) ears.... Ventana, Dumb question, but explain to me how you get both a dirty and a clean catch on your male patients? I have pretty much stopped the sadistic practice of swabbing guys for G/C - but the ideal specimen for a urine G/C is a dirty/first-catch urine, whereas if I'm still on the fence if they might just have a UTI (frequency/dysuria, no grossly purulent D/C in a guy with a not-so-shady sexual HX) the ideal specimen is a clean/mid-stream catch. Do you have them go twice & provide two samples, send the first dirty or and get a second, clean one later? Or what's your method of obtaining BOTH a dirty an a clean catch in one go? :) Asking as I agree w/ your theory above, but don't have the patience for the ones with stage fright to work up a single pee most days, much less sit around waiting for two specimens! Maybe I'm missing something obvious?!? :) Link to comment Share on other sites More sharing options...
skyblu Posted April 7, 2014 Share Posted April 7, 2014 Pee a little in one cup (before wiping), then wipe, then pee in the other cup. Make sure to clearly mark which is the clean and which is the dirty Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 7, 2014 Moderator Share Posted April 7, 2014 Ventana, Dumb question, but explain to me how you get both a dirty and a clean catch on your male patients? I have pretty much stopped the sadistic practice of swabbing guys for G/C - but the ideal specimen for a urine G/C is a dirty/first-catch urine, whereas if I'm still on the fence if they might just have a UTI (frequency/dysuria, no grossly purulent D/C in a guy with a not-so-shady sexual HX) the ideal specimen is a clean/mid-stream catch. Do you have them go twice & provide two samples, send the first dirty or and get a second, clean one later? Or what's your method of obtaining BOTH a dirty an a clean catch in one go? :) Asking as I agree w/ your theory above, but don't have the patience for the ones with stage fright to work up a single pee most days, much less sit around waiting for two specimens! Maybe I'm missing something obvious?!? :) Pee a little in one cup (before wiping), then wipe, then pee in the other cup. Make sure to clearly mark which is the clean and which is the dirty Yup thats it.... problem is that if you get only a clean catch - you can not go back and get a dirty catch as the urethra is cleaned out and you need to wait hours for any bacteria to build back up ------ so have to get dirty first------ then clean catch and you do it all at once....... Link to comment Share on other sites More sharing options...
ToppDog Posted April 10, 2014 Share Posted April 10, 2014 Yup thats it.... problem is that if you get only a clean catch - you can not go back and get a dirty catch as the urethra is cleaned out and you need to wait hours for any bacteria to build back up ------ so have to get dirty first------ then clean catch and you do it all at once....... Yep. This is why I teach my MA students to not instinctively ask for a urine specimen if the patient is male with symptoms of dysuria, as they would with a female patient. I have them ask the provider first to see if they want to do a swab or dirty catch, etc. Once the urethra is flushed out, the chances are slim that they'll stick around or come back later when there is enough to sample, & the chances of them never coming back are higher if they know you're planning on swabbing them :) Link to comment Share on other sites More sharing options...
jen0508 Posted May 2, 2014 Share Posted May 2, 2014 i never do clean and dirty urine on men. i dont think anyone in my ED does. we swab them. maybe next time they will go to the health department for their STD's Link to comment Share on other sites More sharing options...
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