Question for my fellow colleagues

[EMSGuy1982]

While working a shift in my rural walk in clinic/urgent care another colleague (PA) and I were discussing urine cultures. Lately we have had a run of cultures coming back with a result of Gardnerella vaginalis from the lab. These appear with varying degrees of amounts 50k- >100k as a final result. Some with coexisting e.coli or other organisms. 

We were discussing treatment options. Some fellow colleagues, including myself are in the camp of treating with Flagyl 500mg BID x 7 days. Two other PA’s in the clinic opt for the metrogel topical/intravaginal. I’ve seen a few bounce backs from those who received the gel and wondered if oral is the way to go. Just wondering if anyone wanted to share their thoughts. I’ve attempted to find some literature that discusses oral vs gel and have come up with nothing. On one hand I could understand the gel preparation having an advantage given it’s not a systemic drug, but I keep thinking that this is a result of a clean catch (if the patient folllowed the MA/LPN directions) from the bladder so I can’t see how a topical would be of benefit. 

 

Any comments, references to articles appreciated! Thanks in advance! 

 

[EMEDPA]

I use the po flagyl in that situation.

[sas5814]

PO.

[GetMeOuttaThisMess]

Technically, you don't have a UTI at <100,000 colonies.  That being said, do you actually know for a fact that the organism in the urine isn't a byproduct of the next door neighbor?  If so, treat it as you would from the vagina.  To answer your question from my perspective, po as well.

I had an elderly lady years ago that I saw like clockwork for UTI's with either negative or <100,000 colonies on culture.  Finally got her to go to urology and sure enough she had an estrogen deficient vaginitis that with treatment cured her "UTI's".

[EMSGuy1982]

18 minutes ago, GetMeOuttaThisMess said:

Technically, you don't have a UTI at <100,000 colonies.  That being said, do you actually know for a fact that the organism in the urine isn't a byproduct of the next door neighbor?  If so, treat it as you would from the vagina.  To answer your question from my perspective, po as well.

I had an elderly lady years ago that I saw like clockwork for UTI's with either negative or <100,000 colonies on culture.  Finally got her to go to urology and sure enough she had an estrogen deficient vaginitis that with treatment cured her "UTI's".

I definitely agree about <100,000. I’ve even had a few cultures come back with less than <100k who had a positive dip with leuks and nitrates (thus I try not to get to excited about dips)  I still typically go for PO for results that come back with Gardnerella but a few other PA’s opt for the metrogel. I typically don’t just do a typical dip on women over 65. I try to do a symptomatic urinalysis with a reflex to culture if indicated to try to tease out that dysuria vs an atrophic vaginitis. I often question if the sample is really a clean catch vs dirty even though nursing staff gives directions every time. That whole following directions thing doesn’t work for some people.  I definitely  see a lot of those elderly women that think they have recurring UTI that fall into the same category as the one you mentioned! 

 

Thanks for all the responses. 

[ventana]

1 hour ago, GetMeOuttaThisMess said:

Technically, you don't have a UTI at <100,000 colonies.  That being said, do you actually know for a fact that the organism in the urine isn't a byproduct of the next door neighbor?  If so, treat it as you would from the vagina.  To answer your question from my perspective, po as well.

I had an elderly lady years ago that I saw like clockwork for UTI's with either negative or <100,000 colonies on culture.  Finally got her to go to urology and sure enough she had an estrogen deficient vaginitis that with treatment cured her "UTI's".

 

I disagree

 

Have seen uro and some literature say you can have UTI all the way down to 10k,  I use about 25k with classic syptoms as the cut off, or for scary bugs, down to 10k

[GetMeOuttaThisMess]

23 minutes ago, ventana said:

 

I disagree

 

Have seen uro and some literature say you can have UTI all the way down to 10k,  I use about 25k with classic syptoms as the cut off, or for scary bugs, down to 10k

85% sensitivity based on history alone.  65% accuracy with urine dip alone.  Use dip to confirm clinical suspicion, not the other way around.  V, I'm not disagreeing with you, I'm just stating what the "experts" say to use as the defining measurement.  We've all seen those with growth of heaven knows what at less than 100K colonies.  You have to draw a line in the sand at some point.  Heck, we've even decided that sterile urine is not the norm any longer.  If it walks, quacks, looks like one in my setting then they get medication (UTI), especially considering that I don't have culture capability there.