Background Urine testing (dipstick and culture) is used in the rheumatology outpatient setting as a screening tool for proteinuria or hematuria (connective tissues diseases) or for assessment of those with symptoms of urinary tract infection (UTI). Additionally urine testing is also widely but variably used to diagnose UTI in asymptomatic patients with inflammatory arthritis.
Objectives Our aim was to develop an understanding of rheumatologists' diagnostic and management strategies relating to urine testing and bacteriuria in asymptomatic patients, and to identify variations in practice.
Methods A four question survey (image 1) was developed and sent to Consultant Rheumatologists and Specialty Trainees in Rheumatology in the Northern Region of the UK.
Results In total 42 clinicians responded. We found considerable variance amongst respondents in the use of urine dipstick and culture testing, interpretation of results and treatment of asymptomatic bacteriuria (image 1). All supported urine dipstick testing in patients with symptoms suggestive of UTI. 64% would routinely perform a urine dipstick test in asymptomatic patients prior to intramuscular (IM) steroid injection. In asymptomatic dipstick positive patients 90% of respondents said they would send urine for culture and 60% would await the result of culture prior to administration of IM steroid. In an asymptomatic patient with a positive urine culture result, 50% of clinicians reported they would start antibiotics.
Image 1 below shows survey questions and results (total number of respondents 42, choosing multiple options allowed).
Conclusions Patients with rheumatoid arthritis have a high prevalence of asymptomatic bacteriuria due to bacterial colonization (1). Urine testing in asymptomatic patients may result in unnecessary treatment with antibiotics and delays in getting immunosuppressive treatment while there is strong evidence that treatment of asymptomatic patients does not reduce episodes of symptomatic UTI, hospital admissions or sepsis (2). Similar results have been observed in studies in immunosuppressed individuals (3). The available guidance from the Scottish Intercollegiate Guidelines Network, British Infection Society and Infectious Diseases Society of America recommends against screening for or treatment of asymptomatic bacteriuria (4). We would advocate adherence to this guidance while acknowledging that further study of this subject, specifically looking at patients with inflammatory arthritis on immunosuppressive therapy, is required.
Burry H. Bacteriuria in rheumatoid arthritis. Ann Rheum Dis. 1973;32:208-211.
Asscher AW, Sussman M, Waters WE, Evans JA, Campbell H, Evans KT, et al. Asymptomatic significant bacteriuria in the non-pregnant woman. II. Response to treatment and follow-up. British medical journal. 1969;1(5647):804-6.
El Amari EB, Hadaya K, Buhler L, Berney T, Rohner P, Martin PY, et al. Outcome of treated and untreated asymptomatic bacteriuria in renal transplant recipients. Nephrology, dialysis, transplantation: official publication of the European Dialysis and Transplant Association - European Renal Association. 2011;26(12):4109-14.
Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 2005;40(5):643-54.
Disclosure of Interest None declared