Urology & Urogynecology > Education and Reference

Clinical Application Note: Patients with Infections / Antibiotic Prophylaxis
Unfortunately, it is extremely difficult to find published urodynamic guidelines (or commentary for that matter) for patients who:
>> Have clinical urinary tract infections
>> May require antibiotic prophylaxis before urodynamics
>> Have clinical infections of any type
>> Are in isolation for an infectious disease.

CLINICAL URINARY TRACT INFECTIONS
NOTE: In this discussion, it is important to differentiate between patients who have CLINICAL urinary infections and those who are colonized with bacteria. Persons on ISC (intermittent self-catheterization) will have positive UA and cultures for organisms, however they are not CLINICALLY infected. They have no SYMPTOMS of infections (elevated temp, pain, etc.) and are at no particular risk (from this) when having urodynamic testing.

The best recommendation, by the experts is "don't do urodynamics on patients with Clinical Urinary Tract Infections." (see references 1, 2, 3). The best way to determine the presence of infection is to simply do a dipstick on the patient's urine when they arrive and perform a uroflow (see references 1, 2, 3). The fact that the patient had a urine C&S last week at the physician's office is not satisfactory (a lot can happen in a week's time). Patient's with positive dips (nitrite) should be rescheduled and treated after a catheterized urine is sent for analysis.

ANTIBIOTIC PROPHYLAXIS
Many labs choose to routinely cover patients having urodynamics with the "antibiotic of the day." This is a facility/practice-based decision. A more critical issue with antibiotic coverage is remembering to follow the AHA Prophylaxis Guidelines for patients with heart valve disease, orthopedic prostheses, GU prostheses, pacemakers and other artificial implant devices (see references 3, 4, 5, 6, 7). These guidelines are readily available on the internet (see references 4 - 7).

PATIENTS IN ISOLATION
The last issue, and least frequent raised, is how to perform urodynamics on patients in isolation for infectious conditions. I searched the Internet and twelve books on urodynamics/urology and found no reference to this matter. When my trusty books fail, I turn to my best resource - our Clinical Consultants. Here is what they had to say:

From the Director (RN) of a large private Urology practice in Texas: "I'll do it..........for the 'right price'. I think they use things like IVAC, O2 saturation monitors, and other equipment in isolation. I'd just get the hospital's disinfection policy from Central Supply and make sure I clean all non-disposables very carefully. ... put a clear plastic bag over the equipment."

From a self-employed consultant in the Midwest: "I did one just today. The patient had MRSA and CMV. I had the patient wear a mask during the procedure. I double gloved and changed the outer pair every time I had to touch something different. When I went to the keyboard, I ripped the outer gloves off, and put on a new pair. After the test, I wiped everything off with disinfectant. I also double gowned during the test and I had scrubs on. Prior to the test, I set out all the supplies that I would need. Anything that I had gotten out, even if not used, was thrown away. I did not enter any drawers, or cupboards during the procedure or until after everything was wiped down. Can't think of any other way of doing it, except ... wait until they are out of isolation."

From the Nurse Manager of a hospital based out-patient urology center in Texas: "We have done one patient, who had just come out of isolation for VRE (Vancomycin resistant ecoli) and our infection control dept recommended that we use universal isolation precautions, anyway and schedule patient for last procedure of the day - because the room needed to sit empty to dry for 30 minutes after thorough cleaning. We had one person operate the computer and the other handled patient and patient items. We threw everything away (including transducers) after finishing procedure. There was another patient scheduled who was still in isolation and our medical director said no way - it could wait until the isolation precautions were removed."

From the PA that runs the Urodynamic Lab at a major university hospital in North Carolina: "The public opinion here is the tests should be deferred until the infections are cleared. Any urologic problems such as retention should be managed with intermittent catheterization, etc, and, as you say, incontinence is not an emergency (unless they sneeze while sitting on an electric outlet). If the infection involves or started in the bladder, then the risk is even greater until it is cleared. The risk of spreading the bacteria or causing urosepsis in this setting is significant and is probably a lawsuit you will not win. We've never faced this question, at least to the point it got to the lab.....however, our policy is we do not test anyone with an infection."

From the Director of the Urodynamic Lab at a major VA hospital in the Southeast US: "We are possibly a bit more conservative than (others). There is no such thing as an "Emergency Urodynamics". That said, one can maintain current management until the infection is gone. If it is bladder related, its presence may alter any result. We know they want to D/C as soon as possible, but UDS could be done as an OP and should not hinder the rehab or d/c process. Require an additional assistant for this "complex" case. If it is so vital and urgent, require the MD who ordered it to be there to help (per the CPT it IS under his/her direct supervision). They may then decide it is not that urgent. If all else fails, as (others have) suggested, cover everything with drapes, change gloves as necessary and above all, allow for sufficient time to perform the procedure carefully (don't allow them to rush you)."

SUMMARY: How to best handle patients with infections is a facility/practice based decision. The best references available are the policies and procedures of peer resources and the recommendations made by speakers at Urologic meetings, seminars and conferences. Remember the American Heart Association's Antibiotic Prophylaxis Guidelines for patients with valve disease or implants.

REFERENCES:
1. Lecture by George Webster, MB, (Professor of Urology and Director of Urodynamic Lab at Duke University, Raleigh, NC) at the Life-Tech Clinical Urodynamics Workshop (1980-2001).
2. Abrams P; Urodynamics, 2nd edition. Springer-Verlag London Ltd. 1997, p 144.
3. Nitti V; Practical Urodynamics. Philadelphia, WB Saunders Company. 1998, pp 244, 256.
4. Dajani A S, et al. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association. Circulation. 1997; 96:358-366 Available for download at htttp://circ.ahajournals.org/cgi/content/full/96/1/358#T5.
5. The American Academy of Orthopaedic Surgeons Bulletin, Volume 48, No. 1, February 2000. Available for download at http://www.aaos.org/wordhtml/bulletin/feb00/fline7.htm
6. American Academy of Orthopedic Surgeons & American Association of Orthopedic Surgeon Advisory Statement: Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements. Available for download at http://www.aaos.org/wordhtml/papers/advistmt/denta.htm.
7. MCW & FMLH Antibiotic Guide for Froedtert Hospital: AHA Prophylaxis Guidelines... Available for download at http://www.intmed.mcw.edu/drug/AHAguidelines.html.