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The purpose of this study was to determine whether pressing a dipstick into a pad within 2 hours of urine saturation detected pyuria as effectively as immersing a dipstick in a urine specimen. Sensitivity, specificity, and positive and negative predictive values indicated that results of the pad method were as effective as those of direct dipstick into clean-catch urine in detecting pyuria. In the elderly, sensitivity of the pad method was 100%, indicating this would be an effective method for initial assessment of pyuria.
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Urinary tract infections (UTIs) are the most common nosocomial infecion in the nursing home population (Beck-Sague et al., 1994; Farber, Brannen, Puntereri, & Brody, 1984; Jacobson & Strausbaugh, 1990). In older adults, bacteria in the urine (bacteriuria) without symptoms and WBCs in urine (pyuria) is considered benign and transient (Boscia, Abrutyn, Levison, Pitsakis, & Kaye, 1989; Gleckman, 1992). Determining symptomatic infection may be difficult because UTI symptoms may be chronic or atypical; they can also be masked by disease processes or medications (Abrutyn et al., 1996; Barkham, Martin, & Eykyn, 1996; Boscia et al., 1989; Yoshikawa, 1984).
The presence of pyuria, however, is an objective evaluation for a UTI. It is indicative of an infection and a need for further laboratory analysis (Norman, Yamamura, & Yoshikawa, 1986; Pfaller, Ringenberg, Rames, Hegeman, & Koontz, 1987; Stamm, 1983; Wigton et al., 1985). The level of pyuria may indicate an infection's virulence (Nicolle, 2001). Pyuria has also been associated with a lower long-term survival rate among the elderly (Heinamaki, Haavisto, Hakulinen, Mattila, & Rajala, 1986). Assessing pyuria in the elderly nursing home population, therefore, may be an important factor in identifying UTIs and improving outcomes in this population.
In the laboratory, the traditional setting of pyuria analysis, dipstick assessment of leukocyte esterase is used to initially screen urine specimens for this condition. "Leukocyte esterase, an enzyme present in WBCs, reacts with a reagent impregnated into the dipstick pad producing a blue color ..." (Pappas, 1991, p. 315). Unfortunately, the nursing home may not have laboratory facilities readily available (Ouslander, 1989). This may lead to a delay in diagnosis, a factor leading to poorer outcomes in the elderly.
There are other difficulties in assessing elderly individuals for UTIs. Urine specimens can be difficult to obtain, especially in the incontinent elderly. Urine in pads, however, may afford an alternative to clean-catch or mid-stream specimens for evaluating bacteriuria and pyuria. Studies of urine extracted from pads that do not contain gel have found bacteriuria detection similar to that of traditional urine specimens (Ahmad, Vickers, Campbell, Coulthard, & Pedler, 1991; Cohen et al., 1997; Vernon, Redfern, Pedlar, Lambert, & Coulthard, 1994). These studies also found reduced WBC counts compared to conventional urine specimens, leading to the hypothesis that pad material retains or breaks apart WBCs. Although WBCs may be affected by pad urine, leukocyte esterase may not. One study found that while WBCs may be retained in the pad and unavailable for microscopy, soluble leukocyte esterase from pad twine could be detected by a test strip (Macfarlane, Houghton, & Hughes, 1999).
Incontinence pads are often monitored every 2 hours. If leukocyte esterase results from a dipstick pressed into pad urine within a 2-hour time frame are similar to leukocyte results from a dipstick immersed in a urine specimen, the former would afford an easy, quick, and inexpensive alternative method for initially assessing pyuria. This method could be used at nursing homes and offer useful, objective data for the residents' clinical picture.
Purpose
The aim of this study was to compare leukocyte esterase results from a urine dipstick pressed into a pad within 2 hours of urine saturation to results obtained from a urine dipstick immersed in a clean-catch urine specimen for the purpose of detecting pyuria.
Method
Sample. A convenience sample was taken from clinic patients and staff and eldercare and nursing home residents who met the following criteria: they were at least 18 years old, able to give informed consent, and antibiotic-free 7 days before the study. No other history was taken. Most clinic patients included in the study had a urinalysis ordered. Reasons for the urinalysis included ruling out UTIs or post-UTI treatment, as well as a need to perform tests due to employment physicals, pregnancy, or diabetic screening. Informed consent was obtained. Procedures conformed to the University of North Dakota's Institutional Review Board's...
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