Asymptomatic bacteriuria, urinary antibody, and survival in the institutionalized elderly

Asymptomatic Bacteriuria and Bacterial Interference

Asymptomatic bacteriuria is very common. In healthy women, asymptomatic bacteriuria increases with age, from <1% in newborns to 10% to 20% of women age 80 years, but is uncommon in men until after age 50 years. Individuals with underlying genitourinary abnormalities, including indwelling devices, may also have a high frequency of asymptomatic bacteriuria, irrespective of age or gender. The prevalence is very high in residents of long-term-care facilities, from 25% to 50% of women and 15% to 40% of men. Escherichia coli is the most frequent organism isolated, but a wide variety of other organisms may occur. Bacteriuria may be transient or persist for a prolonged period. Pregnant women with asymptomatic bacteriuria identified in early pregnancy and who are untreated have a risk of pyelonephritis later in pregnancy of 20% to 30%. Bacteremia is frequent in bacteriuric subjects following mucosal trauma with bleeding, with 5% to 10% of patients developing severe sepsis or septic shock. These two groups with clear evidence of negative outcomes should be screened for bacteriuria and appropriately treated. Asymptomatic bacteriuria in other populations is benign and screening and treatment are not indicated. Antimicrobial treatment has no benefits but is associated with negative outcomes including reinfection with antimicrobial resistant organisms and a short-term increased frequency of symptomatic infection post-treatment. The observation of increased symptomatic infection post-treatment, however, has led to active investigation of bacterial interference as a strategy to prevent symptomatic episodes in selected high risk patients.

Consequences of asymptomatic bacteriuria in the elderly

Asymptotic bacteriuria increases with advancing age for the ambulatory population. Men and women who are resident in long-term care facilities have an exceptionally high prevalence of bacteriuria. Despite this high prevalence and a high incidence of bacteriuria, urinary infection contributes little to morbidity and mortality in the elderly. While urinary infection is the most common source of bacteremic infection in the elderly, episodes of symptomatic urinary are infrequent relative to respiratory, gut, and skin infections. Substantial long-term complications of asymptomatic bacteriuria in the elderly have not been identified and there is no convincing evidence that asymptotic bacteriuria is associated with impaired survival. Further studies of the impact of asymptomatic bacteriuria in elderly populations to better define the association with symptomatic infection are needed.

Urinary tract infections in long-term-care facilities

Urinary tract infection (UTI) is the most common bacterial infection occurring in residents of long-term-care facilities. It is a frequent reason for antimicrobial administration, but antimicrobial use for treating UTIs is often inappropriate. Achieving optimal management of UTI in this population is problematic because of the very high prevalence of bacteriuria, evidence that the treatment of asymptomatic bacteriuria is not beneficial, and the clinical and microbiological imprecision in diagnosing symptomatic UTI. This position paper has been developed, using available evidence, to assist facilities and healthcare professionals in managing this common problem.

Asymptomatic bacteriuria in spinal cord patients and the elderly

The prevalence and incidence of symptomatic and asymptomatic bacteriuria will remain high for many years to come. Antimicrobial agents are necessary to treat symptomatic UTI because no natural methods have been shown to be effective. Treatment of ABU is not appropriate. There is growing resistance to antibiotics, biocides, and antiseptics and, simultaneously, a decreasing rate of introduction of new antibacterial agents; thus the problem of resistance is magnified and potentially complicates the management of patients with SCI and elderly persons. New options of managing health and of preventing ABU and UTI and the complications arising from these diseases must be investigated vigorously and urgently. In particular, further study of the role of bacterial biofilms, the normal microflora, the influence of diet and hygiene, and the importance of the host immune response in the process of urinary tract colonization and infection is relevant and necessary.

Infection control programs in long-term-care facilities: structure and process

Due to the rapid transfer of patients from the acute-care setting, the intensity of nursing care among residents in long-term-care facilities (LTCFs) has increased, transforming today's LTCFs into subacute healthcare facilities. Given the increased risk of infection among residents in LTCFs and the associated morbidity and mortality, evaluation of infection control programs in skilled nursing LTCFs is warranted. This article addresses the current structure and process of infection control programs in skilled nursing LTCFs.

Infection control programs in skilled nursing long-term care facilities: an assessment, 1995

BACKGROUND

In 1989 the Health Care Financing Administration mandated that long-term care facilities (LTCFs) maintain infection control programs; however, few data are available to guide the design of these programs. The purpose of this study was to assess the current status of infection control programs in LTCFs by using methodology adapted from Phase I of the Centers for Disease Control and Prevention Study on the Efficacy of Nosocomial Infection Control.

METHODS

A descriptive study of infection control programs in skilled nursing LTCFs was undertaken in a representative sample of 136 New England skilled nursing LTCFs that have >/=25 beds, with use of a self-report Infection Surveillance and Control Questionnaire.

RESULTS

Nearly all (98%) the LTCFs reported having personnel responsible for infection control, with a median of 8 hours per week spent on infection control activities. Ninety percent of these persons were registered nurses; 52% had formal training in infection control. Twenty-five percent of the respondents reported that their infection control program was either "inactive" or nonexistent in 1988, and 60% rated their programs as either "moderately active" (43%) or "very active" (17%) during that year. By 1994, most LTCFs (67%) rated themselves as "very active," and only 3% as inactive or nonexistent. The mean scores on the questionnaire's surveillance and control indices were 23 (out of a possible 30) and 47 (out of a possible 60), respectively, which indicates medium infection surveillance and control activity. On the basis of the data provided by 72% of the respondents (n = 98), a crude estimate of 13.97 infections per 1000 resident-days was calculated, which is a higher rate than previously reported for LTCFs.

CONCLUSIONS

Findings from the study indicate that it is feasible to use methodology adapted from Phase I of the Centers for Disease Control and Prevention Study on the Efficacy of Nosocomial Infection Control to assess infection control programs in LTCFs; however, further research into the efficacy of nosocomial infection control in skilled nursing LTCFs is needed.

Urinary antibody level and survival in bacteriuric institutionalized older subjects

OBJECTIVE

In a previous study, elevated urine antibody levels in institutionalized subjects with asymptomatic bacteriuria were associated with decreased survival. This study was undertaken to confirm the previous observation in a prospective study in a larger cohort and to explore selected other variables that may be associated with survival.

DESIGN

A prospective, 24-month, observational cohort study.

SETTING

Three large nursing homes in Winnipeg, Manitoba.

PARTICIPANTS

Permanent residents were identified by initial screening urine cultures and subjects with bacteriuria were enrolled. The median age of subjects was 76 years, 51% were women, and the median duration of residence before enrollment was 26 months. Subjects were highly functionally impaired.

MEASUREMENTS

Monthly urine specimens were collected for culture, leukocyte count, and urine antibody. Serum specimens for antibody to uropathogens and IL6 were obtained at enrollment and every 6 months. Anthroporphometric tests of nutritional status and functional and mental status were also measured every 6 months. Residents were stratified as having elevated or not elevated urine antibody, based on the initial urine specimen. The mean urine antibody for all of each subject's specimens was also calculated, and subjects were stratified as low, intermediate, or elevated urine antibody. Outcomes measured included mortality, infection and antibiotic use, and functional, mental, and nutritional decline.

RESULTS

Ninety-eight bacteriuric subjects were enrolled in the study; 34 (35%) had elevated urine antibody and 64 (65%) had not elevated urine antibody. The two groups did not differ in demographic features, co-morbidities, functional status, medication use, or infecting organisms. Survival was significantly (P < .001) poorer in the group with elevated urine antibody. At 24 months, 35% of subjects with an elevated urine antibody were alive compared with 75% with a low urine antibody level. This survival difference was consistent when the two groups were stratified by sex, institution, and presence of a chronic indwelling catheter. Subjects with elevated urine antibody had no evidence for accelerated functional or nutritional decline during the study period compared with the group with low urine antibody. These subjects did, however, have an increased incidence of episodes of symptomatic urinary infection and infections at non-urinary sites.

CONCLUSIONS

Older, bacteriuric, institutionalized subjects with elevated urine antibody had decreased survival rates compared with subjects with lower urine antibody levels. There is no clinical evidence to support accelerated decline caused by chronic infection to explain this observation. Urine antibody may be a marker for immune dysregulation, which precedes death in older impaired subjects.

Asymptomatic bacteriuria in the elderly

Asymptomatic bacteriuria is frequent in elderly, populations. The major contributing factors are selected physiologic aging changes and comorbid illnesses, which occur with increased frequency in these populations. There is little short-term or long-term adverse outcomes attributable to this high prevalence and incidence of asymptomatic bacteriuria and no evidence for an impact on survival. A number of important questions relating to this problem have yet to be resolved. First, further studies in the noninstitutionalized population are needed to characterize the incidence of asymptomatic infection and its relationship to symptomatic infection. In the institutionalized population, studies to refine the clinical diagnosis of symptomatic urinary infection occurring in a population with such a high prevalence of asymptomatic bacteriuria are needed. In addition, further assessment of the impact of the reservoir of asymptomatic bacteriuria in elderly institutionalized subjects as a contributor to the problem of antimicrobial resistance in the institutionalized population should be a priority.

Nursing management of elderly patients with asymptomatic bacteriuria

Nursing management of elderly patients with asymptomatic bacteriuria encompasses an array of basic and complex nursing observations and interventions to eliminate or reduce those risk factors that contribute to persistent bacteriuria and to identify warning signs of an impending inflammatory response. Selected risk factors, the prevalence of bacteriuria in the elderly population, and nursing management of clients with asymptomatic bacteriuria are discussed.

Management of complicated urinary tract infection in older patients

Urinary tract infection (UTI) in older persons is a common medical problem that is seen in both the ambulatory and institutional settings. It affects older women and men with a gender prevalence ratio of 2:1, respectively. UTI in older persons can be a complex problem in terms of the approach to diagnosis, treatment, and prevention. In this report the discussion will begin with the unique aspects of UTI in older persons, particularly as they relate to UTI in the younger, general population. The remaining discussion will then focus on three complicated clinical circumstances and conditions of UTI in the geriatric population: non-catheter recurrent UTI, asymptomatic bacteriuria, and catheter-related bacteriuria and UTI.

Medical care of nursing home residents

OBJECTIVE

To present an overview of the special challenges of providing medical care for nursing home residents.

DESIGN

After researching the current medical literature, we summarized information on nursing home demographics, government regulations, and specific care issues for medical practice in nursing homes.

RESULTS

Almost 2 million Americans currently live in more than 20,000 nursing homes nationwide, and these nursing home residents are increasingly older and more frail than in the past. Most nursing home residents receive multiple prescription medications, and many are cognitively and functionally impaired. Nursing home-acquired infections are a frequent occurrence, as are falls and fall-related injuries. Recent federal laws have had a major effect on medical care in the nursing home and have made physicians more accountable for the care provided. The use of physical restraints and psychotropic drugs has been severely restricted.

CONCLUSION

The medical care of nursing home residents presents many challenges to primary-care physicians. Nevertheless, nursing home residents are among those patients in greatest need of competent, compassionate care. Despite numerous disincentives, provision of medical care for nursing home residents can be gratifying.