Symptomatic urinary tract infection in nursing home residents

Antibiotic management of urinary tract infections in the post-antibiotic era: a narrative review highlighting diagnostic and antimicrobial stewardship

BACKGROUND

As one of the most common indications for antimicrobial prescription in the community, the management of urinary tract infections (UTIs) is both complicated by, and a driver of, antimicrobial resistance.

OBJECTIVES

To highlight the key clinical decisions involved in the diagnosis and treatment of UTIs in adult women, focusing on clinical effectiveness and both diagnostic and antimicrobial stewardship as we approach the post-antimicrobial era.

SOURCES

Literature reviewed via directed PubMed searches and manual searching of the reference list for included studies to identify key references to respond to the objectives. A strict time limit was not applied. We prioritised recent publications, randomised trials, and systematic reviews (with or without meta-analyses) where available. Searches were limited to English language articles. A formal quality assessment was not performed; however, the strengths and limitations of each paper were reviewed by the authors throughout the preparation of this manuscript.

CONTENT

We discuss the management of UTIs in ambulatory adult women, with particular focus on uncomplicated infections. We address the diagnosis of UTIs, including the following: definition and categorisation; bedside assessments and point-of-care tests; and the indications for, and use of, laboratory tests. We then discuss the treatment of UTIs, including the following: indications for treatment, antimicrobial sparing approaches, key considerations when selecting a specific antimicrobial agent, specific treatment scenarios, and duration of treatment. We finally outline emerging areas of interest in this field.

IMPLICATIONS

The steady increase in antimicrobial resistance among common uropathogens has had a substantial affect on the management of UTIs. Regarding both diagnosis and treatment, the clinician must consider both the patient (clinical effectiveness and adverse effects, including collateral damage) and the community more broadly (population-level antimicrobial selection pressure).

Decision Tools and Studies to Improve the Diagnosis of Urinary Tract Infection in Nursing Home Residents: A Narrative Review

The overdiagnosis of urinary tract infection (UTI) in nursing home residents that results in unnecessary antibiotic treatment has been recognized for more than 2 decades. This has resulted in the publication of several decision tools for the diagnosis of UTI in nursing home residents. Given all of the decision tools available, how does one decide on the approach to improve the diagnosis of UTI in nursing home residents in the context of an antimicrobial stewardship program? To address this question, this paper reviews: (a) published decision tools for the diagnosis of UTI in nursing home residents; (b) randomized controlled trials to improve the diagnosis of UTI in nursing home residents; and (c) non-randomized studies to improve the diagnosis of UTI in nursing home residents. Review of published decision tools indicates that the diagnosis of UTI is based on the presence of urinary tract signs and symptoms. However, there is considerable variation in the diagnostic criteria among the decision tools and there is no consensus as to the best clinical criteria for the diagnosis of UTI in nursing home residents. Review of four randomized controlled trials of interventions to improve the diagnosis of UTI in nursing home residents found that different interventions and outcome measures of varying complexity were utilized. Although randomized controlled trials were, to some extent, successful, it was not clear in any trial if one or more components of an intervention contributed the most to the success and there was no evidence that an intervention was feasible or sustainable after a trial was completed. Review of non-randomized trials to improve the diagnosis of UTI in nursing home residents all had methodologic limitations that make interpretation problematic. Randomized controlled trials and non-randomized studies all focused on the process before an antibiotic is prescribed. An alternative approach that focuses on assessment of the post-prescription process (antibiotic time-out protocol) is reviewed; initial studies of this protocol were inconclusive because of design limitations and additional studies are required. Regardless of what interventions are utilized, there must be provider and nursing staff commitment and motivation to improve the management of residents with suspected UTI and methods to achieve improvement must be demonstrated to be feasible and sustainable given the resources available in nursing homes.

The Emergency Department Diagnosis and Management of Urinary Tract Infection

Urinary tract infection (UTI) is a common infection seen in the emergency department. The spectrum of UTI includes simple versus complicated infection and lower versus upper UTI. No one history or examination finding is definitive for diagnosis. Testing often includes urinalysis and/or urine dipstick, and several pitfalls may occur in interpretation. Urine cultures should be obtained in complicated or upper UTIs but not simple and lower tract UTIs, unless a patient is pregnant. Imaging often is not required. Most patients with simple cystitis and pyelonephritis are treated as outpatients. A variety of potentially dangerous conditions may mimic UTI and pyelonephritis.

The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents

Objectives:

To identify a set of signs and symptoms most likely to indicate uncomplicated cystitis in non-catheterized nursing home residents ≥ 65 years of age using consensus based methods informed by a literature review.

Design:

Literature review and modified Delphi survey with strict inclusion criteria.

Setting and Participants:

Expert panel of 20 physicians certified in geriatric medicine and / or medical direction, actively practicing in post-acute and long-term care settings.

Methods:

The authors performed a literature review to produce a comprehensive list of potential signs and symptoms of presumptive uncomplicated cystitis, including non-specific “quality control” items deemed unlikely to indicate uncomplicated cystitis. The expert panel rated their agreement for each sign/symptom using a 5-point Likert scale (1= strongly disagree to 5= strongly agree). Agreed upon signs and symptoms were summarized using a diagnostic algorithm for easy clinical use.

Results:

The literature review identified 16 signs and symptoms that were evaluated in three Delphi survey rounds. The response rate was 100% for round one and 95% for the second two rounds. Consensus agreement for inclusion was achieved for dysuria on round one with exclusion of the three quality controls, and “offensive smelling urine”. Consensus in the second round was reached for including 4 additional items (gross hematuria, suprapubic pain, urinary frequency, and urinary urgency). Round three evaluated dysuria alone and combinations of symptoms. Consensus that dysuria alone is sufficient for diagnosis of cystitis was not reached.

Conclusions/Implications

The panel identified 5 signs and symptoms likely indicative of uncomplicated cystitis in nursing home residents and developed a diagnostic algorithm that can be used to promote antibiotic stewardship in nursing homes. Given similarities in populations, the algorithm may also be applicable to the older adult and the broader post-acute / long-term care populations.

Top Ten Myths Regarding the Diagnosis and Treatment of Urinary Tract Infections

BACKGROUND

Urinary tract infections (UTI) are the most common type of infection in the United States. A Centers for Disease Control and Prevention report in March 2014 regarding antibiotic use in hospitals reported "UTI" treatment was avoidable at least 39% of the time. The accurate diagnosis and treatment of UTI plays an important role in cost-effective medical care and appropriate antimicrobial utilization.

OBJECTIVE

We summarize the most common misperceptions of UTI that result in extraneous testing and excessive antimicrobial treatment. We present 10 myths associated with the diagnosis and treatment of UTI and succinctly review the literature pertaining to each myth. We explore the myths associated with pyuria, asymptomatic bacteriuria, candiduria, and the elderly and catheterized patients. We attempt to give guidance for clinicians facing these clinical scenarios.

DISCUSSION

From our ambulatory, emergency department, and hospital experiences, patients often have urine cultures ordered without an appropriate indication, or receive unnecessary antibiotic therapy due to over-interpretation of the urinalysis.

CONCLUSIONS

Asymptomatic bacteriuria is common in all age groups and is frequently over-treated. A UTI diagnosis should be based on a combination of clinical symptoms with supportive laboratory information. This review will assist providers in navigating common pitfalls in the diagnosis of UTI.

Urinary tract infection diagnosis and response to therapy in long-term care: A prospective observational study

BACKGROUND

The prevalence of asymptomatic bacteriuria among residents of long-term care (LTC) facilities is high, and is a source of inappropriate antibiotic prescription.

OBJECTIVE

To establish symptoms and signs associated with a positive urine culture, and to determine whether antibiotic therapy is associated with functional improvement.

METHODS

A total of 101 LTC patients were prospectively observed after submission of urine for culture.

RESULTS

The culture positivity rate was consistent with the expected asymptomatic bacteriuria rate. Change in mental status and male sex were associated with culture positivity. Treatment decisions were not consistent with culture results. Treatment did not lead to improvement in activities of daily living scores at two days or seven days.

DISCUSSION

Significant growth cannot be well predicted based on clinical variables; thus, the decision to submit urine is somewhat arbitrary. Because urine culture testing and treatment does not lead to functional improvement, restricting access to the test may be reasonable.

CONCLUSION

Urine culture testing in LTC facilities does not lead to functional improvement.

The Role of the Nurse Practitioner and Asymptomatic Urinary Treatments

Asymptomatic urinary tract infections (aUTIs) are common among older adults in long-term care facilities (LTCFs) and studies have shown that they are inappropriately treated with antibiotics. We retrospectively characterized treatment strategies among 89 cases of aUTIs before and after a long-term facility hired a full-time nurse practitioner (NP). We found that residents with aUTIs were prescribed significantly more supportive treatment strategies after hiring an NP. However, there was no significant drop in the rate of inappropriate antibiotic treatments for aUTIs after hiring an NP.

Interleukin-6 concentrations in the urine and dipstick analyses were related to bacteriuria but not symptoms in the elderly: a cross sectional study of 421 nursing home residents

Background

Up to half the residents of nursing homes for the elderly have asymptomatic bacteriuria (ABU), which should not be treated with antibiotics. A complementary test to discriminate between symptomatic urinary tract infections (UTI) and ABU is needed, as diagnostic uncertainty is likely to generate significant antibiotic overtreatment. Previous studies indicate that Interleukin-6 (IL-6) in the urine might be suitable as such a test. The aim of this study was to investigate the association between laboratory findings of bacteriuria, IL-6 in the urine, dipstick urinalysis and newly onset symptoms among residents of nursing homes.

Methods

In this cross sectional study, voided urine specimens for culture, urine dipstick and IL-6 analyses were collected from all residents capable of providing a voided urine sample, regardless of the presence of symptoms. Urine specimens and symptom forms were provided from 421 residents of 22 nursing homes. The following new or increased nonspecific symptoms occurring during the previous month were registered; fatigue, restlessness, confusion, aggressiveness, loss of appetite, frequent falls and not being herself/himself, as well as symptoms from the urinary tract; dysuria, urinary urgency and frequency.

Results

Recent onset of nonspecific symptoms was common among elderly residents of nursing homes (85/421). Urine cultures were positive in 32% (135/421), Escherichia coli was by far the most common bacterial finding. Residents without nonspecific symptoms had positive urine cultures as often as those with nonspecific symptoms with a duration of up to one month. Residents with positive urine cultures had higher concentrations of IL-6 in the urine (p < 0.001). However, among residents with positive urine cultures there were no differences in IL-6 concentrations or dipstick findings between those with or without nonspecific symptoms.

Conclusions

Nonspecific symptoms among elderly residents of nursing homes are unlikely to be caused by bacteria in the urine. This study could not establish any clinical value of using dipstick urinalysis or IL-6 in the urine to verify if bacteriuria was linked to nonspecific symptoms.

Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria

(See the commentary by Moro, on pages 978-980 .) Infection surveillance definitions for long-term care facilities (ie, the McGeer Criteria) have not been updated since 1991. An expert consensus panel modified these definitions on the basis of a structured review of the literature. Significant changes were made to the criteria defining urinary tract and respiratory tract infections. New definitions were added for norovirus gastroenteritis and Clostridum difficile infections.