Is It Really A UTI?
30 Sep Is It Really A UTI?
Urinary tract infections (UTIs) are the top reason for using antibiotics in nursing homes. But research suggests that nursing homes may be over-treating UTIs.
Key takeaways
Over-treatment of suspected UTIs is common in nursing homes
Consensus guidelines and best practices for diagnosing and treating UTIs exist
Reducing UTI incidence and over-treatment of asymptomatic bacteriuria is possible with both education and implementation of new clinical processes
Over-treatment is problematic for multiple reasons, particularly because it may lead to antimicrobial resistance. Antibiotics used to treat UTI’s can also interact with medications a person is already taking, cause side effects, and increased risk of infections.
A key reason that nursing home residents are over-treated with antibiotics is clinical confusion between asymptomatic bacteriuria vs. UTIs. Asymptomatic bacteriuria is common among nursing home residents; decades of research has shown that asymptomatic bacteriuria should not be treated.
A team of researchers led by David A Nace, M.D., MPH, of the University of Pittsburgh went through a detailed, multi-step process to create consensus guidelines for the diagnosis of non-catheter associated, uncomplicated UTIs in nursing home residents. The team created an algorithm to diagnose UTIs which includes the presence of dysuria (discomfort with urination) and one other symptom including the presence of gross hematuria (blood in the urine), suprapubic pain or urinary frequency/urgency. If a resident does not have dysuria, but does have both hematuria and suprapubic pain, then that is also likely a UTI. If a UTI, based on these criteria, is suspected then a urinalysis and culture should be obtained and antibiotic therapy started. Based on the results of the culture, the antibiotic should be adjusted to cover that specific bacteria.
Guidelines like these can be helpful in reducing unnecessary antibiotic use, but only if we create systems to apply them. A recent paper from Stephanie Hong, M.D., and Anshu Singh, CMD reviewed a multi-disciplinary approach to prevent and more appropriately diagnose true UTIs and decrease the use of antibiotics for asymptomatic bacteriuria. This quality improvement project was implemented in a 350-bed nursing facility in New York City.
The team was successful in lowering their overall incidence of UTIs as well as reducing the incidence of treated asymptomatic bacteriuria. They achieved this through nursing education competencies on aseptic foley insertion and perineal care and regular meetings to review appropriate use of foley catheters and voiding trials. Additionally, the facility adopted the “Active Monitoring for Urinary Symptoms” form adapted from the “Improving Outcomes of UTI (IOU) Study” toolkit and created an antibiotic order form given to providers to review the clinical reasoning for antibiotics in cases that did not meet criteria for UTI.
They found that this initiative, combining nursing education, implementation of clinical monitoring processes and tools, and prompting of clinicians to review specific cases achieved significant results. Following the intervention, they noted a reduction in overall monthly incidence of UTIs (0.95/1000 resident days vs. 1.45/1000 resident days) and reduction of asymptomatic bacteriuria treated with antibiotics (0.28/1000 resident days vs. 0.61/1000 resident days).
By implementing best practices in prevention and proper diagnosis, facilities can reduce overtreatment of UTIs, treat patients more appropriately in the comfort of their own room, and reduce avoidable hospitalizations.
References
Nace DA, Perera SK, Hanlon JT, et al. The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents. JAMDA 2018; 19(9):765-769.
Hong S, Singh A. A Multidisciplinary Approach to Improving Incidence Rates of UTI at a Post Acute and Long Term Care Setting. JAMDA 2022;23(3): B10-B11.
