BACTERIURIA IN ELDERLY, CHRONICALLY ILL PATIENTS*

Evidence-based clinical pathways to manage urinary tract infections in long-term care facilities: a qualitative case study describing administrator and nursing staff views

OBJECTIVES

This article examines the views of nursing staff and administrators in long-term care facilities (LTCFs) regarding a clinical pathway for managing urinary tract infections (UTIs) in LTCF residents.

DESIGN

A qualitative (case study) design was used.

SETTING

Data were collected from 8 LTCFs in southern Ontario and 2 in Iowa enrolled in a larger randomized controlled trial of clinical pathway for managing UTIs in LTCF residents, conducted between September 2001 and March 2003. The clinical pathway, designed to more effectively identify, diagnose, and treat UTIs, and reduce inappropriate antibiotics use for asymptomatic UTIs, introduced 2 decision tools to determine when to order a urine culture and initiate antibiotic treatment for suspected UTIs.

PARTICIPANTS

We conducted 19 individual interviews with administrators and 10 focus groups with 52 nurses.

FINDINGS

Nurses generally thought that the pathways were well developed and easy to use, and administrators believed they were an important educational resource. Barriers to their use varied by group-initial lack of buy-in from nurses (medical directors), additional work (directors of nursing), and the need to change the protocol to exclude certain residents based on prior health conditions and/or pressure from physicians or families (nurses).

CONCLUSIONS

Both administrators and staff, once familiar with a new clinical protocol to improve UTI management in LTCFs, generally supported its use.

Optimizing antibiotics in residents of nursing homes: protocol of a randomized trial

BACKGROUND

Antibiotics are frequently prescribed for older adults who reside in long-term care facilities. A substantial proportion of antibiotic use in this setting is inappropriate. Antibiotics are often prescribed for asymptomatic bacteriuria, a condition for which randomized trials of antibiotic therapy indicate no benefit and in fact harm. This proposal describes a randomized trial of diagnostic and therapeutic algorithms to reduce the use of antibiotics in residents of long-term care facilities.

METHODS

In this on-going study, 22 nursing homes have been randomized to either use of algorithms (11 nursing homes) or to usual practise (11 nursing homes). The algorithms describe signs and symptoms for which it would be appropriate to send urine cultures or to prescribe antibiotics. The algorithms are introduced by inservicing nursing staff and by conducting one-on-one sessions for physicians using case-scenarios. The primary outcome of the study is courses of antibiotics per 1000 resident days. Secondary outcomes include urine cultures sent and antibiotic courses for urinary indications. Focus groups and semi-structured interviews with key informants will be used to assess the process of implementation and to identify key factors for sustainability.

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.

Bacteriuria in elderly institutionalized men

Over a two-year period we obtained monthly urine samples from all noncatheterized male residents on two geriatric wards to determine the occurrence and optimal management of bacteriuria in this population. Among 88 men the prevalence of bacteriuria was 33 per cent, and the incidence was 45 infections per 100 patients per year. Outcomes after single-dose therapy for asymptomatic bacteriuria with 43 courses of trimethoprim/sulfamethoxazole and 23 of tobramycin included 15 cures, 40 relapses, and 11 treatment failures. Thirty-six residents who had a relapse or in whom single-dose therapy failed were randomly assigned to receive therapy to eradicate bacteriuria or to receive no therapy. All 20 residents who received no therapy remained bacteriuric. The 16 residents who received therapy had fewer months of bacteriuria after randomization, but at the end of the study only one remained free of bacteriuria. Mortality and infectious morbidity after randomization were similar in the two groups. These data suggest that asymptomatic bacteriuria is common in elderly institutionalized men and that therapy is neither necessary nor effective.