Clinical features to identify urinary tract infection in nursing home residents: a cohort study

Antimicrobial Agent Use for Urinary Tract Infection in Long-Term Care Facilities in Spain: Results from a Retrospective Analytical Cohort Analysis

Urinary tract infections (UTIs) are highly prevalent in long-term care facilities, constituting the most common infection in this setting. Our research focuses on analyzing clinical characteristics and antimicrobial prescriptions for UTIs in residents across nursing homes (NH) in Spain. This is a retrospective analytical cohort analysis using a multifaceted approach based on the normalization process theory to improve healthcare quality provided by nursing staff in 34 NHs in Spain. In this study, we present the results of the first audit including 719 UTI cases collected between February and April 2023, with an average age of 85.5 years and 74.5% being women. Cystitis and pyelonephritis presented distinct symptom patterns. Notably, 6% of asymptomatic bacteriuria cases were treated. The prevalence of dipstick usage was 83%, and that of urine culture was only 16%, raising concerns about overreliance, including in the 46 asymptomatic cases, leading to potential overdiagnosis and antibiotic overtreatment. Improved diagnostic criteria and personalized strategies are crucial for UTI management in NHs, emphasizing the need for personalized guidelines on the management of UTIs to mitigate indiscriminate antibiotic use in asymptomatic cases.

Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents

One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use 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).

Bacteriuria in older adults triggers confusion in healthcare providers: A mindful pause to treat the worry

The evidence base for refraining from screening for or treating asymptomatic bacteriuria (ASB) in older adults is strong, but both practices remain prevalent. Clinical confusion over how to respond to a change from baseline, when to order a urinalysis and urine culture, and what to do with a positive urine culture fuels unnecessary antibiotic use for ASB. If the provider can take a mindful pause to apply evidenced-based assessment tools, the resulting increased clarity in how to manage the situation can reduce overtreatment of ASB.

Management of urinary tract infections in the era of antimicrobial resistance

Urinary tract infections (UTIs) are among the most common infections globally, imposing a substantial personal and economic burden on individuals and health resources. Despite international health concerns and sustained public awareness campaigns about the emergence of resistant microorganisms through the inappropriate therapeutic use of antimicrobial agents, the problem of antimicrobial resistance (AMR) is worsening, and AMR in UTIs represents a critical global healthcare issue. This narrative review summarizes evidence-based scientific material, recommendations from the current medical literature, and the latest clinical guidelines on antibiotic and antibiotic-sparing strategies for managing urological infections, including practical approaches to improve the management of patients with acute and recurrent UTIs (rUTIs) in routine clinical practice. Novel emerging therapies and prophylaxis options are described as potential alternatives to overcome the abuse and overuse of antibiotics and the practical application of the guideline recommendations and issues relating to best practice in managing UTIs.

Effect of inpatient antibiotic treatment among older adults with delirium found with a positive urinalysis: a health record review

BACKGROUND

Among older adults with delirium and positive urinalysis, antibiotic treatment for urinary tract infection is common practice, but unsupported by literature or guidelines. We sought to: i) determine the rate of antibiotic treatment and the proportion of asymptomatic patients (other than delirium) in this patient population, and ii) examine the effect of antibiotic treatment on delirium resolution and adverse outcomes.

METHODS

A health record review was conducted at a tertiary academic centre from January to December 2020. Inclusion criteria were age ≥ 65, positive delirium screening assessment, positive urinalysis, and admission to general medical units. Outcomes included rates of antibiotic treatment, delirium on day 7 of admission, and 30-day adverse outcomes. We compared delirium and adverse outcome rates in antibiotic-treated vs. non-treated groups. We conducted subgroup analyses among asymptomatic patients.

RESULTS

We included 150 patients (57% female, mean age 85.4 years). Antibiotics were given to 86%. The asymptomatic subgroup (delirium without urinary symptoms or fever) comprised 38% and antibiotic treatment rate in this subgroup was 68%. There was no significant difference in delirium rate on day 7 between antibiotic-treated vs. non-treated groups, (entire cohort RR 0.94 [0.41-2.16] and asymptomatic subgroup RR 0.69 [0.22-2.15]) or in 30-day adverse outcomes.

CONCLUSIONS

Older adults with delirium and positive urinalysis in general medical inpatient units were frequently treated with antibiotics - often despite the absence of urinary or other infectious symptoms. We failed to find evidence that antibiotic treatment in this population is associated with delirium resolution on day 7 of admission.

17β-estradiol ameliorates delirium-like phenotypes in a murine model of urinary tract infection

Urinary tract infections (UTIs) are common and frequently precipitate delirium-like states. Advanced age coincident with the postmenopausal period is a risk factor for delirium following UTIs. We previously demonstrated a pathological role for interleukin-6 (IL-6) in mediating delirium-like phenotypes in a murine model of UTI. Estrogen has been implicated in reducing peripheral IL-6 expression, but it is unknown whether the increased susceptibility of postmenopausal females to developing delirium concomitant with UTIs reflects diminished effects of circulating estrogen. Here, we tested this hypothesis in a mouse model of UTI. Female C57BL/6J mice were oophorectomized, UTIs induced by transurethral inoculation of E. coli, and treated with 17β-estradiol. Delirium-like behaviors were evaluated prior to and following UTI and 17β-estradiol treatment. Compared to controls, mice treated with 17β-estradiol had less neuronal injury, improved delirium-like behaviors, and less plasma and frontal cortex IL-6. In vitro studies further showed that 17β-estradiol may also directly mediate neuronal protection, suggesting pleiotropic mechanisms of 17β-estradiol-mediated neuroprotection. In summary, we demonstrate a beneficial role for 17β-estradiol in ameliorating acute UTI-induced structural and functional delirium-like phenotypes. These findings provide pre-clinical justification for 17β-estradiol as a therapeutic target to ameliorate delirium following UTI.

Urinary Tract Infections Impair Adult Hippocampal Neurogenesis

Simple Summary

Urinary tract infections are associated with features of cognitive decline and memory deficits, where the underlying correlation or mechanism is still not clear. In this study, we investigate the effect of urinary tract infections on cognitive functions in rodents and whether it is associated with adult hippocampal neurogenesis, a process that is detrimental for memory formation. We have shown that urinary tract infection affects the time spent exploring a novel arm in the Y-maze test. This was accompanied with a decrease in the proliferation of neural stem cells at an early time point post infection and a persistent decrease in neurogenesis at a later time point (34 days). We also detected decreased levels of neurotrophic factors important for neurogenesis and an elevated expression of interleukin 1β in the hippocampus. Treatment with either anti-inflammatory drugs or anti-biotics does not recover proliferation of neural stem cells. Here, we present hippocampal neurogenesis as a possible contributor to cognitive changes associated with urinary tract infections. Given the significant increase in urinary tract infection occurrence, it is important to address some of the detrimental effects that such an infection can have at the level of the brain.

Abstract

Previous studies have suggested a link between urinary tract infections (UTIs) and cognitive impairment. One possible contributing factor for UTI-induced cognitive changes that has not yet been investigated is a potential alteration in hippocampal neurogenesis. In this study, we aim to investigate the effect of UTI on brain plasticity by specifically examining alterations in neurogenesis. Adult male Sprague Dawley rats received an intra-urethral injection of an Escherichia coli (E. coli) clinical isolate (10⁸ CFU/mL). We found that rats with a UTI (CFU/mL ≥ 10⁵) had reduced proliferation of neural stem cells (NSCs) at an early time point post infection (day 4) and neurogenesis at a later time point (day 34). This was associated with the decreased expression in mRNA of BDNF, NGF, and FGF2, and elevated expression of IL-1β in the hippocampus at 6 h post infection, but with no changes in optical intensity of the microglia and astrocytes. In addition, infected rats spent less time exploring a novel arm in the Y-maze test. Treatment with an anti-inflammatory drug did not revert the effect on NSCs, while treatment with antibiotics further decreased the basal level of their proliferation. This study presents novel findings on the impact of urinary tract infections on hippocampal neurogenesis that could be correlated with cognitive impairment.

Decisions on antibiotic prescribing for suspected urinary tract infections in frail older adults: a qualitative study in four European countries

Background

a suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Frequently, antibiotics are prescribed unnecessarily. To increase appropriate antibiotic use for UTIs through antibiotic stewardship interventions, we need to thoroughly understand the factors that contribute to these prescribing decisions.

Objectives

(1) to obtain insight into factors contributing to antibiotic prescribing for suspected UTIs in frail older adults. (2) To develop an overarching model integrating these factors to guide the development of antibiotic stewardship interventions for UTIs in frail older adults.

Methods

we conducted an exploratory qualitative study with 61 semi-structured interviews in older adult care settings in Poland, the Netherlands, Norway and Sweden. We interviewed physicians, nursing staff, patients and informal caregivers.

Results

participants described a chain of decisions by patients, caregivers and/or nursing staff preceding the ultimate decision to prescribe antibiotics by the physician. We identified five themes of influence: (1) the clinical situation and its complexity within the frail older patient, (2) diagnostic factors, such as asymptomatic bacteriuria, (3) knowledge (gaps) and attitude, (4) communication: interprofessional, and with patients and relatives and (5) context and organisation of care, including factors such as availability of antibiotics (over the counter), antibiotic stewardship efforts and factors concerning out-of-hours care.

Conclusions

decision-making on suspected UTIs in frail older adults is a complex, multifactorial process. Due to the diverse international setting and stakeholder variety, we were able to provide a comprehensive overview of factors to guide the development of antibiotic stewardship interventions.

Urinary Tract Infection in Parkinson’s Disease

Urinary tract infection (UTI) is a common precipitant of acute neurological deterioration in patients with Parkinson’s disease (PD) and a leading cause of delirium, functional decline, falls, and hospitalization. Various clinical features of PD including autonomic dysfunction and altered urodynamics, frailty and cognitive impairment, and the need for bladder catheterization contribute to an increased risk of UTI. Sepsis due to UTI is a feared consequence of untreated or undertreated UTI and a leading cause of morbidity in PD. Emerging research suggests that immune-mediated brain injury may underlie the pathogenesis of UTI-induced deterioration of PD symptoms. Existing strategies to prevent UTI in patients with PD include use of topical estrogen, prophylactic supplements, antibiotic bladder irrigation, clean catheterization techniques, and prophylactic oral antibiotics, while bacterial interference and vaccines/immunostimulants directed against common UTI pathogens are potentially emerging strategies that are currently under investigation. Future research is needed to mitigate the deleterious effects of UTI in PD.

Interleukin-6 mediates delirium-like phenotypes in a murine model of urinary tract infection

Background

Urinary tract infection (UTI) is frequently implicated as a precipitant of delirium, which refers to an acute confusional state that is associated with high mortality, increased length of stay, and long-term cognitive decline. The pathogenesis of delirium is thought to involve cytokine-mediated neuronal dysfunction of the frontal cortex and hippocampus. We hypothesized that systemic IL-6 inhibition would mitigate delirium-like phenotypes in a mouse model of UTI.

Methods

C57/BL6 mice were randomized to either: (1) non-UTI control, (2) UTI, and (3) UTI + anti-IL-6 antibody. UTI was induced by transurethral inoculation of 1 × 10⁸Escherichia coli. Frontal cortex and hippocampus-mediated behaviors were evaluated using functional testing and corresponding structural changes were evaluated via quantification of neuronal cleaved caspase-3 (CC3) by immunohistochemistry and western blot. IL-6 in the brain and plasma were evaluated using immunohistochemistry, ELISA, and RT-PCR.

Results

Compared to non-UTI control mice, mice with UTI demonstrated significantly greater impairments in frontal and hippocampus-mediated behaviors, specifically increased thigmotaxis in Open Field (p < 0.05) and reduced spontaneous alternations in Y-maze (p < 0.01), while treatment of UTI mice with systemic anti-IL-6 fully reversed these functional impairments. These behavioral impairments correlated with frontal and hippocampal neuronal CC3 changes, with significantly increased frontal and hippocampal CC3 in UTI mice compared to non-UTI controls (p < 0.0001), and full reversal of UTI-induced CC3 neuronal changes following treatment with systemic anti-IL-6 antibody (p < 0.0001). Plasma IL-6 was significantly elevated in UTI mice compared to non-UTI controls (p < 0.01) and there were positive and significant correlations between plasma IL-6 and frontal CC3 (r² = 0.5087/p = 0.0028) and frontal IL-6 and CC3 (r² = 0.2653, p < 0.0001).

Conclusions

These data provide evidence for a role for IL-6 in mediating delirium-like phenotypes in a mouse model of UTI. These findings provide pre-clinical justification for clinical investigations of IL-6 inhibitors to treat UTI-induced delirium.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-021-02304-x.

Prospective assessment of catheter-associated bacteriuria clinical presentation, epidemiology, and colonization dynamics in nursing home residents

BACKGROUND

Catheterization facilitates continuous bacteriuria, for which the clinical significance remains unclear. This study aimed to determine the clinical presentation, epidemiology, and dynamics of bacteriuria in a cohort of long-term catheterized nursing home residents.

METHODS

Prospective urine culture, urinalysis, chart review, and assessment of signs and symptoms of infection were performed weekly for 19 study participants over 7 months. All bacteria ≥ 1 × 10³ cfu/mL were cultured, isolated, identified, and tested for susceptibility to select antimicrobials.

RESULTS

In total, 226 of the 234 urine samples were polymicrobial (97%), with an average of 4.7 isolates per weekly specimen. A total of 228 urine samples (97%) exhibited ≥ 1 × 10⁶ CFU/mL, 220 (94%) exhibited abnormal urinalysis, 126 (54%) were associated with at least 1 possible sign or symptom of infection, and 82 (35%) would potentially meet a standardized definition of catheter-associated urinary tract infection (CAUTI), but only 3 had a caregiver diagnosis of CAUTI. Bacterial isolates (286; 30%) were resistant to a tested antimicrobial agent, and bacteriuria composition was remarkably stable despite a combined total of 54 catheter changes and 23 weeks of antimicrobial use.

CONCLUSION

Bacteriuria composition was largely polymicrobial, including persistent colonization by organisms previously considered to be urine culture contaminants. Neither antimicrobial use nor catheter changes sterilized the urine, at most resulting in transient reductions in bacterial burden followed by new acquisition of resistant isolates. Thus, this patient population exhibits a high prevalence of bacteriuria coupled with potential indicators of infection, necessitating further exploration to identify sensitive markers of true infection.

FUNDING

This work was supported by the NIH (R00 DK105205, R01 DK123158, UL1 TR001412).

Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA's Infection Advisory Subcommittee

The diagnosis and management of urinary tract infections (UTIs) among residents of post-acute and long-term care (PALTC) settings remains challenging. Nonspecific symptoms, complex medical conditions, insufficient awareness of diagnostic criteria, and unnecessary urine studies all contribute to the inappropriate diagnosis and treatment of UTIs in PALTC residents. In 2017, the Infection Advisory Subcommittee at AMDA-The Society for Post-Acute and Long-Term Care Medicine convened a workgroup comprised of experts in geriatrics and infectious diseases to review recent literature regarding UTIs in the PALTC population. The workgroup used evidence as well as their collective clinical expertise to develop this consensus statement with the goal of providing comprehensive guidance on the diagnosis, treatment, and prevention of UTIs in PALTC residents. The recommendations acknowledge limitations inherent to providing medical care for frail older adults, practicing within a resource limited setting, and prevention strategies tailored to PALTC populations. In addition, the consensus statement encourages integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and by prescribing clinicians as they care for residents with a suspected UTI.

Bloodstream infections in the elderly: what is the real goal?

Bloodstream infections (BSI) represent a serious bacterial infection with substantial morbidity and mortality. Population-based studies demonstrate an increased incidence, especially among elderly patients. Controversy exists regarding whether presentation of BSI are different in older patients compared to younger patients; our narrative review of the literature suggests that BSI in elderly patients would probably include one or more of the traditional symptoms/signs of fever, severe sepsis or septic shock, acute kidney injury, and/or leukocytosis. Sources of BSI in older adults are most commonly the urinary tract (more so than in younger adults) and the respiratory tract. Gram-negative bacteria are the most common isolates in the old (~ 40-60% of BSI); isolates from the elderly patient population show higher antibiotic resistance rates, with long-term care facilities serving as reservoirs for multidrug-resistant bacteria. BSI entail significantly higher rates of mortality in older age, both short and long term. Some of the risk factors for mortality are modifiable, such as the appropriateness of empirical antibiotic therapy and nosocomial acquisition of infection. Health-related quality of life issues regarding the elderly patient with BSI are not well addressed in the literature. Utilization of comprehensive geriatric assessment and comprehensive geriatric discharge planning need to be investigated further in this setting and might serve as key for improved results in this population. In this review, we address all these aspects of BSI in old patients with emphasis on future goals for management and research.

Reliability of nonlocalizing signs and symptoms as indicators of the presence of infection in nursing-home residents

Antibiotics are among the most common medications prescribed in nursing homes. The annual prevalence of antibiotic use in residents of nursing homes ranges from 47% to 79%, and more than half of antibiotic courses initiated in nursing-home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration). Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile infection (CDI), adverse drug effects, drug-drug interactions, and antimicrobial resistance. In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes.

Diapers as Promising Alternative Collection Method for Urine Specimens in Nursing Home Residents: A Noninferiority Study

OBJECTIVE

There is unmet need for an easy, noninvasive urine collection method to diagnose urinary tract infections (UTIs) in nursing home residents suffering from urinary incontinence or cognitive impairments. UTIs are highly prevalent in nursing home residents, and urine specimen collection can be difficult. The objective of this study was to assess if urine specimens collected from super-absorbing incontinence pads (adult diapers) are a reliable collection method for UTI diagnosis.

DESIGN

This was a paired noninferiority laboratory study, in which pairing refers to UTI diagnostics performed directly using clinical urine specimens (reference specimen) and indirectly using urine extracted from diapers (diaper specimen).

SETTING AND PARTICIPANTS

In this study, remnants of 250 clinical urine specimens were used to assess noninferiority in diagnosing UTIs, based on a 1-sided type I error of 2.5%, a power of 90%, and a noninferiority margin of 15%.

METHODS

Urine specimens were poured on super-absorbing disposable adult diapers and extracted after 3 hours, to use for dipstick urinalysis and bacterial culture. UTIs were defined as presence of leukocytes and a positive bacterial culture. Noninferiority was assessed by calculating a Wald-type test statistic.

RESULTS

Noninferiority was established for diagnosing UTIs in diaper specimens, and for each of its components (dipstick leukocyte detection and bacterial culture positivity). Positive bacterial cultures were found in 72 (29.0%) diaper specimens compared with 65 (26.2%) reference specimens (difference -2.8%, 97.5% CI -7.1% to 1.5%). Leukocytes were present in 162 (64.8%) diaper specimens, compared with 175 (70.0%) reference specimens (difference -5.7%, 97.5% CI: -10.6% to -0.7%).

CONCLUSION AND IMPLICATIONS

Our results on diagnosing UTIs, by dipstick analysis and bacterial cultures, using super-absorbing adult diapers are promising. Before translation into clinical practice, further studies are needed to evaluate the risk of bacterial contamination by wearing adult diapers, possibly resulting in overdiagnosis of UTI.

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.

Registered Nurses' Decisions Around Referral of Residents With Urinary Tract Infections: A Retrospective Cohort Study

Background

Referral of residents with urinary tract infections (UTIs) in residential aged care facilities (RACFs) to hospital are common. However, there is limited information on what influences Registered Nurses’ (RN) decision-making process.

Aim

To investigate resident factors that influence RN’s decisions to escalate care.

Design

A retrospective cohort approach audited electronic clinical records of residents with UTIs.

Methods

Data were extracted from the electronic database and analyzed using descriptive and regression analysis. Approval was obtained from both the RACFs and University Human Research Ethics Committee.

Results

There was a higher likelihood of being referred to hospital if residents were female, had had a past fall, had related comorbidity, or had abnormal vital signs. However, being older and having a urinary catheter were protective factors for referral by the RN.

Conclusion

Referral of residents with UTIs by RNs to hospital is common in RACFs. Resident characteristics such as abnormal vital signs, past falls, and presence of comorbidity influence referrals by RNs. Nurse Practitioners dedicated to the RACFs could complement the role of a general practitioner. UTI-specific escalation protocols can assist RNs to make decisions about referrals. RNs’ related risk factors also need to be examined to understand other influencing factors.

Antibiotic prescribing and non-prescribing in nursing home residents with signs and symptoms ascribed to urinary tract infection (ANNA): study protocol for a cluster randomized controlled trial

BACKGROUND

Antibiotic overprescribing for suspected urinary tract infection (UTI) in nursing homes (NHs) is common. Typical clinical scenarios in which antibiotics are inappropriately prescribed include response to nonspecific signs and symptoms and/or a positive urine test in the absence of symptoms referable to the urinary tract. These and other scenarios for inappropriate antibiotic prescribing were addressed in a recent international Delphi study which resulted in the development of a decision tool for the empiric treatment of UTI in frail older adults. The aim of the current study is to implement this decision tool, by integrating it into the electronic health record (EHR) and providing education on its content and use, and to evaluate its effect on appropriate antibiotic prescribing. An additional aim is to evaluate the quality of the intervention and the implementation process.

METHODS

A cluster Randomized Controlled Trial (cRCT) is conducted in sixteen NHs and aims to include 897 residents diagnosed with suspected UTI. NHs in the intervention group use the EHR-integrated decision tool, and receive education for physicians and nursing staff; in the control group care as usual is provided. Data is collected through case report forms within the EHR at the day of diagnosis and at 3, 7, and 21 days thereafter. The primary outcome is appropriate antibiotic prescribing for suspected UTI at the day of diagnosis. Secondary outcomes include the course of symptoms, alternative diagnoses, treatment changes, complications, hospitalization, and mortality. Data on total antibiotic prescribing are additionally collected in the participating NHs 12 months before and during the study. Finally, the process evaluation combines cRCT data with questionnaires and qualitative interviews with NH professionals.

DISCUSSION

This is the first cRCT to evaluate the recently developed, international decision tool for empiric treatment of suspected UTI in NH residents. Study findings will elucidate the effect of the intervention on appropriate antibiotic prescribing for suspected UTI, and provide insight into the applicability of the decision tool in NHs in general and in specific subgroups of NH residents. With this study we aim to contribute to antibiotic stewardship efforts in long-term care.

TRIAL REGISTRATION

The ANNA study was registered at the Netherlands Trial Register on 26 February 2019, with identification number NTR NL7555 .

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

A Multifaceted Antimicrobial Stewardship Program for the Treatment of Uncomplicated Cystitis in Nursing Home Residents

IMPORTANCE

Urinary tract infections are the most common infections in nursing home residents. However, most antibiotic use is for unlikely cystitis (ie, nonspecific symptoms and positive culture results secondary to asymptomatic bacteriuria or a urine sample improperly collected for culture) that is unnecessary and inappropriate. This antibiotic use is associated with an increased risk of antimicrobial resistance, adverse drug events, and Clostridioides difficile (formerly Clostridium difficile) infections.

OBJECTIVE

To determine the association of a multifaceted antimicrobial stewardship and quality improvement intervention with the reduction in unnecessary antimicrobial use for unlikely cystitis among noncatheterized nursing home residents.

DESIGN, SETTING, AND PARTICIPANTS

A quality improvement intervention evaluation was conducted to target antimicrobial use among residents with unlikely cystitis in 25 nursing homes across the United States. Baseline data were collected between February 1, 2017, and April 30, 2017. The intervention was conducted from May 1, 2017, to April 30, 2018.

INTERVENTIONS

Intervention nursing homes (n = 12) were randomized to receive a 1-hour introductory webinar, pocket-sized educational cards, tools for system change, and educational clinical vignettes addressing the diagnosis and treatment of suspected uncomplicated cystitis. Monthly web-based coaching calls were held for staff of intervention nursing homes. All facilities received quarterly feedback reports regarding the management of uncomplicated cystitis. Control group nursing homes (n = 13) received usual care.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of antibiotic treatment for unlikely cystitis cases, defined using published criteria. Secondary outcomes included overall antibiotic use for any urinary tract infection and the safety outcomes of C difficile infections, as well as all-cause hospitalizations and death.

RESULTS

Among the 25 nursing homes participating in this quality improvement study, including 512 408 intervention facility resident-days and 443 912 control facility resident-days, fewer unlikely cystitis cases were treated with antibiotics in intervention facilities compared with control facilities (adjusted incident rate ratio [AIRR], 0.73 [95% CI, 0.59-0.91]); C difficile infection rates were also lower in intervention nursing homes vs control nursing homes (AIRR, 0.35 [95% CI, 0.19-0.64]). Overall antibiotic use for any type of urinary tract infection was 17% lower in the intervention facilities than the control facilities (AIRR, 0.83 [95% CI, 0.70-0.99]; P = .04). There was no increase in all-cause hospitalizations or deaths due to the intervention (all-cause hospitalizations: AIRR, 0.95 [95% CI, 0.75-1.19]; all-cause death: AIRR, 0.92 [95% CI, 0.73-1.16]).

CONCLUSIONS AND RELEVANCE

This study suggests that a low-intensity, multifaceted intervention was associated with improved antibiotic prescribing for uncomplicated cystitis in a cohort of nursing homes without an adverse association with other safety outcomes. Although promising, further study is needed to determine whether the intervention could be widely implemented to assist facilities in meeting new federal nursing home requirements for antimicrobial stewardship and quality assurance performance improvement programs.

Treatment of urinary tract infections in the old and fragile

INTRODUCTION

Urinary tract infection (UTI) is highly prevalent in the frail elderly population. This review aimed to outline the diagnostic, treatment, and prevention of UTI in the frail aging population.

METHODS

Pubmed and Web of Science search to identify publications until March 2019 relating to the management of UTI in the elderly population was performed. A narrative review of the available literature was performed.

RESULTS

64 publications were considered as relevant and included in this review. The diagnosis of symptomatic UTI in the old and fragile could be challenging. Routine screening and antimicrobial therapy for asymptomatic bacteriuria should not be recommended for frail elderly patients. Cautious choice of antibiotics should be guided by uropathogen identified by culture and sensitivity. Understanding local antibiotic resistance rates plays a fundamental part in selecting appropriate antimicrobial treatment. Impact of associated adverse effect, in particular those with effects on cognitive function, should be considered when deciding choice of antibiotics for symptomatic UTI in the elderlies. Optimal management of comorbidities such as diabetes mellitus, adequate treatment of urinary incontinence, and judicious use of urinary catheter is essential to reduce the development of UTI.

CONCLUSION

UTI is a significant but common problem in elderly population. Physicians who care for frail elderly patients must be aware of the challenges in the management of asymptomatic UTI, and identifying symptomatic UTI in this population, and their appropriate management strategies. There is strong need in studies to evaluate nonantimicrobial therapies in the prevention of UTI for the frail elderly population.

Prevalence, impact, and management strategies for asymptomatic bacteriuria in the acute care elderly patient: a review of the current literature

Introduction: It is unclear how to prevent the negative impact of inappropriate urine cultures in older acute care patients who have a high rate of asymptomatic bacteriuria.Areas covered: A nonsystematic literature review of the definition, impact, and management of elderly acute care patients with asymptomatic bacteriuria (ASB).Expert opinion: In the elderly, patients with ASB include those with extra-urinary tract diseases (e.g. pneumonia) and those with symptoms/signs that resolve without antibiotic therapy, but the diagnosis of ASB is unclear in febrile patients responding to antibiotics. We consider four management strategies that could decrease the negative impact of culturing the urine including unnecessary antibiotic therapy in those with ASB: (1) Prevent urine testing in patients with extra-urinary tract reasons for their acute care (2) Cancel urine cultures if the urine dipstick is negative. (3) Avoid catheterization in stable patients who cannot provide a urine specimen on demand and (4) Withhold antibiotics in stable non-febrile elderly patients who do not have new local urinary tract symptoms or decompensation on follow-up, and pursue further investigations for another etiology/diagnosis.

Developing evidence-based guidance for assessment of suspected infections in care home residents

BACKGROUND

The aim of this study was to update and refine an algorithm, originally developed in Canada, to assist care home staff to manage residents with suspected infection in the United Kingdom care home setting. The infections of interest were urinary tract infections, respiratory tract infections and skin and soft tissue infection.

METHOD

We used a multi-faceted process involving a literature review, consensus meeting [nominal group technique involving general practitioners (GPs) and specialists in geriatric medicine and clinical microbiology], focus groups (care home staff and resident family members) and interviews (GPs), alongside continual iterative internal review and analysis within the research team.

RESULTS

Six publications were identified in the literature which met inclusion criteria. These were used to update the algorithm which was presented to a consensus meeting (four participants all with a medical background) which discussed and agreed to inclusion of signs and symptoms, and the algorithm format. Focus groups and interview participants could see the value in the algorithm, and staff often reported that it reflected their usual practice. There were also interesting contrasts between evidence and usual practice informed by experience. Through continual iterative review and analysis, the final algorithm was finally presented in a format which described management of the three infections in terms of initial assessment of the resident, observation of the resident and action by the care home staff.

CONCLUSIONS

This study has resulted in an updated algorithm targeting key infections in care home residents which should be considered for implementation into everyday practice.

A multifaceted intervention to reduce antimicrobial prescribing in care homes: a non-randomised feasibility study and process evaluation

Background

The most frequent acute health-care intervention that care home residents receive is the prescribing of medications. There are serious concerns about prescribing generally, and about antimicrobial prescribing in particular, with facilities such as care homes being described as an important ‘reservoir’ of antimicrobial resistance.

Objectives

To evaluate the feasibility and acceptability of a multifaceted intervention on the prescribing of antimicrobials for the treatment of infections.

Design

This was a non-randomised feasibility study, using a mixed-methods design with normalization process theory as the underpinning theoretical framework and consisting of a number of interlinked strands: (1) recruitment of care homes; (2) adaptation of a Canadian intervention (a decision-making algorithm and an associated training programme) for implementation in UK care homes through rapid reviews of the literature, focus groups/interviews with care home staff, family members of residents and general practitioners (GPs), a consensus group with health-care professionals and development of a training programme; (3) implementation of the intervention; (4) a process evaluation consisting of observations of practice and focus groups with staff post implementation; and (5) a survey of a sample of care homes to ascertain interest in a larger study.

Setting

Six care homes – three in Northern Ireland and three in the West Midlands.

Participants

Care home staff, GPs associated with the care homes and family members of residents.

Interventions

A training programme for care home staff in the use of the decision-making algorithm, and implementation of the decision-making algorithm over a 6-month period in the six participating care homes. REACH (REduce Antimicrobial prescribing in Care Homes) Champions were appointed in each care home to support intervention implementation and the training of staff.

Main outcome measures

The acceptability of the intervention in terms of recruitment, delivery of training, feasibility of data collection from a variety of sources, implementation, practicality of use and the feasibility of measuring the appropriateness of prescribing.

Results

Six care homes from two jurisdictions were recruited, and the intervention was adapted and implemented. The intervention appeared to be broadly acceptable and was implemented largely as intended, although staff were concerned about the workload associated with study documentation. It was feasible to collect data from community pharmacies and care homes, but hospitalisation data from administrative sources could not be obtained. The survey indicated that there was interest in participating in a larger study.

Conclusions

The adapted and implemented intervention was largely acceptable to care home staff. Approaches to minimising the data-collection burden on staff will be examined, together with access to a range of data sources, with a view to conducting a larger randomised study.

Trial registration

Current Controlled Trials ISRCTN10441831.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 8. See the NIHR Journals Library website for further project information. Queen’s University Belfast acted as sponsor.

National trends in the treatment of urinary tract infections among Veterans' Affairs Community Living Center residents

OBJECTIVE

To describe urinary tract infection (UTI) treatment among Veterans' Affairs (VA) Community Living Centers (CLCs) nationally and to assess related trends in antibiotic use.

DESIGN

Descriptive study.

SETTING AND PARTICIPANTS

All UTI episodes treated from 2013 through 2017 among residents in 110 VA CLCs. UTI episodes required collection of a urine culture, antibiotic treatment, and a UTI diagnosis code. UTI episodes were stratified into culture-positive and culture-negative episodes.

METHODS

Frequency and rate of antibiotic use were assessed for all UTI episodes overall and were stratified by culture-positive and culture-negative episodes. Joinpoint software was used for regression analyses of trends over time.

RESULTS

We identified 28,247 UTI episodes in 14,983 Veterans. The average age of Veterans was 75.7 years, and 95.9% were male. Approximately half of UTI episodes (45.7%) were culture positive and 25.7% were culture negative. Escherichia coli was recovered in 34.1% of culture-positive UTI episodes, followed by Proteus mirabilis and Klebsiella spp, which were recovered in 24.5% and 17.4% of culture-positive UTI episodes, respectively. The rate of total antibiotic use in days of therapy (DOT) per 1,000 bed days decreased by 10.1% per year (95% CI, -13.6% to -6.5%) and fluoroquinolone use (ciprofloxacin or levofloxacin) decreased by 14.5% per year (95% CI, -20.6% to -7.8%) among UTI episodes overall. Similar reductions in rates of total antibiotic use and fluoroquinolone use were observed among culture-positive UTI episodes and among culture-negative UTI episodes.

CONCLUSION

Over a 5-year period, antibiotic use for UTIs significantly decreased among VA CLCs, as did use of fluoroquinolones. Antibiotic stewardship efforts across VA CLCs should be applauded, and these efforts should continue.

Asymptomatic bacteriuria in older adults: the most fragile women are prone to long-term colonization

Background

The diagnosis of urinary tract infections (UTIs) in institutionalized older adults is often based on vague symptoms and a positive culture. The high prevalence of asymptomatic bacteriuria (ABU), which cannot be easily discriminated from an acute infection in this population, is frequently neglected, leading to a vast over-prescription of antibiotics. This study aimed to identify subpopulations predisposed to transient or long-term ABU.

Methods

Residents in a long-term care facility were screened for ABU. Mid-stream urine samples were collected during two sampling rounds, separated by 10 weeks, each consisting of an initial and a confirmative follow-up sample.

Results

ABU occurred in approximately 40% of the participants and was mostly caused by Escherichia coli. Long-term ABU (> 3 months) was found in 30% of the subjects. The frailest women with urinary incontinence and dementia had drastically increased rates of ABU and especially long-term ABU. ABU was best predicted by a scale describing the functional independence of older adults.

Conclusions

Institutionalized women with incontinence have ABU prevalence rates of about 80% and are often persistent carriers. Such prevalence rates should be considered in clinical decision making as they devalue the meaning of a positive urine culture as a criterion to diagnose UTIs. Diagnostic strategies are urgently needed to avoid antibiotic overuse and to identify patients at risk to develop upper UTI.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1181-4) contains supplementary material, which is available to authorized users.

Alternative to antibiotics for managing asymptomatic and non-symptomatic bacteriuria in older persons: a review

Recurrent urinary tract infection (UTI) is one of the most common reasons for long-term antibiotic use in frail older people, and these individuals often have non-symptomatic bacteriuria. This article reviews the literature and recommendations for the treatment of UTIs particularly in the older population (>65 years). It considers the question: is there an alternative for antibiotics for asymptomatic and non-symptomatic bacteriuria in older adults? D-mannose powder has been recommended for the treatment of UTIs, as when applied locally, it reduces the adherence of Escherichia coli. In one study, D-mannose was reviewed for the prophylaxis of recurrent UTIs in women, and the findings indicated that it may be useful for UTI prevention instead of prophylactic antibiotics. There is a lack of information about the efficacy of cranberry products combined with D-mannose in this regard, and this is an area for further research.

Limited evidence for diagnosing bacterial skin infections in older adults in primary care: systematic review

Background

Older adults with bacterial skin infections may present with atypical symptoms, making diagnosis difficult. There is limited authoritative guidance on how older adults in the community present with bacterial skin infections. To date there have been no systematic reviews assessing the diagnostic value of symptoms and signs in identifying bacterial skin infections in older adults in the community.

Methods

We searched Medline and Medline in process, Embase and Web of Science, from inception to September 2017. We included cohort and cross-sectional studies assessing the diagnostic accuracy of symptoms and signs in predicting bacterial skin infections in adults in primary care aged over 65 years. The QUADAS-2 tool was used to assess study quality.

Results

We identified two observational studies of low-moderate quality, with a total of 7991 participants, providing data to calculate the diagnostic accuracy of 5 unique symptoms in predicting bacterial skin infections. The presence of wounds [LR+: 7.93 (CI 4.81–13.1)], pressure sores [LR+: 4.85 (CI 2.18–10.8)] and skin ulcers [LR+: 6.26 (CI 5.49–7.13)] help to diagnose bacterial skin infections. The presence of urinary incontinence does not help to predict bacterial skin infections (LR + ‘s of 0.99 and 1.04; LR-‘s of 0.96 and 1.04).

Conclusions

Currently, there is insufficient evidence to inform the diagnosis of bacterial skin infections in older adults in the community; clinicians should therefore rely upon their clinical judgement and experience. Evidence from high quality primary care studies in older adults, including studies assessing symptoms traditionally associated with bacterial skin infections (e.g. erythema and warmth), is urgently needed to guide practice.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1061-y) contains supplementary material, which is available to authorized users.

The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing - a systematic literature review

Background

Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI despite many other potential causes. This leads to significant overdiagnosis of UTI, inappropriate antibiotic use and potential harmful outcomes. This problem is particularly prevalent in nursing home settings.

Methods

A systematic review of the literature was conducted assessing the association between confusion and UTI in the elderly. PubMed, Scopus and PsychInfo were searched with the following terms: confusion, delirium, altered mental status, acute confusional state, urinary tract infection, urine infection, urinary infection and bacteriuria. Inclusion criteria and methods were specified in advance and documented in the protocol, which was published with PROSPERO (registration ID: CRD42015025804). Quality assessment was conducted independently by two authors. Data were extracted using a standardised extraction tool and a qualitative synthesis of evidence was made.

Results

One thousand seven hunderd two original records were identified, of which 22 were included in the final analysis. The quality of these included studies varied, with frequent poor case definitions for UTI or confusion contributing to large variation in results and limiting their validity. Eight studies defined confusion using valid criteria; however, no studies defined UTI in accordance with established criteria. As no study used an acceptable definition of confusion and UTI, an association could not be reliably established. Only one study had acceptable definitions of confusion and bacteriuria, reporting an association with the relative risk being 1.4 (95% CI 1.0–1.7, p = 0.034).

Conclusions

Current evidence appears insufficient to accurately determine if UTI and confusion are associated, with estimates varying widely. This was often attributable to poor case definitions for UTI or confusion, or inadequate control of confounding factors. Future well-designed studies, using validated criteria for UTI and confusion are required to examine the relationship between UTI and acute confusion in the elderly. The optimal solution to clarify this clinical issue would be a randomized controlled trial comparing the effect of antibiotics versus placebo in patients with new onset or worsening confusion and presence of bacteriuria while lacking specific urinary tract symptoms.

Diagnostic value of symptoms and signs for identifying urinary tract infection in older adult outpatients: Systematic review and meta-analysis

OBJECTIVES

To critically appraise and evaluate the diagnostic value of symptoms and signs in identifying UTI in older adult outpatients, using evidence from observational studies.

METHODS

We searched Medline and Medline in process, Embase and Web of Science, from inception up to September 2017. We included studies assessing the diagnostic accuracy of symptoms and/or signs in predicting UTI in outpatients aged 65 years and above. Study quality was assessed using the QUADAS-2 tool.

RESULTS

We identified 15 eligible studies of variable quality, with a total of 12,039 participants (range 65-4259), and assessed the diagnostic accuracy of 66 different symptoms and signs in predicting UTI. A number of symptoms and signs typically associated with UTI, such as nocturia, urgency and abnormal vital signs, were of limited use in older adult outpatients. Inability to perform a number of acts of daily living were predictors of UTI: For example, disability in feeding oneself, + ve LR: 11.8 (95% CI 5.51-25.2) and disability in washing one's hands and face, + ve LR: 6.84 (95% CI 4.08-11.5).

CONCLUSIONS

The limited evidence of varying quality shows that a number of symptoms and signs traditionally associated with UTI may have limited diagnostic value in older adult outpatients.

Urine cultures in a long-term care facility (LTCF): time for improvement

Background

Urinary tract infections (UTIs) are the most prevalent infections in long-term care facilities (LTCFs). Numerous studies have described the problem of inadequate UTI diagnosis and treatment. We assessed the role of urine cultures in the diagnosis and treatment of UTIs in a LTCF.

Methods

In a 370-bed non-academic LTCF a retrospective assessment of antibiotic (AB) prescriptions for UTIs and urine cultures was performed from July 2014 to January 2016. The reasons why physicians, including 11 nursing home physicians and 2 junior doctors, ordered urine cultures were recorded using questionnaires.

Results

During the study period, 378 residents were prescribed 1672 AB courses; 803 were for UTIs. One hundred and fifty-five urine cultures were obtained from 135 residents; 66 of these cultures were performed on the same day as ABs were prescribed (8% of all prescriptions for UTI), while 89 were not. There was a discrepancy between the actions that seemed logical based on the culture results and the actions that were actually taken in 75% of the cases. In these cases, initial AB treatment was not adjusted when the isolated microorganism was resistant to the AB prescribed, the urine culture was positive and no ABs had previously been administered, or ABs were prescribed and no microorganism was isolated.

The most frequent reason for ordering a urine culture was to confirm the diagnosis of a UTI.

Conclusion

In the majority of patients, AB therapy was not adjusted when the urine culture results suggested it may be appropriate. The physicians were erroneously convinced that UTIs could be diagnosed by a positive urine culture.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0909-x) contains supplementary material, which is available to authorized users.

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.

Diagnosis and treatment of urinary tract infections across age groups

Urinary tract infections are the most common outpatient infections, but predicting the probability of urinary tract infections through symptoms and test results can be complex. The most diagnostic symptoms of urinary tract infections include change in frequency, dysuria, urgency, and presence or absence of vaginal discharge, but urinary tract infections may present differently in older women. Dipstick urinalysis is popular for its availability and usefulness, but results must be interpreted in context of the patient's pretest probability based on symptoms and characteristics. In patients with a high probability of urinary tract infection based on symptoms, negative dipstick urinalysis does not rule out urinary tract infection. Nitrites are likely more sensitive and specific than other dipstick components for urinary tract infection, particularly in the elderly. Positive dipstick testing is likely specific for asymptomatic bacteriuria in pregnancy, but urine culture is still the test of choice. Microscopic urinalysis is likely comparable to dipstick urinalysis as a screening test. Bacteriuria is more specific and sensitive than pyuria for detecting urinary tract infection, even in older women and during pregnancy. Pyuria is commonly found in the absence of infection, particularly in older adults with lower urinary tract symptoms such as incontinence. Positive testing may increase the probability of urinary tract infection, but initiation of treatment should take into account risk of urinary tract infection based on symptoms as well. In cases in which the probability of urinary tract infection is moderate or unclear, urine culture should be performed. Urine culture is the gold standard for detection of urinary tract infection. However, asymptomatic bacteriuria is common, particularly in older women, and should not be treated with antibiotics. Conversely, in symptomatic women, even growth as low as 10² colony-forming unit/mL could reflect infection. Resistance is increasing to fluoroquinolones, beta-lactams, and trimethoprim-sulfamethoxazole. Most uropathogens still display good sensitivity to nitrofurantoin. First-line treatments for urinary tract infection include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when resistance levels are <20%). These antibiotics have minimal collateral damage and resistance. In pregnancy, beta-lactams, nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole can be appropriate treatments. Interpreting the probability of urinary tract infection based on symptoms and testing allows for greater accuracy in diagnosis of urinary tract infection, decreasing overtreatment and encouraging antimicrobial stewardship.

The Development of a Decision Tool for the Empiric Treatment of Suspected Urinary Tract Infection in Frail Older Adults: A Delphi Consensus Procedure

OBJECTIVES

Nonspecific signs and symptoms combined with positive urinalysis results frequently trigger antibiotic therapy in frail older adults. However, there is limited evidence about which signs and symptoms indicate urinary tract infection (UTI) in this population. We aimed to find consensus among an international expert panel on which signs and symptoms, commonly attributed to UTI, should and should not lead to antibiotic prescribing in frail older adults, and to integrate these findings into a decision tool for the empiric treatment of suspected UTI in this population.

DESIGN

A Delphi consensus procedure.

SETTING AND PARTICIPANTS

An international panel of practitioners recognized as experts in the field of UTI in frail older patients.

MEASURES

In 4 questionnaire rounds, the panel (1) evaluated the likelihood that individual signs and symptoms are caused by UTI, (2) indicated whether they would prescribe antibiotics empirically for combinations of signs and symptoms, and (3) provided feedback on a draft decision tool.

RESULTS

Experts agreed that the majority of nonspecific signs and symptoms should be evaluated for other causes instead of being attributed to UTI and that urinalysis should not influence treatment decisions unless both nitrite and leukocyte esterase are negative. These and other findings were incorporated into a decision tool for the empiric treatment for suspected UTI in frail older adults with and without an indwelling urinary catheter.

CONCLUSIONS

A decision tool for suspected UTI in frail older adults was developed based on consensus among an international expert panel. Studies are needed to evaluate whether this decision tool is effective in reaching its aim: the improvement of diagnostic evaluation and treatment for suspected UTI in frail older adults.

Urinary Tract Infection and Asymptomatic Bacteriuria in Older Adults

Urinary tract infections (UTIs) are a significant cause of morbidity among older adults. However, antibiotic prescriptions for clinically suspected UTIs are often inappropriate. Health care providers frequently struggle to differentiate UTI from asymptomatic bacteriuria, particularly in patients presenting with nonspecific symptoms. Patients with baseline cognitive impairments that limit history-taking can be particularly challenging. This article reviews the epidemiology and pathogenesis of UTI in older adults. It discusses an approach to diagnosis and treatment focused on recognizing patients who would likely benefit from antibiotic treatment and on identifying patients for whom empiric antibiotic therapy should not be given.

Urinary tract infections in the geriatric patients

Objective

Urinary tract infections (UTI) are the second most common infection in geriatric population. This study investigated clinical findings, diagnostic approaches, complicating factors, prognosis, causative microorganisms and antimicrobial susceptibility in geriatric patients diagnosed with UTI.

Methods

A total of 140 hospitalised patients with UTIs were evaluated within three years between January 2011-January 2015 at the Eskisehir Yunus Emre State Hospital. UTI diagnosed when there were systemic and urinary signs and symptoms and a positive dipstick test and urine culture result, leukocyte and CRP like serum parameters.

Results

Among the studied patients, 41.4% had urological diseases, 20.7% had diabetes mellitus and 19.2% had neurological diseases. The most common symptoms and signs were fever, dysuria nausea/vomiting, general condition impairment, pyuria, haematuria. The laboratory values for CRP, ESR and leukocyte count were 84 mg/dL, 56 mm/s and 11.9 (10^3μL), with mean values being determined. Among patients having a urinary catheter (17.1%), 27.9% had a history of UTI, while 29.3% had been hospitalised. Escherichia coli and Klebsiella pneumoniae were the most commonly identified microorganisms. The mean duration for hospitalisation was 7.6 days, while a 5% mortality rate was observed over the course of the disease.

Conclusion

Because of the potential for serious complications and mortality, elderly patients with urinary tract infection, should receive immediate empirical treatment based on anamnesis, clinical evaluation and urinalysis and should be re-examined using results from cultures and antibiograms upon follow-up.

Incidence and antibiotic prescribing for clinically diagnosed urinary tract infection in older adults in UK primary care, 2004-2014

Urinary tract infections (UTI) are an important cause of morbidity and antibiotic use in older adults but there are little data describing disease burden in primary care. The aim of this study was to estimate the incidence of clinically diagnosed UTI and examine associated empirical antibiotic prescribing. We conducted a retrospective observational study using linked health records from almost one million patients aged ≥65 years old, registered with 393 primary care practices in England. We estimated incidence of clinically diagnosed UTI between March 2004 and April 2014, and used multilevel logistic regression to examine trends in empiric antibiotic prescribing. Of 931,945 older adults, 196,358 (21%) had at least one clinically diagnosed UTI over the study period. In men, the incidence of clinically diagnosed UTI per 100 person-years at risk increased from 2.81 to 3.05 in those aged 65–74, 5.90 to 6.13 in those aged 75–84, and 8.08 to 10.54 in those aged 85+. In women, incidence increased from 9.03 to 10.96 in those aged 65–74, 11.35 to 14.34 in those aged 75–84, and 14.65 to 19.80 in those aged 85+. Prescribing of broad-spectrum antibiotics decreased over the study period. There were increases in the proportion of older men (from 45% to 74%) and women (from 55% to 82%) with UTI, prescribed a UTI specific antibiotic. There were also increases in the proportion of older men (42% to 69%) and women (15% to 26%) prescribed antibiotics for durations recommended by clinical guidelines. This is the first population-based study describing the burden of UTI in UK primary care. Our findings suggest a need to better understand reasons for increasing rates of clinically diagnosed UTI and consider how best to address this important clinical problem.

Sensitivity of the dipstick in detecting bacteremic urinary tract infections in elderly hospitalized patients

BACKGROUND

The sensitivity of the dipstick in elderly patients with a suspected urinary tract infection (UTI) is unclear because of the inclusion of patients with urine contamination or asymptomatic bacteriuria in previous studies.

METHODS

We selected consecutive patients aged 65 years or older hospitalized in internal medicine departments with bacteremic UTI (same organism in blood and urine cultures) minimizing misclassifications. The false positive rate was determined in consecutive patients with negative culture results. A positive dipstick was a test result with a trace leukocyte esterase and/or nitrite positivity. Bacteriuria was the growth of at least 105 colony-forming units per milliliter of urine.

RESULTS

Of 20,555 consecutive patients, 228 had a bacteremic UTI, and 4069 a negative culture result. The sensitivity of the dipstick was 96.9% (95% CI-93.7-98.6) with a false positive rate of 42.4% (95% CI, 41.0-43.8) in those with a negative culture result.

CONCLUSIONS

In elderly hospitalized patients with a bacteremic UTI, the dipstick urinalysis is highly sensitive, much higher than reported previously in studies of UTIs in the elderly. It is unclear whether the observed high sensitivity of the dipstick was due to the exclusion of patients with asymptomatic bacteriuria or to spectrum bias. Studies of the clinical utility/disutility of using a negative dipstick to rule out a urinary tract infection are warranted.