Re: Managing UTIs in the NH/Interesting website

[Guest guest]

Dear Janet -

Thanks for passing this on. I want to check into the website further. Meanwhile,

with my mom having chornic UTIs and being around seniors who are very

susceptible to them, I'll stick with the clinical folks who treat at lower

colonization levels, recognize that many elders have no symptoms that look like

UTI in younger people, and who do order full testing and treatment ASAP. My

PharmD colleague has passed on lots of clinical literature on the subject - and

the very first article he pointed out years ago - written for NH docs and nurses

said - Consider UTI or respiratory infection if a resident's behavior changes

suddenly or if a family member mentions their loved one " doesn't seem like

themselves. " Long before I knew anything about UTIs, that made simple common

sense to me.

 

There is so much to watch for!

 

Lin

Subject: Managing UTIs in the NH/Interesting website

To: LBDcaregivers

Date: Thursday, July 17, 2008, 2:27 AM

Managing Urinary Tract Infections in the Nursing Home:

Myths, Mysteries and Realities

Hosam K. Kamel, MD, CMD, AGSF

Director, Assistant Clinical Professor of Geriatrics

Geriatrics and Extended Care

St. ph's Mercy Health Center, University of Arkansas for Medical

Sciences

Hot Springs, Little Rock Arkansas USA

________________________________

Citation:

Hosam K. Kamel: Managing Urinary Tract Infections in the Nursing Home: Myths,

Mysteries and Realities. The Internet Journal of Geriatrics and Gerontology .

2004. Volume 1 Number 2.

________________________________

Table of Contents

Abstract

Epidemiology

Etiology

Risk factors for UTI in the elderly

Asymptomatic bacteriuria or UTI

Diagnosing UTI in the nursing home

Catheter associated UTIs

Treatment

References

AbstractUrinary tract infections (UTIs) are the most common bacterial

infections encountered in older adults.1 Diagnosis, and treatment of UTIs is

often challenging in older adults residing in nursing home as clinical

manifestations are often atypical. In the elderly, female/male ratio of UTI

incidence narrows approaching 2:1. More types of urinary pathogens are isolated

from elder patients with UTI compared to their younger counterparts with E.coli

being the most frequently isolated pathogen. In patients with recurrent

infections resistant gram-negative bacteria other than E. coli and

gram-positive bacteria (e.g. enterococci, coagulase negative staphylococci, and

group B streptococci) are more frequently isolated as a result of using

antibiotics that are only active against gram negative bacteria. Urine cultures

should not be sent if no symptoms, if the outcome is known before hand, or if

the clinician is not going to treat. There is no consensus on the

duration of antibiotic therapy in nursing home residents with UTI. Most

elderly women with uncomplicated lower tract UTI should be treated with

antibiotics for 10 days; elderly men are generally treated for 14 days.

Abbreviated courses (< 7 days) or treatment for UTI are not recommended for

elderly patients because of relatively high rates of failure and relapse.

Patients with pyelonephritis or urosepsis should be treated a minimum of 14

days. Intravenous antibiotics may be given if patient is not able to take

antibiotics orally because of vomiting for example. There is no need to send

urine culture to document clearance of infection after completing the treatment

course as long as the patient is asymptomatic.

Epidemiology

The prevalence of UTIs increases in both sexes with age. In the elderly,

female/male ratio of UTI incidence narrows approaching 2:1. This is attributed

to the fact that elderly men often have bladder outlet obstruction due to

benign prostatic hyperplasia. In addition, there is a relative reduction in UTI

incidence among elderly women due to decreased sexual activity, which can

introduce bacteria into the bladder. Severe UTIs, particularly those

complicated by septicemia, become more common with age. Recurrent and

complicated infections are also more common in older adults because of the

higher frequency of predisposing anatomic and pathophysiologic factors, such as

uterine prolapse, urolithiasis, and genitourinary tract malignancies. Catheter

associated UTIs are common and carry increased risks of complications and

morbidity.

Etiology

More types of urinary pathogens are isolated from elderly patients with UTI

compared to younger patients. Escherichia coli (E. coli) accounts for about 70%

of pathogens of UTI in outpatient elderly females and about 40% in older

patients with indwelling catheters. Kelbseiella pneumonia is the second most

frequently isolated pathogen. Proteus (P) mirabilis, P. vulgaris, P. incostans

and ell moganii are more common in men than women and more frequently

isolated from patients with calculi as they grow best in an alkaline milieu.

Proteus species, M. Moraine and Prudence species are commonly isolated from

patients who are chronically catheterized. Serratia, Nitrobacteria,

Acinetobacter, and Pseudomonas species are isolated mainly from patients with

nosocomial UTIs.

In patients with recurrent UTIs resistant gram-negative bacteria other than E.

coli and gram-positive bacteria (e.g. enterococci, coagulase negative

staphylococci, and group B streptococci) are more frequently isolated.

Enterococcoal superinfection often results from frequent use of antibiotics

that are inactive against these organisms (e.g. quinolones)

Risk factors for UTI in the elderly

There are several factors that have been linked to the development of UTI in

the elderly (table 1). These include increased age, menopause, and

instrumentation of the urinary tract. Another risk factor that is often

overlooked is dehydration. Factors that were found unrelated to the development

of UTI include diet, and personal hygiene.

Table 1: Common Risk Factors for UTI in the elderly

* Atrophic urethritis

* Artrophic vaginitis

* Benign prostatic hyperplasia

* Cancer of prostate

* Catheter use

* Genitourinary abnormalities (e.g. vesicorectal fistula)

* Genitourinary calculi

* Renal and perinephric abscess formation

* Urinary diversion procedure (e.g. ileal bladder diversion)

* Urethral stricture

Asymptomatic bacteriuria or UTI

According to the Association for Practitioners in Infection Control (APIC) and

the Society for Healthcare Epidemiology of America (SHEA), a laboratory

confirmation of > 100,000 colony-forming units (CFU)/ml is the standard to

confirm a positive urine culture. A positive urine culture, however, does not

indicate whether a nursing home resident has a UTI or simply bacteriuria (a

positive couture without dysuria, urinary frequency, incontinence of recent

onset, flank pain, fever, or other signs of infection during the week before a

urine sample was obtained). Asymptomatic bacteriuria is not a UTI and should

not be treated unless accompanied by symptoms that suggest a UTI. A diagnosis

of UTI versus asymptomatic bacteriuria should be based on the combination of

laboratory and clinical findings not the laboratory findings alone. Studies

have shown that asymptomatic bacteriuria does not cause increased mortality or

chronic genitourinary symptoms such as

incontinence.

Diagnosing UTI in the nursing home

Many patients are asymptomatic. Symptoms that may occur include dysuria,

urinary frequency, and incontinence of recent onset, flank pain and fever.

Confusion and delirium are often attributed to a UTI, although without high

fever or sepsis, uncomplicated UTI is unlikely to cause significant central

nervous system dysfunction.

Diagnosis of symptomatic UTI can be challenging in the elderly. Symptoms like

dysuria, urinary frequency, and incontinence of recent onset, flank pain, and

fever may not be present. The diagnosis of UTI requires consideration not only

of clinical symptoms, but also of co-morbidities. For example, confusion and

delirium may indicate a severe UTI, as might a change in appetite and/or

agitation. Or an elder with urinary incontinence and a UTI may experience an

increase in the number of episodes of incontinence. Some practitioners use the

McGeer & MSHD definitions for long term care nosocomial infections to

diagnose symptomatic UTI.2

To meet the criteria for a suspected UTI without an indwelling catheter, three

of the following must be met:

* Fever (>38 degrees C) or chills

* New or increased burning pain on urination

* New flank or suprapubic pain or tenderness

* Changes in character of urine, and worsening mental function

To meet the criteria for a suspected UTTI with an indwelling catheter, two of

the following must be met:

* Fever (>38 degree C) or chills

* New flank or suprapubic pain or tenderness

* Changes in character of urine

* Worsening mental function

The diversity of potential pathogens makes it necessary to obtain urine

cultures in elderly persons with suspected UTI. When or if to send urine

culture is another controversial issue. In general , cultures should not be

sent in the absence of symptoms, if the outcome is known before hand, or if the

clinician is not going to treat. Surveillance cultures for patients with

indwelling catheters are not useful and are not recommended. Asymptomatic

bacteriuria can be identified in 95 to 100% of nursing home residents who had

indwelling catheters for over 30 days.3 The cost of culture and sensitivity

test of the urine is greater than $100 and this need to be taken into

consideration when ordering urine culture and sensitivity.

Treatment for symptomatic UTI should not be delayed while waiting for culture

and sensitivity results. It may be helpful to start empiric treatment based on

previous culture and sensitivity results and information of sensitivity pattern

in the facility. Bacteriologic diagnosis of UTI is often based on the concept of

clinically significant bacteriuria which is usually defined as > 105 CFU/ml

in a clean catch after more than 4 hours of bladder incubation. The urine must

be refrigerated if culture and incubation are delayed; however, storage for

> 4 hours should be avoided because substantial bacterial replication still

occurs, even at cold temperatures.

Dipstick (rapid) tests can help identify bacteruria and can be performed in the

facility.

Studies, however, have shown that dipstick analysis is not sensitive enough to

diagnose UTI in high-risk patient in whom a missed diagnosis would have a

serious consequence.4

In addition, dipstick tests do not detect gram positive organisms such as

enerococcus. The most widely used dipstick test is the nitrite test, in which

the conversion of nitrate to nitrite by bacteria is the urine is demonstrated

by color change on a dipstick. The test has a high degree of sensitivity and

specificity but does not demonstrate bacteriuria caused by pseudomonas sp,

staphylococci or enterococci which are incapable of reducing nitrate to

nitrite.

Catheter associated UTIs

In long-term care facilities, 5 to 15% of residents have chronic urinary

catheter in place. Catheters are commonly used for urinary retention,

incontinence control, wound management, and patient comfort. Transurethral

catheters are more common than suprapubic or condom-type devices, but no method

has been proven superior for use in long-term care. The incidence of symptomatic

urinary tract infection in chronically catheterized residents has been estimated

at 21% per month. When competed with urethral catheterization, most evidence

suggests that the suprapubic route is associated with a reduced risk of

bacteriuria and improved patient satisfaction this method, however, is

associated with a higher degree of mechanical failure and complications.

Intermittent catheterization may be an alternative to indwelling catheter use.

This technique is commonly used in the spinal cord injury population who

perform self-catheterization at home. In nursing home facilities, most

residents are unable to perform this task independently and would rely on

nurses to perform the procedure. The burden on nursing time would prohibit

general use of this technique in many facilities and the cost of disposable

catheters is also not insignificant.

The frequency at which indwelling catheters should be changed remains virtually

unstudied. It is common practice for routine replacement to occur on a monthly

basis. The practice may be a result of the increasing rate of mechanical

catheter failure after 2 to 4 weeks of use. Only one small randomized

controlled study has looked at the frequency of routine catheter change. No

reduction in the risk of symptomatic UTI was demonstrated with monthly versus

as needed catheter changes. Catheter change at the onset of UTI is also a

common practice. This strategy has been shown to hasten clinical improvement,

reduce febrile days and decrease the rate of infection relapse.5

Catheter-related bacteriuria in the elderly is a frequent complication.

Indwelling urinary catheterization causes bacteriuria to occur at a rate of 3

to 10% of patients per day; a single in and out catheterization may cause

bacteriuria in as many as 20% of patients. By about 30 days (the conventional

cutoff between short and long term catheterization), more patients are

bacteriuric. At any given time, an estimated 100,000 nursing home residents

have long-term indwelling urinary catheters. Bacteriuria associated with

short-term catheterization usually involves a single pathogen, most commonly E.

coli; bacteriuria associated with long-term catheterization is often

polymicrobial.

Catheter associated UTI are common and carry increased risks of complications

and morbidity. Federal regulations mandate that certain criteria be met in

order to justify use of an indwelling catcher in long term setting. As noted in

the State Operation Manual, an indwelling catheter should only be used “when

there is valid medical justification. The resident should be assessed for and

provided the care and treatment needed to reach his or her highest level of

continence possible. The facility is expected to show evidence of any medical

factors which caused the intervention”. Many residents are transferred to the

nursing home form the acute care hospitals with indwelling catheter. Unlike long

term care setting, acute care hospitals do not have to adhere to stringent

criteria to justify use of catheter. The results that many nursing home

residents who are sent to hospitals return catheterized although they did not

leave the facility with a catheter.

Although it may have been appropriate to catheterize the patient briefly while

in hospital, in many cases the catheter is inappropriately left in place

throughout the hospitalization, increasing the resident's risk to develop

UTI. The CDC has published guidelines for prevention of catheter associated

urinary tract infections. These are listed in table 2.

Table 2: CDC Guidelines for Prevention of Catheter-Associated Urinary tract

Infections

Strongly recommended

* Catheterize only when necessary

* Educate personnel in correct catheter care and insertion techniques

* Insert catheters using sterile equipment aseptic technique

* Secure catheter

* Maintain closed sterile drainage system

* When irrigation is necessary, use intermittent method

* Obtain urine samples aseptically, when indicated

* Maintain unobstructed urine flow

Moderately recommended

* Periodically reeducate personnel in catheter care

* Use smallest bore of catheter possible

* Avoid continuous irrigation

* Refrain from daily meatal care

* Avoid changing catheters at arbitrary intervals

Urine cultures obtained from the lumen of urinary catheters often contain more

species than are actually present in the bladder; removal of the catheter and

replacement with a new catheter before obtaining cultures are often

recommended. Randomly or routinely screening urine is almost guaranteed to

detect bacterial presence. However, asymptomatic colonization should not be

treated. The use of prophylactic antibiotics to prevent infection is also not

recommended. Table 3 lists recommendations from APIC and SHEA regarding

initiating treatment for UTI in catheterized individuals.

Treatment

Asymptomatic bacteriuria generally need not be treated. The organisms

(especially E.Coli) often lose their virulence and become susceptible to the

bactericidal effect of normal human plasma. Most elderly women with

uncomplicated lower tract UTI should be treated with antibiotics for 10 days;

elderly men are generally treated for 14 days. Abbreviated courses (< 7

days) or treatment for UTI are not recommended for elderly patients because of

relatively high rates of failure and relapse. Patients with pyelonephritis or

urosepsis should be treated a minimum of 14 days. Intravenous antibiotics may

be given if the patient is not able to take antibiotics orally (e.g. because of

vomiting).

There is no consensus on the duration of antibiotic therapy in nursing home

residents. Takahashi et al6 studied 196 elderly women (22% nursing home

residents) and (78% were community dwelling) in Olmsted County Minnesota and

found that nursing home residents were more likely to be treated for longer

duration than community dwelling elderly. Nearly all nursing home residents

were treated for more than 7 days and overall they were 5.1 times more than

community subjects to be treated for 10 days or longer, 80 health care

providers. The results from this study are shown in table 4.

Urologic consultation may be sought when obstructive uropathy, calculi,

abscesses or GU tract anatomic abnormalities are suspected. After treating a

UTI, it is not necessary to necessary to document “clearing of the urine by

culture if the resident is asymptomatic.

References

1. NE. Epidemiology of Urinary tract infection. Infect med

2001;18:153-162

2. Loeb M, Bentley DW, Bradley S, Crossley K, et al. Infect Control Hosp

Epidemilo 2001 Feb;22(2):120-4

3. O'Donnel JA, Hofmann MT. Urinary tract infections. How to manage nursing

home patients with or without chronic catheterization. Geriatrics

2002;57;45'49-52,55-56

4. Eidelman Y, Raveh D, Yinnon AM, et al. Reagent strip diagnosis in a

high-risk population. AM J Emerg Med 2002;20:112-113

5. Gammack JK. Use and management of chronic urinary catheters in long-term

care: much controversy, little consensus. J AM Med Dir Assoc 2002;3:162-168

6. Takahashi P, Trang N, Chutka D, et al. Antibiotic Prescribing and Outcomes

Following Treatment of Symptomatic urinary tract infections in older women.

JAMDA 2004;5:S12-S15

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[Guest guest]

When I was searching posts for previous email, fell upon this - here's

the link to the info listed below:

http://tinyurl.com/3g856v

>

> Managing Urinary Tract Infections in the Nursing Home:

> Myths, Mysteries and Realities

> Hosam K. Kamel, MD, CMD, AGSF

> Director, Assistant Clinical Professor of Geriatrics

> Geriatrics and Extended Care

> St. ph's Mercy Health Center, University of Arkansas for Medical

Sciences

> Hot Springs, Little Rock Arkansas USA

> ________________________________

> [...]