COMMENTARY

UTI Versus Asymptomatic Bacteriuria in Long-term Care

Margaret R. Nolan, DNP, GNP

Disclosures

August 21, 2017

Urinary Tract Infection Versus Asymptomatic Bacteriuria

The Centers for Disease Control and Prevention has named antimicrobial resistance as one of the world's major health threats.[1] Compared with patients living in the community, those living in long-term care (LTC) facilities have a higher incidence of infections with antibiotic-resistant organisms.[2] Urinary tract infections (UTIs) are a frequent reason for antibiotic use in LTC settings.

Bacteria in the urine can be asymptomatic, or associated with the signs and symptoms of a UTI. Rates of asymptomatic bacteriuria in LTC residents are high: 25%-50% in women, 15%-40% in men, and nearly 100% in patients with indwelling urinary catheters.[3] Unlike symptomatic bacteriuria, asymptomatic bacteriuria should not be treated with antibiotics.

Urinalysis doesn't distinguish between a UTI and asymptomatic bacteriuria, and many LTC residents are diagnosed with UTI without assessment of whether sufficient clinical signs and symptoms of infection are present.[4] This leads to unnecessary treatment with antibiotics, and elevates the risk for antibiotic resistance and the development of Clostridium difficile infection.

To improve the diagnosis of UTI in LTC residents, and reduce the unnecessary use of antibiotics, a recent quality improvement project from the University of Michigan used a standardized tool to monitor patients for signs and symptoms of UTI. The Cooper Urinary Surveillance Tool is a novel evidence-based algorithm that guides LTC nurses in their assessment of typical and atypical signs and symptoms of urinary tract infection in residents, and prompts appropriate communication about patient status to primary care providers. The use of this tool significantly reduced the rate of UTI diagnoses and reduced inappropriate diagnoses for suspected UTIs within the facility. These findings support the need for more clear and consistent assessment of the patient before antibiotics are initiated for suspected UTI.

Viewpoint

In 2016, the Centers for Medicare & Medicaid Services began requiring LTC facilities to establish infection prevention and control programs.[5] This antibiotic stewardship program includes protocols for antibiotic use throughout LTC facilities. The stewardship program is complex and requires LTC facilities to develop leadership support, increase accountability throughout its staff, develop drug expertise, create policies to improve antibiotic prescribing, build ways to track antibiotic use, track outcomes of antibiotic use, and provide education not only for the facility's staff but also for the residents and their families.[6]

The prevalence of UTIs in LTC patients is significant, and a frequent obstacle to appropriate prescribing is pressure from families to treat the patient.[7] Elderly patients in LTC can show evidence of cognitive decline unrelated to an infection, and bacteriuria alone is unlikely to be the cause of cognitive decline or mental status changes. As a geriatric consultant nurse practitioner in the emergency department, I often observed that the finding of bacteria in the urine of an elderly patient would essentially end the healthcare team's work-up for other possible causes of mental status changes. It is well known that delirium in elderly persons has many causes, including metabolic abnormalities, adverse reactions to medications, dehydration, pain, cerebral vascular changes, and even worsening dementia.[8] Patients presenting with acute mental status changes must be evaluated for all possible causes, and an individualized assessment is necessary for each patient with presumed UTI.

I hope that this new stewardship program will improve the understanding of asymptomatic and symptomatic bacteriuria in LTC patients, and that all of those involved—staff, patients, and families—will understand when bacteriuria should, and shouldn't, be treated.

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