Evidence-Based Practice in LTC

Identifying & Managing Possible UTIs

by Steven Levenson, MD, CMD
Multi-Facility Medical Director, Baltimore, MD
Chair, Caring's Editorial Board

Charles Crecelius, MD, PhD, CMD
Past President, Missouri Association of Long-Term Care Physicians
Medical Director, Delmar Gardens, St. Louis, MO
Member, Caring's Editorial Board

About This Series: Over the years, certain practices have become common in nursing home care nationwide. Consultants, management, and surveyors offer multiple opinions and conflicting advice that may confuse staff and practitioners. Various sources are advising nursing home staff to refer to "best practices." Yet only some of these practices reflect reliable evidence. Other habitual approaches are problematic and should change. Often, "best practices" is erroneously interpreted to mean that there is a single best treatment, when in reality there may be "better" and "worse" practices. This series will review common practices in nursing homes, comparing habitual to desired approaches, and may recommend important changes.

This month's column addresses the identification and management of possible urinary tract infections.

Common Practice

Symptomatic UTIs are the most common infection experienced by residents of long-term care facilities. Asymptomatic bacteriuria is also very common in LTC residents. But many nursing home staff and practitioners appear to accept and act upon myths and misconceptions regarding these conditions.

There is no consistent, clear presentation for symptomatic UTIs, and so a UTI "diagnosis" is often based on speculation, or on isolated signs and symptoms such as foul smelling or cloudy urine, or fever in the absence of other significant signs or symptoms. It is common to speculate that symptoms such as falling, altered mental status, increasing confusion, and general functional decline are due to "UTIs," or to consider "ruling out a UTI" to be a routine step in evaluating such symptoms.

Descriptions of urine and urinary-tract conditions are often incomplete or imprecise. For example, so-called "bladder infections" could be pyelonephritis, urethritis, or (in men) prostatitis. Documentation for urinalyses and urine culture results often skip important details and may simply indicate that the results showed "infection."

Indwelling urinary catheters markedly increase the risk of having a symptomatic UTI. But many nursing home staff, surveyors, and the public seem to be misguided about issues related to catheters. It is common practice for nurses to request orders for urine cultures of individuals with or without indwelling catheters and to pressure physicians to order antibiotics to treat positive culture results.

Nurses and physicians frequently order follow-up urine cultures after a treatment course, and then respond to positive culture results by continuing antibiotic treatment. There is often little documentation about the patient's overall status or of how the urinary tract problem relates to that broader context.

It is common practice not to identify or document the risks and problems associated with prolonged or recurrent broad-spectrum antibiotic use, and to assume that antibiotic treatment is desirable regardless of conflicting or complicating circumstances.

In many nursing homes, it is routine to transfer residents with fever or altered mental status to the hospital, and it is common for hospitals to admit these individuals with a diagnosis of "urosepsis."

The Evidence

Identifying and managing urinary tract infections is a clinical challenge. But much of the evidence, accumulated over several decades, is consistent and enduring.

Impact As noted earlier, symptomatic UTIs are the most common infection experienced by LTC residents, and bacteriuria is also very common. Bacteriuria is not normal, but is only sometimes problematic. Bacteriuria does not materially affect survival in LTC residents, and urosepsis infrequently causes death.

Prevention Relatively little can be done to substantially reduce the high frequency of symptomatic UTIs in LTC. Significant patient factors influencing bacteriuria, such as age-related changes and chronic comorbid illnesses (especially those resulting in neurogenic bladder or fecal incontinence), are not readily modifiable. There is no substantive evidence that techniques for cleaning the pelvic area cause or contribute to bacteriuria or infection. However, an individual with an indwelling catheter is 40 times more likely to develop bacteremia than without one. Therefore, chronic indwelling urinary catheters should be used only when there is no viable alternative.

Recognition & Assessment The urinary tract includes the kidneys, ureters, and the urethra, as well as the bladder. There is no consistent, clear presentation of symptomatic UTIs. The impact of symptomatic UTI on functional status and daily activities of LTC residents is unclear. Chronic symptoms unrelated to the genitourinary tract don't occur more often in individuals with bacteremia. New onset of nonspecific symptoms (change in mental status, decline in appetite, etc.) is not a reliable indicator of a UTI, especially in the absence of acute symptoms referable to the genitourinary tract.

Only about one in 10 febrile episodes in individuals without a chronic indwelling catheter and without other localizing signs has a urinary source. Foul-smelling urine and cloudy urine do not necessarily indicate bacteriuria or a UTI. A positive urine culture in someone with chronic genitourinary symptoms is not enough to diagnose a symptomatic UTI. But an acute deterioration in stable chronic symptoms may indicate an acute infection. Multiple concurrent findings such as fever with hematuria or catheter obstruction are more likely to be due to a urinary source.

Diagnosis & Cause Identification The diagnosis of UTI should be made cautiously, especially in afebrile individuals. Other conditions such as fluid and electrolyte imbalance, adverse drug reactions, or other occult infection may cause or contribute to acute symptoms or condition changes in individuals with bacteriuria.

Urinalysis or urine culture alone cannot distinguish symptomatic from asymptomatic infection. Although all individuals with indwelling catheters are bacteriuric, cultures. may reflect the bacteriology of the catheter, not the bladder. The presence of pyuria or a positive leukocyte esterase test is not enough to confirm that an individual has a UTI, but the absence of pyuria or a negative leukocyte esterase test is fairly strong evidence that a UTI is not present. Recurrent symptomatic infections may necessitate more thorough investigations of possible bladder, ureter, and renal pathology, especially in individuals with chronic indwelling catheters.

Management In asymptomatic individuals, "antimicrobial therapy does not decrease the frequency of symptomatic infection, alter chronic symptoms such as urinary incontinence, nor alter long-term outcomes, including death" (see The Evidence, below). But antimicrobial therapy for asymptomatic bacteriuria does increase the cost of therapy and cause adverse effects, including reinfection with resistant organisms.

Treatment of symptomatic individuals should take into consideration the patient's overall situation, as well as efficacy, potential adverse effects, cost, and possible emergence of antibiotic resistance.

The goal of treating individuals with chronic indwelling catheters who have a symptomatic UTI should be to control systemic symptoms, not to eliminate bacteriuria, which will remain as long as they have an indwelling catheter. Thus, treatment of such individuals can be for less time than for individuals with symptomatic UTIs who are not catheterized.

Compared with community settings, fewer LTC patients are appropriate candidates for intermittent catheterization. Chronic bacteriuria or "asymptomatic infections" in intermittently catheterized residents should not routinely be treated with antibiotics, because doing so promotes antibiotic resistance.

In addition, cranberry juice has not been shown to decrease bacteriuria or episodes of symptomatic infection.

Monitoring "Post-therapy urine cultures are not recommended as a test of cure and should not be obtained unless symptoms have persisted or recurred" (see The Evidence, below). Approximately half of those treated will have a positive urine culture within six weeks after the end of treatment. Therefore, the primary approach should be to monitor the patient for recurrent signs and symptoms. If symptomatic infections recur, then cultures may be indicated to identify new or resistant organisms. Additionally, a urologic evaluation may be indicated to look for conditions such as tumors that might predispose to recurrent infections.

Conclusions

Because of the challenges of identifying and managing UTIs in LTC, there will inevitably be disagreements about whether someone has a UTI and whether and how to treat it. However, the tremendous variability in nursing homes nationwide in identifying and treating UTIs is a disservice to patients. After 30 years, desirable approaches to bacteriuria have not changed substantially.

All facilities should adopt, and require adherence to, an evidence-based policy for identifying and managing problems and symptoms related to the urinary tract. The medical director and other health professionals can help develop and enforce such a policy and ensure that the practices therein are consistent with the literature.

Related procedures should address issues such as collecting information to support the diagnosis of a symptomatic UTI, proper and precise documentation of findings, and prerequisites for calling physicians or requesting orders for antibiotics. Residents, families, and staff should be given information to dispel myths and promote appropriate practices.

Facility staff and practitioners everywhere should use standard diagnostic criteria to identify symptomatic UTIs, and make a UTI diagnosis cautiously, especially in afebrile individuals. Unsubstantiated speculation about UTIs as a cause of multiple symptoms and condition changes should be discouraged. Unless an individual is febrile and has symptoms referable to the urinary tract, other potential causes--such as fluid and electrolyte imbalance or adverse drug reactions--should be strongly considered instead of, or in addition to, a UTI.

Careful observation and detailed documentation and reporting of signs and symptoms (for example, fever or hematuria) are key. Physicians should not be pushed to treat individuals without adequate clinical evidence, or when evidence suggests that treatment is not warranted. When physicians are called, they should be given detailed symptom descriptions--something more than just culture results or the smell or clarity of urine. The patient's overall picture should be reviewed and inquiries made about specific evidence that might confirm or refute a UTI diagnosis before antibiotic orders are authorized.

Generally, symptomatic UTIs should be treated. But bacteriuria (an "asymptomatic UTI") should not be treated routinely. Treating it does not materially improve longevity or correct underlying problems.

In certain situations, empirical antimicrobial therapy may be warranted for afebrile individuals with non-specific symptoms. Any empirical treatment should be based on a documented description of an individual's symptoms, co-existing illnesses and conditions, and identification of pertinent risk factors and alternative explanations for symptoms. Routine antibiotic treatment of individuals with bacteriuria should not be encouraged or condoned, nor should antibiotics be prescribed routinely to treat individuals with symptoms such as recurrent falling or change in mental status.

Routine follow-up cultures after antibiotic treatment should be discouraged because they are costly and don't help good clinical decision making. Antibiotic treatment should not be continued based solely on culture results, but pertinent clinical factors such as recurrent fever should be documented.

Transfer of individuals with symptomatic UTIs is rarely necessary. Fever and change in mental status alone do not automatically warrant hospitalization, nor is there evidence that hospitalization improves outcomes in individuals with symptomatic UTIs. Hospital diagnoses of "urosepsis" are often speculative and imprecise, and may be unwarranted for aforementioned reasons.

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