Using Antibiotics Wisely in Long-Term Care
Antibiotics
Using Antibiotics Wisely
Many older adults receive antibiotics for urinary tract infections (UTIs) even though they do not have UTI symptoms. Help reduce unnecessary antibiotic prescribing for asymptomatic bacteria with our Using Antibiotics Wisely recommendations, tools, and resources.
The following key practice changes have been identified and are intended to reduce unnecessary antibiotic use for asymptomatic bacteriuria in LTC. They are not a substitute for timely individual clinical assessment and management and do not apply to acutely unwell resident with suspected sepsis.
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Institutional policy/order sets: Don’t perform screening urinalysis/urine dipstick and/or urine culture and sensitivity for residents on admission, during periodic health examinations, or prior to new specialist referrals.
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Urine dipsticks: Don’t perform urine dipstick/urinalysis to diagnose a UTI. Although it has some value in ruling out infection of the urinary tract, accuracy is poor in older adults, and the harms of using this test in terms of triggering overtreatment outweigh the benefits.
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Nurses, physicians, and nurse practitioners: Don’t assume a UTI is the cause of any change in health status, including behaviors, until alternate explanations are excluded, such as volume depletion, constipation, skin breakdown, medication side effects, and other sources of infection. Don’t send a urine culture unless the change noted is accompanied by minimum criteria (see Practice Change Recommendation #5) for a UTI (specific for residents with and without catheters). Do perform a clinical assessment to identify alternate causes for change in health status including examination of the perineal skin. Do complete a comprehensive delirium workup, if clinically indicated, which may include a urine culture (see Practice Change Recommendation #5). Do encourage increased fluid intake if urine is concentrated or malodorous. Do document and reassess.
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Nurses, physicians, and nurse practitioners: Don’t collect a urine culture upon request without first seeking to understand and address resident/substitute decision-maker/family concerns. If the resident does not meet the minimum criteria (see Practice Change Recommendation #5) for a UTI, provide educational materials about the risks of treating positive urine cultures in the absence of convincing features of infection. Provide resident/substitute decision maker/family with a differential diagnosis and a rationale for the investigations that will help identify the etiology of the symptoms.
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When to collect a urine culture: Don’t order a urine culture unless minimum criteria for a UTI are present (modified Loeb criteria[1],[2]).
- In a non-catheterized resident, the minimum criteria include:
- acute dysuria or
- 2 or more of the following:
- fever [> 37.9°C (100°F) or a 1.5°C (2.4°F) increase above baseline on at least two occasions over the last 12 hours], new or worsening urgency, frequency, suprapubic pain, gross hematuria, flank pain, urinary incontinence
- In a catheterized resident, minimum criteria include:
- Any one of the following after alternate explanations have been excluded: fever [> 37.9°C (100°F) or a 1.5° C (2.4°F) increase above baseline on at least two occasions over the past 12 hours], flank pain, shaking chills, new onset delirium
How to collect a urine culture: Don’t collect urine specimens that are likely to be contaminated (not urine hat or catheter bag). Use an approved sterile collection container. Non-catheterized residents should have a midstream urine if they are able, or alternatively, a urine sample collected through intermittent catheterization. Catheterized residents should have a new urinary catheter placed before collecting the first void if the catheter has remained in place for more than 14 days.
When to treat: Don’t initiate antimicrobial therapy empirically without a strong clinical suspicion of a UTI and until after the appropriate urine specimen has been collected (assuming laboratory pick-up within 24 hours), unless the resident is hemodynamically unstable.
[1] Please note that these are clinical criteria validated for the diagnosis for a UTI and differ from criteria that are used for surveillance
[2] Note that confusion alone is not a symptom of UTI in non-catheterized residents.
- In a non-catheterized resident, the minimum criteria include:
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Nurses: Before calling a physician/nurse practitioner, reassess for the presence of minimum criteria (see Practice Change Recommendation #5) for a UTI in order to inform recommendation.
Physicians/nurse practitioners:
- Don’t prescribe antibiotics before first asking why a urine culture was submitted, and if the initial reason has improved already without antibiotic treatment, don’t treat
- Ask about localizing symptoms of a UTI and only prescribe antibiotics if minimum criteria are still present
Pharmacist: Verify with the physician or nurse practitioner for any antibiotics prescription received, typically used for a UTI, that has a duration greater than a 7-day course.
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Physicians/nurse practitioners/pharmacists: Don’t treat a UTI for excessive durations. Empiric antibiotic choice should be based on resident tolerance, renal function, and local/institutional resistance pattern (antibiogram) where available. Duration of therapy depends on the UTI syndrome: uncomplicated cystitis is 3–5 days depending on the antibiotic chosen; complicated cystitis (male resident, catheterized residents, urological abnormalities) requires 7 days; acute pyelonephritis can generally be treated for 7 days.
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Nurses/physicians/nurse practitioners/pharmacists: Don’t forget to reassess the need for antibiotic therapy within 3 days of starting antibiotics to check antibiotic sensitivity results and that the resident is improving. Urine culture results should be reviewed and antibiotic therapy adjusted according to culture results and sensitivity testing. Antibiotic therapy should be stopped if the result of the urine culture collected before antibiotics is negative. An alternate diagnosis should be considered for residents without improvement despite 3 days of effective therapy. Don’t repeat urine culture (test of cure) for residents who have improved or completed their treatment course.
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Emergency medicine physicians and nurse practitioners: Don’t routinely screen residents from LTC homes with a urinalysis/urine dipstick unless minimum criteria (see Practice Change Recommendation #5) for a UTI are present. Look for alternate explanations for the change in clinical status, refer to Practice Change Recommendation #3.
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Key Practice Change 1
Juthani-Mehta M, Tinetti M, Perrelli E, Towle V, Quagliarello V. Role of dipstick testing in the evaluation of urinary tract infection in nursing home residents. Infect Control Hosp Epidemiol. 2007;28(7):889-891. PMID: 17564998
Nicolle LE, Gupta K, Bradley SF, Colgan R, DeMuri GP, Drekonja D, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68(10):e83–e110.
Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med. 1987;83(1):27-33. PMID: 3300325
Key Practice Change 2
Juthani-Mehta M, Tinetti M, Perrelli E, Towle V, Quagliarello V. Role of dipstick testing in the evaluation of urinary tract infection in nursing home residents. Infect Control Hosp Epidemiol. 2007;28(7):889-891. PMID: 17564998
Nicolle LE, SHEA Long-Term-Care-Committee. Urinary tract infections in long-term-care facilities. Infect Control Hosp Epidemiol. 2001;22(3):167-175. PMID: 11310697
Key Practice Change 3
Begum MN, Johnson CS. A review of the literature on dehydration in the institutionalized elderly. e-SPEN. 2010;5(1):e47-e53. DOI: https://doi.org/10.1016/j.eclnm.2009.10.007
Boscia JA, Kobasa WD, Abrutyn E, Levison ME, Kaplan AM, Kaye D. Lack of association between bacteriuria and symptoms in the elderly. Am J Med. 1986;81(6):979-982. PMID: 3799658
Eeles E, Rockwood K. Delirium in the long-term care setting: clinical and research challenges. J Am Med Dir Assoc. 2008;9(3):157-161. PMID: 18294597
Inouye SK. Delirium in older persons. N Engl J Med. 2006;354(11):1157-1165. PMID: 16540616
Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ. 2005;331(7518):669. PMID: 11232875
McKenzie R, Stewart MT, Bellantoni MF, Finucane TE. Bacteriuria in individuals who become delirious. Am J Med. 2014;127(4):255-257. PMID: 24439075
Midthun SJ, Paur R, Lindseth G. Urinary tract infections. Does the smell really tell? J Gerontol Nurs. 2004;30(6):4-9. PMID: 15227931
Nace DA, Perera SK, Hanlon JT, Saracco S, Anderson G, Schweon SJ, et al. The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents. J Am Med Dir Assoc. 2018;19(9):765-769.e3. PMID: 30037743
Nicolle LE, Gupta K, Bradley SF, Colgan R, DeMuri GP, Drekonja D, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68(10):e83–e110.
Orr PH, Nicolle LE, Duckworth H, Brunka J, Kennedy J, Murray D, et al. Febrile urinary tract infection in the institutionalized elderly. Am J Med. 1996;100(1):71-77. PMID: 8579090
Key Practice Change 4
Nicolle LE, Gupta K, Bradley SF, Colgan R, DeMuri GP, Drekonja D, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68(10):e83–e110.
Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ. 2005;331(7518):669. PMID: 16150741
Orr PH, Nicolle LE, Duckworth H, Brunka J, Kennedy J, Murray D, et al. Febrile urinary tract infection in the institutionalized elderly. Am J Med. 1996;100(1):71-77. PMID: 8579090
Walker S, McGeer A, Simor AE, Armstrong-Evans M, Loeb M. Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? A qualitative study of physicians’ and nurses’ perceptions. CMAJ. 2000;163(3):273-277. PMID: 10951723
Key Practice Change 5
Hanlon JT, Perera S, Drinka PJ, Crnich CJ, Schweon SJ, Klein-Fedyshin M, et al. The IOU Consensus Recommendations for Empirical Therapy of Cystitis in Nursing Home Residents. J Am Geriatr Soc. 2019;67(3):539-545. PMID: 30584657
Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, Saint S, Schaeffer AJ, Tambayh PA, Tenke P, Nicolle LE; Infectious Diseases Society of America. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. 2010 Mar 1;50(5):625-63. PMID: 20175247
Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ. 2005;331(7518):669. PMID: 16150741
Nace DA, Perera SK, Hanlon JT, Saracco S, Anderson G, Schweon SJ, et al. The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents. J Am Med Dir Assoc. 2018;19(9):765-769.e3. PMID: 30037743
Key Practice Change 6
Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ. 2005;331(7518):669. PMID: 16150741
Nace DA, Perera SK, Hanlon JT, Saracco S, Anderson G, Schweon SJ, et al. The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents. J Am Med Dir Assoc. 2018;19(9):765-769.e3. PMID: 30037743
Key Practice Change 7
Hanlon JT, Perera S, Drinka PJ, Crnich CJ, Schweon SJ, Klein-Fedyshin M, et al. The IOU Consensus Recommendations for Empirical Therapy of Cystitis in Nursing Home Residents. J Am Geriatr Soc. 2019;67(3):539-545. PMID: 30584657
van Buul LW, van der Steen JT, Veenhuizen RB, Achterberg WP, Schellevis FG, Essink RT, et al. Antibiotic use and resistance in long term care facilities. J Am Med Dir Assoc. 2012;13(6):568.e1-13. PMID: 22575772
Key Practice Change 8
Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ. 2005;331(7518):669. PMID: 16150741
van Buul LW, van der Steen JT, Veenhuizen RB, Achterberg WP, Schellevis FG, Essink RT, et al. Antibiotic use and resistance in long term care facilities. J Am Med Dir Assoc. 2012;13(6):568.e1-13. PMID: 22575772
Key Practice Change 9
Begum MN, Johnson CS. A review of the literature on dehydration in the institutionalized elderly. e-SPEN. 2010;5(1):e47–e53. DOI: https://doi.org/10.1016/j.eclnm.2009.10.007
Boscia JA, Kobasa WD, Abrutyn E, Levison ME, Kaplan AM, Kaye D. Lack of association between bacteriuria and symptoms in the elderly. Am J Med. 1986;81(6):979-982. PMID: 3799658
Eeles E, Rockwood K. Delirium in the long-term care setting: clinical and research challenges. J Am Med Dir Assoc. 2008;9(3):157-161. PMID: 18294597
Inouye SK. Delirium in older persons. N Engl J Med. 2006;354(11):1157-1165. PMID: 16540616
Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ. 2005;331(7518):669. PMID: 16150741
McKenzie R, Stewart MT, Bellantoni MF, Finucane TE. Bacteriuria in individuals who become delirious. Am J Med. 2014;127(4):255-257. PMID: 24439075
Midthun SJ, Paur R, Lindseth G. Urinary tract infections. Does the smell really tell? J Gerontol Nurs. 2004;30(6):4-9. PMID: 15227931
Orr PH, Nicolle LE, Duckworth H, Brunka J, Kennedy J, Murray D, et al. Febrile urinary tract infection in the institutionalized elderly. Am J Med. 1996;100(1):71-77. PMID: 8579090
- Practice Change Handout: This handout includes practice change recommendations to help optimize your antibiotic prescribing for asymptomatic bacteriuria in long-term care settings.
- A poster developed for clinical areas in long-term care. The poster encourages clinicians to reflect before collecting urine for suspected UTIs in older adults.
Antibiotics for Urinary Tract Infections in Older People
When you need them and when you don’t.