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.
-
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.
-
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.
-
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.
-
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.
-
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:
-
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.
-
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.
-
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.
-
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.
-
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
Advani SD, North R, Turner NA, Ahmadi S, Denniss J, Francis A, Johnson R, Hasan A, Mirza F, Pardue S, Rao M, Rosshandler Y, Tang H, Schmader KE, Anderson DJ. Performance of Urinalysis Parameters in Predicting Urinary Tract Infection: Does One Size Fit all? Clin Infect Dis. 2024 Apr 26:ciae230. PMID: 38666412.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
Stall NM, Kandel C, Reppas-Rindlisbacher C, Quinn KL, Wiesenfeld L, MacFadden DR, Johnstone J, Fralick M. Antibiotics for delirium in older adults with pyuria or bacteriuria: A systematic review. J Am Geriatr Soc. 2024 Jun 19. PMID: 38895992.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
Stall NM, Kandel C, Reppas-Rindlisbacher C, Quinn KL, Wiesenfeld L, MacFadden DR, Johnstone J, Fralick M. Antibiotics for delirium in older adults with pyuria or bacteriuria: A systematic review. J Am Geriatr Soc. 2024 Jun 19. doi: 10.1111/jgs.18964. Epub ahead of print. PMID: 38895992.
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
Sources:
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
Urine dipstick or urinalysis is a commonly ordered test but in older adults, it is not reliable for ruling in or ruling out infection. This test can result in misdiagnosis, delays in accurate diagnosis, and contribute to the problem of unnecessary antibiotic prescriptions that can lead to significant patient harms.
In response to this problem, ten societies, associations, and organizations have come together to endorse a practice change across healthcare settings with the aim of reducing the overuse of antibiotics among older adults and promote evidence-based best practice.
These groups recommend that in the investigation of older adults:
-
Note: Routine and microscopic urine evaluation should continue to be used for non-infectious indications only (e.g. to rule out hematuria, proteinuria); Urine culture should continue to be used and only collected after clinical assessment if localizing urinary symptoms are present suggesting cystitis (e.g. acute dysuria, suprapubic tenderness) or pyelonephritis (e.g. fever, flank pain).
Sources:
Advani SD, North R, Turner NA, Ahmadi S, Denniss J, Francis A, Johnson R, Hasan A, Mirza F, Pardue S, Rao M, Rosshandler Y, Tang H, Schmader KE, Anderson DJ. Performance of Urinalysis Parameters in Predicting Urinary Tract Infection: Does One Size Fit all? Clin Infect Dis. 2024 Apr 26:ciae230. doi: 10.1093/cid/ciae230. Epub ahead of print. PMID: 38666412.
Piggott KL, Trimble J, Leis JA. Reducing unnecessary urine culture testing in residents of long term care facilities. BMJ. 2023 Aug 9;382:e075566. doi: 10.1136/bmj-2023-075566. PMID: 37558239.
Cooper MA. The Diagnosis and Management of UTI in >65s: To Dipstick or Not? The Argument For Dipsticks. Infect Prev Pract. 2020 May 8;2(3):100064. doi: 10.1016/j.infpip.2020.100064. PMID: 34368712.
Nace DA, Perera SK, Hanlon JT, Saracco S, Anderson G, Schweon SJ, Klein-Fedyshin M, Wessel CB, Mulligan M, Drinka PJ, Crnich CJ. The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) consensus guidelines for the diagnosis of uncomplicated cystitis in nursing home residents. Journal of the American Medical Directors Association. 2018 Sep 1;19(9):765-9. PMID: 30037743.
Nicolle LE, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54. PMID: 15714408.
Stone ND, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol. 2012 Oct;33(10):965-77. PMID: 22961014.
-
- College of Family Physicians of Canada
- Canadian Society for Long-Term Care Medicine
- Canadian Nurses Association
- Canadian Pharmacist Association
- Nurse Practitioner Association of Canada
- Association of Medical Microbiology and Infectious Disease Canada
- Canadian Urological Association
- Canadian Geriatrics Society
- Canadian Association for Long Term Care
- Health Standards Organization (HSO)
Sources:
Advani SD, North R, Turner NA, Ahmadi S, Denniss J, Francis A, Johnson R, Hasan A, Mirza F, Pardue S, Rao M, Rosshandler Y, Tang H, Schmader KE, Anderson DJ. Performance of Urinalysis Parameters in Predicting Urinary Tract Infection: Does One Size Fit all? Clin Infect Dis. 2024 Apr 26:ciae230. doi: 10.1093/cid/ciae230. Epub ahead of print. PMID: 38666412.
Piggott KL, Trimble J, Leis JA. Reducing unnecessary urine culture testing in residents of long term care facilities. BMJ. 2023 Aug 9;382:e075566. doi: 10.1136/bmj-2023-075566. PMID: 37558239.
Cooper MA. The Diagnosis and Management of UTI in >65s: To Dipstick or Not? The Argument For Dipsticks. Infect Prev Pract. 2020 May 8;2(3):100064. doi: 10.1016/j.infpip.2020.100064. PMID: 34368712.
Nace DA, Perera SK, Hanlon JT, Saracco S, Anderson G, Schweon SJ, Klein-Fedyshin M, Wessel CB, Mulligan M, Drinka PJ, Crnich CJ. The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) consensus guidelines for the diagnosis of uncomplicated cystitis in nursing home residents. Journal of the American Medical Directors Association. 2018 Sep 1;19(9):765-9. PMID: 30037743.
Nicolle LE, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54. PMID: 15714408.
Stone ND, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol. 2012 Oct;33(10):965-77. PMID: 22961014.
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
NEW: Rule Out a Bladder Infection: Suite of Resources
Download our new resources featuring frequently asked questions, a poster on urine dipsticks, and a four-step guide to ruling out bladder infections.
"Reflect Before You Collect" Poster
A poster to encourage thoughtful ordering of urine tests in long-term care homes.
Practice Change Handout
Practice change recommendations to help optimize your antibiotic prescribing for asymptomatic bacteriuria in long-term care settings.
Antibiotics for Urinary Tract Infections in Older People
A patient pamphlet on avoiding antibiotic use for older adults who do not have urinary tract infections.