Reducing the treatment of asymptomatic bacteriuria in seniors in a long-term care facility
Cases of asymptomatic bacteriuria (ASB) in elderly people are often treated with antibiotics, but current guidelines recommend that bacteriuria in seniors not be treated unless it is associated with a urinary tract infection (UTI). Stanford Place Care Campus is a 182-bed complex-care facility in Parksville, B.C., catering primarily to seniors. To increase the accuracy of the clinical diagnosis of UTIs and reduce the treatment of ASB in this facility, the author developed a self-learning package and a clinical pathway to help nurses and other care providers better assess, manage and monitor residents with suspected UTIs. She also provided education sessions for the nursing and support staff. In the year after the new clinical pathway was introduced, the number of treated UTIs decreased, as did the percentage of treated UTIs that had been inadequately assessed (i.e., diagnosed solely on the basis of a dipstick urinalysis).
The prevalence of bacteria in the urine (bacteriuria) in elderly people in long-term care facilities is as high as 50 per cent in women and 40 per cent in men (Beveridge, Davey, Phillips, & McMurdo, 2011). Bacteriuria may be an indication of a urinary tract infection (UTI) or it may simply represent asymptomatic bacteriuria (ASB). Antibiotic therapy is warranted for UTIs but not for ASB (Toward Optimized Practice [TOP], 2010). Because bacteriuria is so common in this population, when a resident of a long-term care facility has a new or worsening symptom along with bacteriuria, it can be hard to know whether the bacteriuria is related to the symptom and signals a UTI that needs to be treated (Sundvall, Ulleryd, & Gunnarsson, 2011).
Elderly people living in long-term care facilities are prone to UTIs because they are more likely to have comorbid illnesses (Beveridge et al., 2011; TOP, 2010) and may be facing age-related changes that make them more susceptible to UTIs, such as decreased feelings of thirst, dehydration, incontinence, constipation, incomplete bladder emptying and estrogen deficiency (Beveridge et al., 2011; TOP, 2010).
Typical symptoms of UTIs include fever, dysuria, increased urgency, increased frequency of urination, suprapubic pain, changes in the character of urine, bacteriuria of more than 105 colony-forming units/mL, and changes in functional and/or mental status (note that in elderly people, it is quite possible that changes in functional or mental status may signal a general decline in health rather than a UTI) (Health Protection Agency, 2011; Phillips et al., 2012; Zabarsky, Sethi, & Donskey, 2008). Too often, a diagnosis of UTI is made in the absence of these symptoms (i.e., in individuals who have ASB), and antibiotics are prescribed. However, the American Geriatrics Society (2013) has emphasized the importance of not treating elderly people with ASB with antibiotics.
In fact, there is a great deal of evidence suggesting that antibiotic use for ASB can be harmful because of the possibility of adverse drug reactions (Chowdhury et al., 2012; Trivedi & Van Schooneveld, 2012). Also, the overuse of antibiotics increases the incidence of bacterial resistance to these products and the incidence of antibiotic-associated diarrhea caused by organisms such as Clostridium difficile (Gross & Patel, 2007).
The aim of this article is to outline some of the factors that influence the decision to treat cases of ASB with antibiotics in elderly residents of long-term care facilities and to describe a project to improve the accuracy of differentiating between UTIs and ASB in one such facility in British Columbia.
ASB is defined by the presence of bacteria in the urine, which may also be odorous and turbid, but without the presence of dysuria, increased urinary frequency or urgency, fever, flank pain or other symptoms related to irritation of the urethra, bladder or kidney (TOP, 2010).
Because ASB is very common in seniors living in long-term care facilities, the diagnosis of UTIs must be based on clinical as well as laboratory findings (Beveridge et al., 2011). Facilities often use dipstick urinalysis to rule in or rule out a UTI (TOP, 2010). Unfortunately, dipstick urinalysis (or urine culture for that matter) cannot differentiate between symptomatic UTI and ASB (TOP, 2010).
Symptomatic UTIs are defined by the presence of significant bacterial count (>105 colony-forming units/mL) with new symptoms typical of UTIs such as fever, dysuria, increased frequency and urgency of urination, and suprapubic pain (TOP, 2010). It is unclear from the research how many new typical UTI symptoms must be present to be indicative of UTI.
Reasons for overtreatment
Complexity in assessing symptoms. UTI symptoms often present differently in seniors than in younger people (Beveridge et al., 2011; Phillips et al., 2012). For example, elderly people have a lower baseline body temperature, which means that even if their temperature is elevated it may not meet typical fever criteria. An increase of 1.5⁰C over an individual’s baseline temperature qualifies as a fever (Beveridge et al., 2011). Therefore, it is very important to know residents’ baseline temperature to be able to determine when they have a fever (TOP, 2010).
Another complexity is that seniors may have communication difficulties and may not be able to accurately describe their symptoms. It is often difficult to obtain an accurate history from seniors because hearing loss, speech difficulties and cognitive impairment can make communication challenging (Beveridge et al., 2011).
As noted earlier, changes in the functional or mental abilities of elderly people may or may not be related to a UTI. Sometimes symptoms that are not typically seen with UTIs, such as an increase in falls, may in fact signal the presence of this type of infection (Beveridge et al., 2011). Caregivers may notice an increase in restlessness, fatigue, disorientation, confusion, sleepiness, aggressiveness or pain in a resident, but these symptoms may or may not be connected with a UTI: they may instead be caused by dehydration, malnutrition/anorexia, delirium, arthritis, a chronic disease process or progression of already established dementia (Sundvall et al., 2011). In addition, seniors are often already experiencing some of the typical UTI symptoms because of medications they are taking or the aging process.
Communication between physicians, nurses and families. In long-term care facilities, nurses play an important role in performing comprehensive assessments when residents’ condition declines (Sundvall et al., 2011; Zabarsky et al., 2008). It has been found that it is nurses, more often than not, who prompt the physician to order urine cultures and prescribe antibiotics (Sundvall et al., 2011; Zabarsky et al., 2008). Physicians have reported that they often are not provided with sufficient information about a resident when a urine culture is positive (Zabarsky et al., 2008). Some physicians may fear that if they do not treat a resident with antibiotics for an ASB, the resident may later develop symptoms and the family and nurses may question the physician’s decision (Phillips et al., 2012).
The Stanford Place Experience
At Stanford Place Care Campus, a 182-bed complex-care facility on Vancouver Island that caters primarily to seniors, I noticed that for more than 60 per cent of the UTIs that were treated in early 2012, antibiotic therapy was prescribed on the basis of vague symptoms (e.g., confusion, restlessness) and a positive urine dipstick only. The facility’s managers, registered nurses and I set a goal to increase the accuracy of the clinical diagnosis of UTIs and therefore reduce the treatment of ASB in our residents. We wanted to improve residents’ outcomes through decreased morbidity and mortality, optimize our facility’s use of testing and laboratory services, reduce inappropriate prescribing of antibiotics, and optimize antibiotic therapy for residents with a UTI by ensuring that they received the right antibiotic for the particular bacterium with which they were infected (TOP, 2010).
To attain our goal we decided to focus on developing guidelines and standardized criteria for diagnosing and treating UTIs and on educating staff. Several studies have shown that better education is needed for health-care providers in long-term care facilities about ASB and how UTIs present in seniors (Beveridge et al., 2011; Chowdhury et al., 2012; Phillips et al., 2012; Zabarsky et al., 2008).
Self-learning package. After months of researching best practices concerning ASB and the treatment of UTIs and looking at what other long-term care facilities were doing, I created a self-learning package for the nursing staff and distributed it to all licensed practical nurses and RNs working at Stanford Place. I also prepared a handout for the facility’s health care aides (HCAs). I based the content and format of my self-learning package on “Urinary Tract Infections — A Self Learning Program,” a resource created by the Vancouver Island Health Authority (VIHA), which is now known as Island Health.
To ensure that my package was as comprehensive and accurate as possible, I included information from additional sources, such as the “Guideline for the Diagnosis and Management of Urinary Tract Infections in Long Term Care” (TOP, 2010). My self-learning package included information on risk factors for UTIs in the elderly population, typical signs and symptoms of UTIs, actions that may help prevent UTIs, and pointers on how to collect urine samples from residents (with or without a catheter). The package also provided definitions of bacteriuria, pyuria and ASB. In addition, I adapted resources from the Health Protection Agency, TOP and VIHA to create a clinical pathway (Fig. 1) tailored to the needs of a facility such as Stanford Place. I highlighted practice points such as the complexity of assessing elderly people for a suspected UTI and the importance of assessing for typical symptoms to differentiate between an ASB and a UTI. LPNs and RNs at Stanford Place were required to read the package and complete a post test (included in the package). I reviewed the material informally with the small number of participants who scored poorly on the test.
Staff education sessions. In November 2012 I offered several education sessions. Each staff member was required to attend one of the sessions. The sessions for RNs and LPNs were 20-30 minutes long and were intended to increase the accuracy of clinical diagnosis of UTIs and to reduce inappropriate prescribing of antibiotics for ASB. I reviewed the material in the self-learning package and stressed the importance of basing the diagnosis of UTI on symptoms. I also explained our facility’s new clinical pathway and together we examined VIHA’s guideline for caring for residents with a suspected UTI. In addition, I presented some case studies to help participants consolidate their knowledge.
The sessions for HCAs were 15 minutes long and focused on the HCAs’ role in helping LPNs prevent and assess UTIs. I reviewed the typical signs and symptoms of UTIs as well as the difference between ASB and UTIs. I also reviewed how to collect urine samples from residents (with or without catheters) as well as basic catheter care.
Clinical pathway. The new clinical pathway (Fig. 1) was implemented on all units in December 2012. The RNs encouraged the LPNs to use the clinical pathway whenever they suspected a resident had a UTI. A copy of the pathway was posted in each unit for quick reference.
Getting physicians involved. Because some physicians were treating residents with antibiotics on the basis of non-specific symptoms only, I stressed to the LPNs that when they contacted physicians they needed to paint a full clinical picture of the resident’s condition to facilitate the physician’s decision-making about ordering antibiotics. I also encouraged them to ask physicians for an order to collect a urine sample for laboratory analysis. About six months after nurses began using the clinical pathway, the facility’s medical director forwarded the self-learning package and clinical pathway to physicians in the community. One month later, the medical director followed up with a letter describing the training the nurses had received and our goal to reduce the treatment of ASB.
Monitoring. I retrospectively compiled data on the number of antibiotic-treated UTIs and the number of UTIs diagnosed solely on the basis of a dipstick result in 2012. After the clinical pathway was introduced, I tracked the same measures throughout 2013. Whenever I noticed an increase in the number of residents treated with antibiotics in a particular unit in any given month, I investigated the cause and supported staff by providing more training or encouraging nurses to use the clinical pathway.
Outcomes. The total number of antibiotic-treated UTIs decreased from 198 in 2012 to 127 in 2013, representing a 36 per cent reduction. The percentage of treated UTIs in which antibiotics were ordered solely on the basis of a urine dipstick test (indicating inadequate assessment) also decreased, from 62 per cent in 2012 to 38 per cent in 2013. Communications between nurses and physicians concerning UTI treatment improved. Nurses became increasingly comfortable encouraging physicians to investigate suspected UTIs further via urine culture before ordering antibiotics and asking them to discontinue antibiotic therapy when a urine culture came back negative and only non-specific UTI symptoms were observed. Physicians began asking nurses more regularly if residents were experiencing typical UTI symptoms, and some physicians decided not to treat residents unless they were symptomatic. Other nurses and I found that residents’ non-specific symptoms often improved if we increased their fluid intake.
Diagnosing a UTI in elderly people is a complex and multi-faceted process. Stanford Place Care Campus has found that by establishing guidelines to better assess, manage and monitor residents with suspected UTIs and by educating nurses and HCAs on how to use these guidelines, the number of potentially unnecessary antibiotic prescriptions for suspected UTIs can be reduced. When we instituted our clinical pathway at Stanford Place, we also found that an increase in fluid intake was sufficient to alleviate non-specific UTI symptoms in some of our residents. Dehydration has been noted to be a preventable risk factor for UTIs and ASB (Stewart, Longino, Burton, & Corder, 2009).
The aim of this small-scale project was to educate health-care providers at Stanford Place to improve the clinical diagnosis of suspected UTIs in residents. I assumed that if we were able to reduce the number of treated UTIs we would also reduce the number of treated ASBs, but data were not available on the number of ASB cases in our facility before I started this project so I was unable to determine if the project resulted in a reduction in the treatment of ASB. In addition, because of time constraints I was not able to provide as much education as I would have liked to physicians on the importance of not treating ASB.
The self-learning package and the clinical pathway have now been shared with other complex care facilities owned by the Ahmon Group in British Columbia to ensure greater uniformity in the care delivered across these facilities.
The author thanks the Stanford Place Care Campus multidisciplinary team of managers, registered nurses, licensed practical nurses, health care aides, dietitian, and physicians for their help with and support for the project and this article.
American Geriatrics Society. (2013). Choosing wisely: Five things physicians and patients should question.
Beveridge, L. A., Davey, P. G., Phillips, G., & McMurdo, M. (2011). Optimal management of urinary tract infections in older people. Clinical Interventions in Aging, 6, 173-180.
Chowdhury, F., Sarkar, K., Branche, A., Kim, J., Dwek, P., Nangit, A.,…Visconti, E. (2012). Preventing the inappropriate treatment of asymptomatic bacteriuria at a community teaching hospital. Journal of Community Hospital Internal Medicine Perspectives, 2, 17814-17819.
Gross, P. A., & Patel, B. (2007). Reducing antibiotic overuse: A call for a national performance measure for not treating asymptomatic bacteriuria. Clinical Infectious Diseases, 45(15 November), 1335-1337.
Health Protection Agency. (2011). Diagnosis of UTI: Quick reference guide for primary care.
Phillips, C. D., Adepoju, O., Stone, N., McMaughan Moudouni, D. K., Nwaiwu, O., Zhao, H.,…Garfinkel, S. (2012). Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract infections in four nursing homes. BioMed Central Geriatrics, 12, 73-80.
Stewart, L., Longino, H., Burton, D., & Corder, A. (2009, April). Combating dehydration and UTIs in long-term care. Dietary Manager, 30-34.
Sundvall, P.-D., Ulleryd, P., & Gunnarsson, R. K. (2011). Urine culture doubtful in determining etiology of diffuse symptoms among elderly individuals: A cross-sectional study of 32 nursing homes. BioMed Central Family Practice, 12, 36-42.
Toward Optimized Practice [TOP]. (2010). Guideline for the diagnosis and management of urinary tract infections in long term care.
Trivedi, K. K., & Van Schooneveld, T. C. (2012, May 1). Antimicrobial stewardship in long-term care. Medscape Infectious Diseases.
Zabarsky, T. F., Sethi, A. K., & Donskey, C. J. (2008). Sustained reduction in inappropriate treatment of asymptomatic bacteriuria in a long-term care facility through an educational intervention. American Journal of Infection Control, 36(7), 476-480.