URINARY TRACT INFECTIONS IN LONG TERM CARE
OBJECTIVES UNDERSTAND THE SCALE OF DISEASE IN LTC SETTINGS DEVELOP AN UNDERSTANDING OF THE DIFFERENT PRESENTATIONS OF UTIs IN THIS SETTING AND WORKUP BECOME AWARE OF THE PREVALENCE OF ASYMPTOMATIC BACTERIURIA AND RELEVANCE TO DIAGNOSIS OF UTIs BE AWARE OF TREATMENT OPTIONS
WHAT ARE WE TRYING TO DO accurately identify and treat UTIs while keeping in mind: impact on morbidity/mortality effects on antimicrobial resistance cost to healthcare system need to prevent hospital transfers multiple unknowns: which patients will get worse?
THE BASICS
Background UTI most common infection experienced by residents of LTC facilities UTI is the most common cause of bacteremia in LTCFs UTIs are a frequent reason for transfers to hospitals UTI is the most common reason for antimicrobial prescriptions in LTCFs (20-60%)
Background Escherichia coli is the most common organism isolated from woman and Proteus mirabilisis the most frequent in men. Other organisms frequently isolated include Klebsiella pneumoniae, Citrobacter species, Enterobacter species, Serratia species, Providencia stuartii, Morganella morganii, and Pseudomonas aeruginosa.
DEFINITIONS Asymptomatic Bacteriuria(ASB): midstream urine collection in asymptomatic individual showing greater than 10 5 cfu/ml. UTI:same as ASB, but with symptoms and potential to cause morbidity/mortality
DIAGNOSTIC TOOLS URINE DIP NITRITES:enterobacteriacea convert urine nitrate to nitrite.(v.good sens/spec in identifying >10 5 CFUs of enterobacteriacea) LEUKOCYTES:measures leukocyte esterase to determine presence of pyuria (spec: ~90%, sens: ~95%) 90% of patients with bacteriuria have pyuria 30% of patients without bacteriuria have pyuria Use to rule out UTI only
THE DIAGNOSIS
WHY IS THIS POPULATION SO DIFFERENT? PREVALENCE OF ASB (50%, 30% ) SIGNS AND SYMPTOMS, COMMUNICATION ISSUES
(ASB)ASYMPTOMATIC BACTERIURIA Up to 30% of male residents and 50% of female residents have asymptomatic bacteriuria?beneficial colonization of urinary tract Significantly reduces value of Urine C&S as diagnostic tool
WE KNOW THAT: SCREENING AND TREATING ASYMPTOMATIC BACTERIURIA IN LTC RESIDENTS HAS NO EFFECT ON MORBIDITY/MORTALITY, AND IS POSSIBLY DETRIMENTAL.
WHY IS THIS POPULATION SO DIFFERENT? PREVALENCE OF ASB (50%, 30% ) SIGNS AND SYMPTOMS, COMMUNICATION ISSUES
TYPICAL SYMPTOMS Acute cystitis (frequency,dysuria,incontinence,suprapubic discomfort)
ATYPICAL SYMPTOMS/ SIGNS Dizziness, acute confusion, falls, anorexia, nausea, general functional deterioration without genitourinary complaints +/- Fever
POSSIBLY HELPFUL SYMPTOMS/SIGNS Acute deterioration in continence Acute pyelonephritis (cva pain/tenderness; with fever) Fever with hematuria Fever with no localizing findings (10% due to UTIs)
UNHELPFUL SYMPTOMS Not symptoms of UTI: Chronic genitourinary symptoms Cloudy or foul smelling urine Clinical deterioration without fever or localizing genitourinary symptoms or signs
OVERALL To date, no constellation of symptoms is identified in older adults who have bacteriuria that can distinguish symptomatic from asymptomatic patients reliably in all situations (Asymptomatic Bacteriuria and Urinary Tract Infection in Older Adults Manisha Juthani-Mehta, MD)
THE BOTTOM LINE UTIs in this population should be a diagnosis of exclusion.
ALGORITHMS
MCGEER CRITERIA 1991 To make an empiric diagnosis of UTI in a nursing home resident who does not have an indwelling catheter, 3 of the following symptoms must be present: Fever (temperature of at least 38 C [100.4 F]). New or increased frequency, urgency, or burning on urination. New flank or suprapubic pain or tenderness. Change in character of urine. Worsening of mental or functional status
LOEB CRITERIA 2001 Minimum criteria for initiating antibiotics include acute dysuria alone or fever (37.9 C) (or 1.5 C increase above baseline temperature) and at least one of the following: new or worsening urgency frequency suprapubic pain gross hematuria costovertebral angle tenderness urinary incontinence
+/- EMPIRIC ABX THERAPY +/- EMPIRIC ABX THERAPY LOEB(2001) ALGORITHM
LOEB(2001) ALGORITHM
Towards Optimized Practice Alberta Guidelines
Towards Optimized Practice Alberta Guidelines
TREATMENT
SUGGESTED THERAPY Empiric UNSTABLE Nitrofurantoin or TMP/SMX ciprofloxacin if can take po ceftriaxone IM otherwise
WHY NITROFURANTOIN? 50 years of experience very little antimicrobial resistance to Low risk of inducing c.diff Low tissue penetration caution: only use if normal renal function
WHY NITROFURANTOIN?
WHY NITROFURANTOIN?
THERAPY DURATION 10 DAYS