Key messages
Diagnosis of urinary tract infections (UTI) in residents over 65 years requires a combination of reliable clinical signs and symptoms and a positive urine culture result.
Only perform urine dipstick testing or send urine for culture in patients who are symptomatic. Do not perform urine dipstick testing or send urine for culture solely on the basis of urine odour or appearance.
Residents in long term care facilities have high rates of abnormal dipstick and urine test results without infection necessarily being present. Antibiotic therapy in these cases does not reduce mortality or prevent symptomatic episodes, rather it increases side effects and leads to antibiotic resistance.
Do not routinely use antibiotic prophylaxis to prevent urinary tract infection.
Background
The second national prevalence survey of healthcare-associated infection (HCAI) and antibiotic use in Irish long term care facilities (LTCFs) took place in May 2011. This report highlighted the high rate of prophylactic antibiotic use and the low rate of urinary specimens sent from patients with suspected urinary tract infections (UTIs). Of the 5,922 residents surveyed in 108 LTCF, 4.1% (242) had an infection. UTIs were one of the most common infections and were more common in residents with a urinary catheter. One in ten residents were on antibiotics, which is high when compared with European figures. Antibiotics were prescribed for treatment of infection (58%) and for prophylaxis (39%).(Fig 1)
Figure 1. Indications for antibiotic prescriptions in first and second national LTCF surveys: Infection type and reason for the prescription
Only 45% of residents who were prescribed antibiotics for a UTI had a specimen taken for culture. Prophylactic antibiotics were predominantly prescribed for the prevention of urinary infection; 11.5% of residents on prophylaxis for a urinary infection had a urinary catheter. Overall, 61.7% of all antibiotics prescriptions for the urinary tract were for prophylactic use.
With these results in mind, the Steering group of the second national prevalence study and the SARI community antimicrobial stewardship committee produced a two page guidance document on diagnosis and management of UTI in elderly LTCF residents. This document is available for download here and summarised in this article. With the advent of the RCPI /HSE clinical programme on HCAI and antimicrobial resistance, the SARI committee(s) agreed to complete its work and hand over its functions to a new committee. A new national committee was established in September 2011 as part of the HSE and RCPI clinical programme on HCAI. Dr Nuala O’ Connor represents the ICGP on this national committee. This committee has taken over the functions of the SARI National Committee.
Diagnosis of UTI
Diagnosis of UTI should be based on a full clinical assessment. Symptoms & signs suggestive of urinary tract infection include dysuria, frequency, urgency, new onset incontinence, fever >38°C, suprapubic tenderness and haematuria. In patients with a urinary catheter, loin pain and fever >38°C are significant indicators of a UTI.
A positive urine dipstick result in an asymptomatic patient is not significant and should not be treated. Likewise, it is not recommended that a urine specimen is sent in asymptomatic residents. Dipstick urinalysis is not a reliable way to diagnose UTI and should not be performed if patients are asymptomatic or if a urinary catheter is present as false positives will occur.
Empiric treatment may be considered in a symptomatic patient with a positive dipstick. A urine sample should be sent to the microbiology laboratory for culture and antimicrobial susceptibility testing in these cases.
Interpretation of Urine Culture Results
Table 1 summarises interpretation of urinary culture results in residents without a urinary catheter.
For residents with urinary catheters:
- Laboratory microscopy should not be used to diagnose UTI in catheterised patients as urine white cells are often elevated due to the presence of the catheter.
- If the urine culture result is positive (i.e. single organism ≥ 10,000 (104) colony forming units (CFU)/mL OR ≥ 100,000 (105) mixed growth with one predominant organism OR Escherichia coli or Staphylococcus saprophyticus ≥ 1,000 (103)CFU/mL) treat only if the resident has symptoms or signs suggestive of UTI and no other source is identified.
- In the presence of a urinary catheter antibiotics will not eradicate bacteriuria.
Table 1: Interpretation of urine culture results in residents without a urinary catheter
Empiric therapy of UTI
Empiric antibiotic therapy should only be considered in symptomatic patients pending urine culture result and should be guided by local resistance rates where available. Empiric therapy of UTI in residents over 65 years is summarised in Fig 2 and Fig 3. For treatment of uncomplicated UTI in patients under 65, please refer to page 9 of the National Guidelines for Antimicrobial Prescribing in Primary Care in Ireland (2011). Antibiotic therapy should be modified when culture results are available. If in doubt, contact your local consultant microbiologist for advice.
Figure 2. Empiric therapy of UTI in residents without a urinary catheter
Figure 3. Empiric therapy of UTI in residents with a urinary catheter
Antibiotic Prophylaxis
DO NOT ROUTINELY USE ANTIBIOTIC PROPHYLAXIS TO PREVENT URINARY TRACT INFECTION
Antibiotic prophylaxis is not recommended
- for the prevention of symptomatic UTI in catheterised patients.
- for urinary catheter changes unless there is a definite history of symptomatic UTIs due to catheter change.
Antimicrobial prophylaxis may be considered in patients for whom the number of urinary infections are of such frequency or severity that they chronically impinge on function and well-being.
Dr. Joanne O’Gorman,1 Dr. Fidelma Fitzpatrick, 1-3 Dr. Nuala O’Connor4
1.Department of Clinical Microbiology, Beaumont Hospital, Dublin
2. DublinHSE-Health Protection Surveillance Centre, Dublin
3. HSE-Patient Safety and Quality, Dublin
4. Elmwood Medical Practice, Frankfield, Cork
Further information
Diagnosis and management of urinary tract infection in elderly LTCF residents. Click here.
Guidelines for Antimicrobial Prescribing in Primary Care in Ireland 2011. Click here.
Second National Prevalence Survey on Healthcare Associated Infections and Antibiotic use in Irish Long-Term Care Facilities 2011. Click here.
