URINARY TRACT INFECTION IN THE NURSING HOME
CLINICAL PRACTICE GUIDELINE

 

DISEASE RECOGNITION

  • Worsening or new urinary incontinence or urinary retention
  • Unexplained new anorexia, functional decline [falling, leaning over in seat], mental status changes [restless, crying, agitated]
  • Unexplained fever and/or chills, dysuria, hematuria, urgency, frequency
  • New flank or suprapubic pain

 

CONTEXT / / COMMUNICATION

If the resident is moribund work-up is not indicated. If the resident is on End of Life Care, and relatively stable, work-up and treatment of symptomatic UTI is appropriate. The facility nurse should communicate with the responsible party with MD or NP contact as needed. 

 

ASSOCIATED RISKS

  • History of DM, immunosuppression, renal calculi or insufficiency, previous UTIs
  • Known functional or structural urologic abnormalities [BPH, stones, estrogen deficiency, retention, cystocele]
  • Urologic procedure or discharge from hospital within past 2 weeks
  • Presence of indwelling foley catheter
  • Bowel and bladder incontinence
  • MS, spinal cord injury, HIV

 

PHYSICAL EXAMINATION

  • Vital signs - current and since symptoms began
  • Complete enough to rule out other causes for signs and symptoms noted above
  • Include evaluation of bowel status to rule out fecal impaction

 

DIAGNOSTIC WORK-UP

  • UCS by clean catch or straight catheter (if quality of collection in doubt) in women
  • UCS from lumen of catheter in catheterized resident (change catheter before collection)
  • Accucheck if diabetic - other blood work if urosepsis or other cause for symptoms possible
  • PVR or bladder scan if retention suspected
  • CLINICAL CRITERIA FOR DIAGNOSIS OF SYMPTOMATIC UTI:

Must have at least 3 of the following:

Fever > 100 F or chills

Burning, frequency, urgency

Flank or suprapubic pain/tenderness

Change in character of urine

Worsening mental or functional status

 

DIAGNOSTIC OPTIONS

TREATMENT OPTIONS

If fever > 100 F on 2 occasions over last 12 hours AND indication of other system infection {GI, skin, respiratory] DO NOT ORDER UCS

If fever > 100 F on 2 occasions over last 12 hours AND NO indication of other system infection [GI, skin, respiratory] AND AT LEAST 2 OF THE FOLLOWING ARE PRESENT: new onset burning, frequency, urgency, flank or suprapubic pain, change in character of urine, new onset delirium or change in functional status - ORDER UCS

If fever > 100 F NOT PRESENT on 2 occasions over last 12 hours BUT there is concern about the possibility of a UTI AND a foley is present ORDER UCS

 

 

 

If resident has clinical evidence of symptomatic UTI and UCS is pending:

        If they become hypotensive or develop fever >102F Consider hospitalization

        If foley catheter present change foley [if present >30 days] and start empiric antibiotic [Claforan, Gentamicin, Ampiciilin, Bactrim - 7 days in women, 7-14 days in men]

        Use prior UCS sensitivities if done within last 2 months

        Consider Claforan I GM IM Q12 hours x 48 hours will awaiting UCS results

 

Cranberry juice or caplets: In the elderly there is limited data to indicate that bacteruria may be reduced but no data on infection prevention

For women with recurrent UTIs (with or without symptoms) consider low-dose topical estrogen replacement - Estradiol Vaginal Cream 4 gm intravaginally 2 X a week to reduce vaginal pH

Whenever possible catheters should be changed every 2-4 weeks and always before collecting urine sample for UCS and when UCS results indicate UTI

 

 

References for Urinary Tract Infection

  1. Alcaide, M, Lichtstein, DM: How Best to Treat Urinary Tract Infections in Adults: A Rational Approach in Consultant, Vol. 44, No. 8, July 2004, 1145-1151.
  2. Clinical Presentation by Dr. Joseph Mylotte: Urinary Tract Infection in Long-Term Care, September 18, 2004.
  3. Krogh, RH, Bruskewitz, RC: Disorders of the Lower Genitourinary Tract in Clinical Geriatrics, 1998.
  4. Maloney, C.: Hormone Replacement Therapy in Female Nursing Home Residents With Recurrent Urinary Tract Infection in Annals of Long-Term Care, Vol. 6, No.3, March, 1998, 77-82.
  5. McCue, JD: Infectious Disease in the Elderly: Recent answers to febrile questions in Family Practice Recertification, Special Geriatric Issue, May 15, 2001, 41-52.
  6. Merck Manual of Geriatrics, Urinary Tract Infection, 2nd Edition, 1995-1999.
  7. Murphy, DP: Urinary Tract Infection in Elderly Patients: How Best to Diagnose and Treat in Consultant, October 2004, 1502-1507.
  8. ODonnell, JA, Hofmann MT: Urinary tract infections How to manage nursing home patients with or without chronic catheterization in Geriatrics, Vol. 57, No. 5, May 2002, 45-58.
  9. Riehmann, M: Urinary Tract Infections in the Elderly in Clinical Geriatrics, August, 1998.
  10. Stamm, WE: Scientific and Clinical Challenges in the Management of Urinary Tract Infections in The American Journal of Medicine, Vol. 113 (1A), July 8, 2002, 1S-4S.

MS/10.99
EMS
Revised 12.04