Managing Urinary Tract Infections: Guide for Nursing Home Practitioners
- Fri, 9/5/08 - 4:54pm
- 0 Comments
- 24338 reads
EPIDEMIOLOGY OF URINARY TRACT INFECTIONS IN THE ELDERLY
Urinary tract infections (UTIs) are the most common bacterial infections encountered in nursing home residents.1 The prevalence of UTIs increases with advancing age in both men and women. With advancing age, the female/male ratio of UTI incidence narrows, approaching 2:1 in older adults. This change is attributed to the increased incidence of UTI among elderly men that accompanies the increased prevalence of bladder outlet obstruction due to prostatic enlargement, as well as to the relative reduction in UTI incidence among elderly women due to decreased sexual activity.2 Recurrent and complicated UTIs are also more common in older adults compared to younger adults. This is attributed to the increased frequency of predisposing anatomic and pathophysiologic factors, such as uterine prolapse, urolithiasis, and genitourinary tract malignancies. Urinary tract infections that complicate the use of urinary catheters are common in the elderly and are associated with increased morbidity.3 Older adults with UTI have more types of urinary tract pathogens compared to younger patients. Escherichia coli (E. coli) is the most frequently isolated urinary pathogen identified in 70% of outpatient elderly females with UTI and in 40% of older patients with urethral catheters.4 Gram-positive bacteria (eg, enterococci, coagulase-negative staphylococci, and group B streptococci) are more frequently isolated in patients with recurrent UTI as a result of frequent use of antibiotics that are inactive against these organisms (eg, quinolones).4
Several factors have been linked to the development of UTI in the elderly. These include increased age, menopause, and instrumentation of the urinary tract. Another risk factor that is often overlooked is dehydration.5 Factors that were found unrelated to the development of UTI include diet and personal hygiene.6,7
As part of the Nursing Home Quality Initiative (NHQI) that became effective January 1, 2004, the percentage of residents with a urinary tract infection over the past 30 days and the percentage of residents who have or had a catheter inserted and left in their bladder over the past 14 days became two of the quality measures publicly released by the Centers for Medicare and Medicaid Services (CMS) on all Medicare- and Medicaid-certified nursing homes on the Nursing Home Compare website.8
ASYMPTOMATIC BACTERIURIA OR UTI
The Association for Professionals in Infection Control and Epidemiology (APIC) defines a positive urine culture as a laboratory confirmation of > 100,000 colony-forming units (CFU)/mL.9 However, a positive urine culture does not indicate whether a nursing home resident has a UTI or asymptomatic bacteriuria (a positive culture without dysuria, urinary frequency, incontinence of recent onset, flank pain, fever, or other signs of infection during the week before a urine sample was obtained).10 Asymptomatic bacteriuria is not a UTI and should not be treated unless accompanied by symptoms that suggest a UTI.7 The prevalence of asymptomatic bacteriuria among residents in long-term care facilities is estimated to be 10-50%.10 Prospective studies have shown that untreated asymptomatic bacteriuria in long-term care residents without indwelling urinary catheters did not result in increased morbidity or mortality.11,12
Bacteriuria is a frequent complication of urinary catheter placement in nursing home residents. Bacteriuria has been detected at a rate of 3-10% per day among patients with urethral catheters. A single in-and-out catheterization may cause bacteriuria in as many as 20% of patients. By about 30 days (the cutoff period between short- and long-term catheterization), most patients have some degree of bacteriuria. Bacteriuria associated with short-term catheterization usually involves a single pathogen, most commonly E. coli.
References
1. Bentley DW, Bradley S, High K, et al. Practice guidelines for evaluation of fever and infection in long term care facilities. J Am Med Dir Assoc 2001;2:246-258.
2. Nicole NE. Epidemiology of urinary tract infection. Infect Med 2001;18:153-162.
3. Gammack JK. Use and management of chronic urinary catheters in long-term care: Much controversy, little consensus. J Am Med Dir Assoc 2002;3:162-168.
4. Nicolle LE. Urinary tract infections in geriatric and institutionalized patients. Curr Opin Urol 2002;12:51-55.
5. Kamel HK. Predicting urinary tract infection in patients undergoing hip fracture surgery. J Am Med Dir Assoc. In press.
6. Beyer I, Mergam A, Benoit F, et al. Management of urinary tract infections in the elderly. Z Gerontol Geriatr 2001;34:153-157.
7. Kamel HK. Managing urinary tract infections in the nursing home: Myths, mysteries and realities. Internet Journal of Geriatrics and Gerontology 2004;1(2).
8. Nursing Home Compare website. Available at: www.medicare.gov/NHcompare. Accessed May 6, 2005.
9. McGeer A, Campbell B, Emori TG, et al. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control 1991;19(1):1-7.
10. Nicolle LE. Urinary tract infections in long-term care facilities. Infect Control Hosp Epidemiol 1993;14:220-225.
11. Nicolle LE, Bjornson J, Harding GK, MacDonnell JA. Bacteriuria in elderly institutionalized men. N Engl J Med 1983;309:1420-1425.
12. Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized women. Am J Med 1987;83:27-33.
13. Garibaldi RA, Mooney BR, Epstein BJ, Britt MR. An evaluation of daily bacteriolgic monitoring to identify preventable episodes of catheter-associated urinary tract infection. Infect Control 1982;3:466-470.
14. Berman P, Hogan DB, Fox RA. The atypical presentation of infection in old age. Age Ageing 1987;16:201-207.
15. Loeb M, Bentley DW, Bradley S, et al. Development of minimum criteria for the initiation of antibiotics in residents of long-term facilities: Results of a consensus conference. Infect Control Hosp Epidemiol 200;22(2):120-124.
16. The American Medical Directors Association. The OBRA ’87 Enforcement Rule. Columbia, MD: American Medical Directors Association; 1995.
17. Ouslander JG, Greengold BA, Silverblatt FJ, Garcia JP. An accurate method to obtain urine for cultures in men with external catheters. Arch Intern Med 1987;147:286-288.
18. Eidelman Y, Raveh D, Yinnon AM, et al. Reagent strip diagnosis of UTI in a high-risk population. Am J Emerg Med 2002;20:112-113.
19. Ouslander JG, Greengold B, Chen S. External catheter use and urinary tract infections among incontinent male nursing home patients. J Am Geriatr Soc 1987;35:1063-1070.
20. Ouslander JG, Greengold B, Chen S. Complications of chronic indwelling urinary catheters among male nursing home patients: A prospective study. J Urol 1987;138:1191-1195.
21. Saint S, Lipsky BA, Baker PD, et al. Urinary catheters: What type do men and their nurses prefer? J Am Geriatr Soc 1999;47(12):1453-1457.
22. Saint S, Lipsky BA. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Intern Med 1999;159(8):800-808.
23. Hirsh DD, Fainstein V, Musher DM. Do condom catheter collecting systems cause urinary tract infection? JAMA 1979;242(4):340-341.
24. Kunin CM, Douthitt S, Dancing J, et al. The association between the use of urinary catheters and morbidity and mortality among elderly patients in nursing homes. Am J Epidemiol 1992;135:291-301.
25. Hebel JR, Warren JW. The use of urethral, condom and suprapubic catheters in aged nursing home patients. J Am Geriatr Soc 1990;38:777-784.
26. Tangtrakul S, Taechaiya S, Suthutvoravut S, Lindsmita V. Post-cesarean section urinary tract infection: A comparison between intermittent and indwelling catheterization J Med Assoc Thai 1994; 77:244-248.
27. Dobbs SP, Jackson SR, Wilson AM, et al. A prospective, randomized trial comparing continuous bladder drainage with catheterization at abdominal hysterectomy. Br J Urol 1997;80:554-556.
28. Priefer BA, Duthie EH, Gambert SR. Frequency of urinary catheter change and clinical urinary tract infection: Study in hospital-based skilled nursing home. Urology 1982;20:141-142.
29. Raz R, Schiller D, Nicolle LE. Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection. J Urol 2000;164:1254-1258.
30. Wong E, Hooton T. Guideline for prevention of catheter-associated urinary tract infection. Infect Control 1981;2:125-130.
31. Warren JW, Tenney JH, Hoopes JM, et al. A prospective microbial study of bacteriuria in patients with chronic indwelling urethral catheters. J Infect Dis 1982;146:719-723.
32. Breitenbucher RB. Bacterial changes in the urine samples of patients with long-term indwelling catheters. Arch Intern Med 1984;144:1585-1588.
33. Saint S, Elmore JG, Sullivan SD, et al. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: A meta-analysis. Am J Med 1998;105:236-241.
34. O’Donnell J, Gelone SP, Abrutyn E. Selecting drug regimens for urinary tract infections: Current recommendations. Infect Med 2002;19:14-22.
35. Takahashi P, Trang N, Chutka D, Evans J. Antibiotic prescribing and outcomes following treatment of symptomatic urinary tract infections in older women. J Am Med Dir Assoc 2004;5(2 Suppl):S11-S15.
36. Albert X, Huertas I, Pereiro II, et al. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev 2004;(3):CD001209.
37. Trautner BW, Darouiche RO. Catheter-associated infections: Pathogenesis affects prevention. Arch Intern Med 2004;164(8):842-850.
38. Warren JW, Anthony WC, Hoopes JM, Muncie HL. Cephalexin for susceptible bacteriuria in afebrile, long-term catheterized patients. JAMA 1982;248:454-458.
39. O’Donnell JA, Hofmann MT. Urinary tract infections: How to manage nursing home patients with or without chronic catheterization. Geriatrics 2002;57:49-56.
Post new comment