Welcome to preventing urinary tract infections in nursing home residents. This module is intended to help educate nursing home staff about the risk of urinary tract infections among the residents, and prevention strategies for helping residents stay healthy and UTI free. There are four objectives for this module. Describe the causes and risk factors for UTIs in nursing home residents. Differentiate between asymptomatic bladder colonization and symptomatic urinary tract infections in nursing home residents. Understand when and when not to test for and treat UTIs. Discuss prevention strategies to reduce the incidents of UTIs among residents. A urinary tract infection is the invasion of the urinary system by a disease causing microorganisms that is characterized by urinary tract specific symptoms in the setting of significant bacteria greater than 100,000 or 10^5 in a urine specimen. Asymptomatic bacteriuria or asymptomatic bladder colonization is the presence of bacteria in the urine without any urinary tract specific signs or symptoms suggestive of a UTI. Pyuria is the presence of white blood cells, pus, in the urine, indicating inflammation of the urinary tract due to infectious or non-infectious causes. Urinary tract infection is one of the most commonly diagnosed infections in older adults, and is the most frequently diagnosed infection in long-term care residents, accounting for over 1/3 of all nursing home associated infections. Data from several studies suggests that the rate of symptomatic UTI in non catheterized residents is around 1.1 percent of the population. This is substantially lower than the rate of symptomatic UTIs among residents with an indwelling catheter, which has been measured at 5.5 percent of the population. UTIs are a common reason for hospitalizations, comprising almost 30 percent of hospital readmissions from nursing homes within 30 days. Nationally, 5-10 percent of long-term care residents have urinary catheters in place. Of new residents admitted to nursing homes from hospitals, 12 percent have urinary catheters present upon transfer. Because of this high frequency of residents with catheters in place upon transfer to long-term care facilities, it is important that a medical justification for the catheter is provided by the sending facility and the resident is assessed upon admission for continued need. The presence of bacteria in the bladders of older adults residing in long-term cares facilities is often normal and increases considerably with age for both men and women. For instance, in women residing in the community, the estimated prevalence of asymptomatic colonization of the bladder is 1-5 percent, increasing to almost 20 percent in women over the age of 80. In long-term care facilities, the prevalence is much higher with rates reaching up to 50 percent. For men, the trend is the same. The use of urinary catheters predisposes men and women to asymptomatic bladder colonization. The risk and catheterized older adults ranges from 3-10 percent per day of catheterization, reaching 100 percent in chronically catheterized residents. To summarize, bacteria in the bladder is often a normal and expected finding and does not, by itself, represent an infection. A number of factors predispose older persons to urinary tract infections. The use of urinary catheters and external urinary collection devices increase the frequency of colonization of the bladder. Asymptomatic bacteria urea is more common in people with cognitive impairment and urinary and fecal incontinence. Neurological conditions such as strokes, Alzheimer's disease, and Parkinson's disease, are all common later in life and associated with impaired bladder emptying. Older people with diabetes also have an increased prevalence of asymptomatic bladder colonization, especially with contributing factors like neurogenic bladder and poor blood sugar control. In post-menopausal women, decreased estrogen has been linked with increased colonization and increased urinary tract infections. In men, prostate enlargement leads to urinary symptoms and urinary retention, which can result in colonization and UTIs. A urinary tract infection or UTI, occurs when bacteria or germs get into the urinary tract and multiply. The urinary tract is made up of the bladder, urethra and the two ureters and kidneys. These germs usually enter the urinary tract through the urethra, the tube that carries urine out of the body and travel up to the bladder. The result is redness, swelling, and pain in the urinary tract. When a catheter is in place, this creates an easy avenue for the bacteria to enter the bladder. Bacteria can travel up the outside of the catheter, or it can enter the bladder through the lumen of the catheter itself, especially when the system is disconnected or the collection bag becomes contaminated. Now, let's watch gowns and gloves to see what new symptoms Elaine has. Previously on Gowns and Gloves and MRSA outbreak has kept the nurses busy at Sunnyside as they work hard to contain the infection and keep their residents calm. Meanwhile, Elaine Houston and her husband Dimitri, have been busy trying to confirm that Priscilla is in fact Mrs. Houston, so long lost granddaughter. Will their search for answers prove fruitful or are Mrs. Houston infection troubles, just a very sad turn of events. Will the nursing staff ever figure out the cause of the infections? Will David's recent win on the technique cause a rift with his fellow Sunnyside nursing staff? Find out this week on Gowns and Gloves. There you're again. You have amazing covers. I love David, crazy. Hi David. Welcome back and congratulations on winning the technique. Yes. Welcome back. You're quite the celebrity. I saw you on the today show. You and Minerva. It's amazing. It's fantastic. I don't know. It's getting on my nerves. These are your 15 minutes of fame, you should enjoy them. Well, fame and Minerva are fun. But now I'd rather practice my technique on people who really need me. Speaking of people who need you, your grandma has gone through quite an ordeal since arriving at Sunnyside. She's a funny one. You didn't tell me she and Dimitri were so intense. Now how so? Well, you'd almost think that they wanted to be stuck here at Sunnyside. They keep asking for me to personally look after them. Vanessa doesn't stand a chance when she walks in the room. Dimitri is getting on my nerves. It's funny. I was actually just going to go see her. Want to come with me? Sure. Vanessa and I were just about to go check in on her anyway. Let's go. Grandma. David, sweetheart. How good to see you. I'm so proud of you for winning the technique. I watch every episode on TV. But don't get too close. I have all kinds of bugs. Grandma, tell me how you are. By the way, I hear you've gotten close to my coworker, Priscilla. Oh,we have had the great pleasure of Priscilla's company and care. She has taken great care of your grandmother. Elaine, why don't you tell David about your ailments? As you know, I was admitted to Sunnyside after my hip surgery. Before I knew it, I was colonized, bursa. Then I became infected and everybody including Dimitri was under contact precautions. Then I had the flu and I had to go on droplet precautions, which means I had to wear a mask. But the funny thing is, that when both Priscilla and I are on masks we look so much like that. Why don't you go on with your story dear. Right. Now we're here. I'm not feeling at all my best. Grandma, you need to work on gaining your strength back so that you can recuperate at home as soon as possible. David has a great point. You're almost ready to go home. Actually, I'm not feeling well at all today. I'm a little weak and woozy. Tell me more about your symptoms. Are you experiencing any discomfort or any changes from what is normal? Now that you mentioned it, I do have a little stomach pain and I've been going to the bathroom more frequently. Sometimes, I barely make it. Let's get a urine sample just to make sure everything's okay. Now that the MRSA outbreak is under control and no flu cases this week, we're going to focus on getting you discharged Mrs. Houston. But first, let's see if we can get you feeling a little bit better. Thank you. I appreciate that. Grandma, I'm heading out now. I'm on Letterman tonight, but then I'm headed home for good. Well, you remember to bring Minerva back with you. Okay. How do you diagnose a UTI? Let's look at the example given in the video. Elaine had some general non-specific symptoms like feeling weak and fatigued. These could be caused by any number of things, including dehydration, medication side effects, poor sleep, or the start of an infection. Those symptoms alone would not be enough of an indication to test. When the nurse asked questions, Elaine said she was experiencing some urinary-specific symptoms that are indicative of a potential infection. Suprapubic tenderness, new onset of frequency, and new onset of urgency. This information from the resident prompted the next step. Take a careful look at the cause of the symptoms and collect a urine specimen for testing. Here are general guidelines for what to do whenever you're deciding whether the person should have their urine tested. The first step is to decide whether the person has fever or any signs or symptoms suggestive of a urinary infection. If the answer is yes, the doctor should be notified and urine should be sent for testing. If the answer is no, fluids, toileting and hygiene management, and close monitoring for clinical changes are appropriate. As a note, urine testing should only be performed when there is a reasonable likelihood the resident may have a UTI as judged by meeting the minimal criteria listed here. Over-testing leads to overtreatment which can cause adverse events from unnecessary antibiotics. UTI is less likely without the specific symptoms listed previously. Non-specific symptoms such as a sudden change in behavior, fatigue, or a fall may be caused by other factors including dehydration, hypo or hyperglycemia, depression, poor sleep, medication side effects, hypoxia, constipation, or pain. It is important to consider these other possible causes of the resident's symptoms. Residents with significantly advanced dementia present a challenge because they often have minimal to no verbal communication. This makes it nearly impossible for them to meaningfully express typical symptoms. Moreover, these residents also have profound cognitive deficits and urinary incontinence, which makes mental status changes hard to discern, and urinary frequency difficult to detect. Fever alone may be adequate evidence of UTI so long as there are no additional symptoms such as new cough to suggest an alternative source of infection. Other symptoms such as leukocytosis or hemodynamic instability may also be helpful. Any treatment decisions made regarding infections in this population have to incorporate the resonance preferences regarding the goal of their care as defined by their healthcare proxies. The potential disadvantages to work up in treatment of a suspected UTI in residents with advanced dementia may outweigh the advantages, particularly when the likelihood of UTI is low. After collecting Elaine's urine using an in-and-out catheter, the following results come back from the urinalysis. Let's take a look at what each one means. First, we note that there is a small amount of blood present in the urine. This can result from an infection or catheter trauma. Next, we note that the urine is positive for nitrites, which is the result of bacteria in the urine. This is confirmed by the three-plus bacteria also noted. A positive nitrite can be caused by bacterial colonization, contamination, or infection. The sample is also positive for leukocyte esterase, which indicates the presence of white blood cells in the urine. This too is confirmed by the high numbers of white blood cells seen under the microscope. The presence of pus or pyuria in older adults can be caused by an infection, but can also be caused by bladder or kidney inflammation without an infection. When looked at in total. The urinalysis is only helpful when trying to rule out an infection. When nitrite and leukocyte esterase are both negative, this means there is a very low likelihood of an infection when one or both are positive, as is often the case with nursing home residents, the meaning of the results depends on the culture result in clinical signs and symptoms present. A positive urine culture is necessary for a diagnosis of a UTI. For residents without an indwelling catheter, at least 100,000 colony forming units per milliliter of no more than two species of microorganisms is the recommended count for a voided specimen. For a specimen collected by in and out catheterization, at least 100 colony forming units per milliliter of organisms is recommended before urine samples for culture are obtained from residents with a chronic indwelling catheter in place for more than 14 days. The original urinary catheter should be removed and replaced and the specimen should be obtained from the new catheter. For residents with indwelling catheters present, at least 100,000 colony forming units per milliliter of organisms is required for a diagnosis of a UTI. Let's look at the Elaine's results. It shows that her urine grew no more than 100,000 colony forming units per milliliter of E Coli with resistance to ampicillin, bactrim, and cipro. What does this culture results tell us? As with urinalysis, it only tells part of the story. Elaine has bacteria in her urine that could cause an infection, but it is not enough to distinguish between colonization and infection. Again, we need to rely on the resident's clinical signs and symptoms to see the complete picture. In the elderly population, a wide spectrum of infecting organisms can cause urinary tract infections, and many infecting organisms have developed increased anti-microbial resistance. E Coli is the most frequently isolated organism. Proteus mirabilis. Klebsiella pneumoniae, and enterococcus species are also frequently isolated. Now back at Sunnyside. Well, it looks like Mrs. Houston has a urinary tract infection. I would have expected her to be much more uncomfortable than she seems. Now that we know that she has one though, what should we do? Hey guys, remember me? Content expert. I'm sorry to interrupt, but we have a lot of information to convey in this scene and I just want to make sure that you can handle it. Hi Jean. We've been rehearsing our lines all day. I'm glad to hear that. You know that just because the resident has bacteria in their urine does not mean that they have an infection. Older persons, especially in long-term health care facilities, are known to have bladders that are colonized with bacteria, but they never exhibit symptoms of infection. That's why it is very important to tell the difference between bacterial colonization of the bladder and symptomatic urinary tract infection. Never treat colonization with an antibiotic. Only symptomatic urinary tract infection. Now in Mrs. Houston's situation, she has symptoms that warrant the use of an antibiotic, suprapubic pain, frequency, urgency, and a positive lab result. Okay. I think we've got it. I just want let you down. Great. You're doing great. I already talked with Dr. Kennedy and he said to start Mrs. Houston on levofloxacin. Okay. I'll go get the medication and I'll meet you in Mrs. Houston's room. I can't bear to break any more bad news by myself. We already know that up to 40 percent or more of residents without an indwelling catheter have asymptomatic colonization of the urinary tract, and that a positive culture is a common and expected finding at any time. When localizing and systemic symptoms or signs such as fever or shaking, chills, painful urination, blood in urine, pain or tenderness along the urinary tract at a new or increased frequency, urgency or in continents are also present. Diagnosis and treatment of a UTI is appropriate. In residents without any signs or symptoms who have a positive urinalysis and positive culture, these are often benign findings and should not be treated as this can be harmful to the resident. Prescribing antibiotics is the subject of increased scrutiny due to the overuse of antibiotics and resulting resistance to antibiotics that many organisms develop. The upward trend of C difficile diarrhea cases and increasing antibiotic resistance has led to the positive practice of shifting from broad to narrow spectrum antibiotics. The use of narrow spectrum antibiotics is based on the need for accurate diagnoses and the importance of obtaining cultures in the elderly population before starting antibiotics. Local antibiotic resistance patterns are increasingly utilized for aiding in the prescribing of antibiotics to ensure that the infecting bacteria and available antibiotics are appropriately matched up. When clinicians are selecting antibiotics for treating UTIs, they should follow evidence-based clinical guidelines, such as those published by the Infectious Disease Society of America or other professional societies. Clinicians faced with the decision to treat with antibiotics or employ, monitor and observe, often opt for antibiotics due to the concerns over missing an infection, delaying treatment or not meeting a residence or family's expectations. In doing so, physicians overvalue the benefits of antibiotic therapy while undervaluing the strong likelihood of negative outcomes related to treating asymptomatic bacterial colonization, such as Clostridium difficile, adverse drug events and antibiotic resistance. The appropriate choice is to monitor and observe the resident, which is called watchful waiting. The example observation order set shown here ensures that the resident is receiving supportive care, provides reassurance that the resident is being adequately cared for and emphasizes prompt communication for changes in condition. The goal of treatment for UTI is to alleviate symptoms, not to create a sterile bladder. If the resident appears to be responding to the therapy, it is not necessary to reculture after a course of antibiotics. Polymicrobial bacteriuria often persist after a course of antibiotics and does not mean the treatment has failed. A urine test alone does not provide sufficient information, increases the risk of treating asymptomatic bacteriuria, as well as the risk of adverse drug events C difficile infection and antimicrobial resistance. To sum up, for residents with no symptoms of a UTI, do not test or treat the urine, but do implement an observation protocol. If a resident develops new signs or symptoms such as weakness, delirium, or fever, consider other causes to promote individualized care and be mindful of prevalence of asymptomatic bacteriuria. Always check for specific UTI symptoms to be present, to then proceed to testing and treating the urine as needed. Let's check back in at Sunnyside to see how she handles her diagnosis of a urinary tract infection. Hello, Mrs. Houston. Well, we got your test results back and it appears you have a urinary tract infection. Good grief, you've got to be kidding me. I'm afraid it's no joke. We're going to start you on an antibiotic to help your body fight the infection. It's going to be very important that you finish the entire course of medicine. How did I get a urinary tract infection? Well, Mrs. Houston, you may be experiencing normal changes that occur with age, limited mobility, and poor hydration. You really have been distracted watching David on the TV and not taking care of yourself as well as you could. Cut. You should also point out that people with a urinary catheter or those experiencing functional or cognitive impairment are at greater risk for UTIs. Cognitive impairment. How dare you? My character was fit as a fiddle, until you put me in this joint. Of course. But generally speaking, functional and cognitive impairment can lead to a decrease in self care. Decrease cues to void, difficulty in finding a location to void, and an elevated residual volume of urine in the bladder. All of these are risk factors that can contribute to urinary tract infections. That's all there is to it. Watching David on the TV gave me this urinary tract infection? Well, Mrs. Houston, instead of focusing on how you got the UTI, let's talk about how to prevent another one in the feature. Like better hydration, regular toileting, improved personal care, and increased mobility. I need to go check on the other residents. I'm going to let Priscilla finish up here and give you the medication. You'll be taking a medicine called Levofloxacin. You're going to take one pill once a day for five days. This should help clear up the infection and get you back on your feet and no time just in time to see how that new hip is treating now. Five days you say? Well Elaine, that's not so bad. Well, I feel better already here you're right Dimitri. Go bring me a whole pitcher of water. That's the spirit. Elaine, I've never noticed that beautiful locket you have. Elaine had me bring that to her from home. She wanted it here closer to her heart. We'll have to tell me about that special locket the next time I check in on you. I will Priscilla. I will. Next time on Gowns and Gloves, Mrs. Houston suffers another unfortunate setback as her health continues on a downward spiral. Will her luck and her health ever take a turn for the better? Find out next on Gowns and Gloves. Click on each image to learn how to promote good urinary health. When considering the prevention of UTIs, much can be done to promote good urinary health among all residents in a facility. Without adequate hydration, the bladder cannot be sufficiently flushed out. Unfortunately, many elderly do not drink adequate fluids and are at risk for experiencing dehydration. With dehydration comes the heightened risk of UTI, pneumonia, pressure ulcers, disorientation, and electrolyte imbalances. The general recommendation is to consume the greater of 30 milliliters of fluid per kilogram per body weight, or 1.5 liters per day. For 150-pound man, the ideal fluid intake would be two liters per day. Another step in promoting good urinary health is to encourage mobility, even in those that are bed-bound. Several studies have demonstrated that improving mobility and exercise greatly reduces UTIs and can protect against hospitalizations for UTIs. Mobility and exercise reduce long periods of urinary stasis in the bladder, improves voiding and can help to prevent or better manage incontinence, which leads to improved urinary health. Promoting complete bladder emptying is also very important. Residents should empty their bladders every 3-4 hours or should be on programmed toileting if not able to go on their own. For those incontinent of stool, provide timely removal and good perineal care, cleaning from front-to-back towards the bottom. Click on each image to learn how to promote good urinary health. Constipation prevention is very important for promoting good urinary health. In elders marked or severe constipation has been noted to contribute to bladder instability and may encourage UTI by creating a degree of bladder outlet obstruction. In terms of prevention, there is evidenced from several studies that indicates that cranberries and cranberry derived substances can prevent bacterial adherence, especially of E. coli to urinary epithelial cells. Pathogens are more easily flushed from the urinary tract and infection risk is then minimized. In studies, a minimum of 300 milligrams to 400 milligrams of cranberry extract taken twice daily, or 8-16 ounces of at least 30 percent cranberry juice blend is needed for this therapeutic effect. Cranberry regimens should be started in consultation with a physician as it can interact with some medications. In post-menopausal women, estrogen deficiency has been linked to increased UTIs. The use of intravaginal estrogen cream is effective in reducing UTIs in elderly women. Alternatives to indwelling urinary catheters should be considered based on the resident's individual care needs. In general, alternative devices and procedures provide a much lower risk of infectious complications, such as a UTI. These alternative methods can also reduce or eliminate the non-infectious complications associated with indwelling catheters, namely immobility and discomfort. The three alternatives are programmed toileting, intermittent catheterization used in combination with bladder ultrasound and external catheters for males and females. Click on a picture to learn more about each alternative. Programmed toileting typically consists of a residence specific assessment of incontinence, followed by a program of prompted voiding, habit retraining, and/or timed voiding as part of an individualized care plan. Evidence from one investigation demonstrates toileting programs can significantly lessen risk of falls, skin breakdown, and if lifting technology is available, back injuries experienced by personnel during patient assists. Emphasis on self voiding also results in less post void residual compared to use of indwelling urinary catheters. Intermittent catheterization, often used in residents with neurogenic bladder or spinal cord injuries, lessens the risk of UTIs. Intermittent catheterization is preferable to indwelling or suprapubic catheters in residents with bladder emptying dysfunction. Intermittent catheterization should be performed at regular intervals to avoid over distending the bladder. When combined with portable bladder ultrasound, unnecessary catheterizations can be avoided if the resident has insufficient quantities of urine to justify catheterization. External catheters are a safer alternative in men and women who are able to void spontaneously. Male and female external catheters have a lower risk of bacterial colonization and UTIs compared to indwelling catheters. There are some drawbacks, including improper fit with condom catheters, urinary leakage, and skin breakdown. Though these can be mitigated by selecting the appropriate size for condom catheters, applying the male and female external catheters correctly, and removing or replacing at recommended intervals. Catheter-associated UTIs are common and carry increased risk of complications and morbidity. Every attempt must be made to minimize the duration of short-term catheterization and to avoid long-term catheterization altogether. Federal regulations, specifically CMS F-Tag 315, mandates that certain criteria be met in order to justify the use of an indwelling catheter in a long-term care facility. F-Tag 315 states that an indwelling catheter should only be used when there is a valid medical justification. The resident should be assessed for and provided care and treatment needed to reach his or her highest level of continence possible. The facility is expected to show evidence of any medical factors which caused the intervention. It is important to walk through the steps of management of a urinary catheter. First, verify that the resident meets one of the qualifying conditions. If the resident does not, seek an alternative method for management. If the resident does meet the criteria for placement of a catheter, it should be done using sterile equipment and aseptic technique to avoid introduction of pathogens during insertion. Once the catheter is inserted, the need for continued use of the urinary catheter should be assessed daily. It should be secured using a catheter lock, urine flows should be unobstructed, and the bag should be placed below the level of the resident and should not rest on the floor. Additionally, it is important that the system remains closed and intact, and anytime the system is manipulated or accessed, it is done so aseptically. Finally, the drainage bag should be emptied using a dedicated clean container. If the resident no longer requires the catheter, it should be removed promptly. Review this list of 10 things residents can do to improve urinary health. Today, you learned how to differentiate between asymptomatic bacterial colonization and a true symptomatic UTI, and the indications for treating UTIs. You also learned good urinary health practices that you can promote among residents, including improved mobility, hydration, regular toileting, and constipation management. In addition, you learned that indwelling urinary catheters should be avoided when possible, and alternative management strategies should be used. If a catheter is needed due to an indicated condition, it should be inserted aseptically, managed appropriately, and removed promptly when no longer needed.
