Diagnosis & Management of Urinary Tract Infection (UTI) in Long Term Care Residents > 65 years

Adapted from guideline document: Diagnosis & Management of Urinary Tract Infection (UTI) in Long Term Care Residents > 65 years, www.hpsc.ie

Signs and Symptoms of UTI

Doses are oral and for adults unless otherwise stated. Visit the Health Products Regulatory Board website or the printed Irish Medicines Formulary for drug SPCs, dosage, contraindications, interactions, or IMF/BNF/BNFC/MIMS. See guidance on dosing in children for quick reference dosage/weight guide. Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion). Statins can interact with some antibiotics and increase the risk of rhabdomyolysis. Amiodarone and drugs which prolong the QT interval can interact with many antibiotics. Many antibiotics increase the risk of bleeding with anticoagulants. Please refer to our Drug Interactions Table for further information.

Diagnosis of UTI should be based on a full clinical assessment.
Symptoms and signs suggestive of urinary tract infection include:
Dysuria, Frequency, Urgency, New Onset Incontinence, Fever >38°C, Suprapubic Tenderness, Haematuria
In patients with a urinary catheter loin pain and fever >38°C are significant indicators of a UTI. ***DO NOT SEND URINE FOR CULTURE IF THERE ARE NO SIGNS AND SYMPTOMS OF UTI***
Dipstick urine testing is NOT a reliable way to diagnose UTI. Do not perform dipstick urinalysis 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.
A positive urine dipstick result in an asymptomatic patient is not significant and should not be treated

How to Interpret Urine Culture Results in Residents Without a Urine Catheter

Microscopy

White Cells	No white cells present indicate no inflammation therefore culture result is unlikely to indicate UTI. White cells ≥100/µl are considered to represent infl ammation.
Epithelial cells/ Mixed growth	Presence indicates perineal contamination and therefore culture result is unlikely to indicate UTI
Red cells	May be present in UTI, patients with persistent hamaturia post UTI should be referred

Culture

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

Usually indicates UTI but only in patients with symptoms

Positive culture/microscopy result and no symptoms = bacteriuria, not infection and does not require antibiotic treatment.

How to Interpret Urine Culture Results in Residents With a Urine Catheter

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 (see section 2) treat only if the resident has symptoms or signs suggestive of UTI and no other source is identify ed.
In the presence of a urinary catheter antibiotics will not eradicate bacteriuria

Empirical Treatment of UTI in Residents

Only consider empiric antibiotic therapy in SYMPTOMATIC patients pending urine culture result.
Choice of empirical therapy should be guided by local resistance rates where available.
Modify treatment according to culture result when available.
For treatment of uncomplicated UTI in patients < 65, please refer to other UTI sub-headings.

Uncomplicated UTI i.e. no fever or ﬂank pain, first presentations / low risk of resistant organisms	Acute pyelonephritis
Trimethoprim 200mg BD OR Nitrofurantoin* 50mg QDS for 7 days (*Avoid in renal impairment)	Co-amoxiclav 625mg TDS for 14 days OR Ciprofloxacin 500mg BD for 7 days
Use of Cephalexin 500mg BD or Co-amoxiclav 625mg TDS may also be considered - based on local resistance rates	If no response within 24 hours consider hospital referral

Empirical Treatment of UTI in Residents With a Urinary Catheter

First presentations / low risk of resistant organisms	Previous resistance to, or risk of, trimethoprim or nitrofurantoin resistance
Trimethoprim 200mg BD OR Nitrofurantoin* 50-100mg QDS (*Avoid in renal impairment)	Cephalexin 500mg BD OR Co-amoxiclav 625mg TDS (Consider based on local resistance rates)

Duration of therapy

Prompt resolution of symptoms: 7 days
Delayed response (regardless of whether patient remains catheterised or not): 10-14 days
If an indwelling catheter has been in place for >2 weeks at the onset of UTI and is still indicated, the catheter should be replaced.

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.
Antibiotic prophylaxis is not recommended for urinary catheter changes unless there is a defi nite 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.

Patient Information

The HSE Health A-Z website provides patient information on many hundreds of conditions and treatments.

Click here to view information about UTI Infections
Visit HPSC Information Leaflets pages for the General Public, (MRSA, CRE, etc)

We recommend patients use the website developed by HSE/ICGP/IPU partnership www.undertheweather.ie for tips on how to get better from common infections without using antibiotics, what you can do for yourself or a loved one and when to seek help.

Key Messages

Diagnosis of UTI in residents > 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

Reviewed November 2017