Diagnosis & Management of Urinary Tract Infection (UTI) in Residential/Long Term Care/Nursing Home Residents (non-catheter associated)

Results from the HALT Study

  • In the 2016 point-prevalence survey of Healthcare-associated infection and Antimicrobial use in Long-Term care facilities (“HALT”), 4.7% of residents in long-term care facilities (LTCFs) were on an antibiotic for either treatment or prophylaxis (prevention) of UTI.
  • The 2013 European HALT report found that residents of Irish LTCFs were more than twice as likely to be on an antibiotic as their European counterparts.
  • In HALT 2016, UTI prevention accounted for 68% of prophylactic prescribing.
  • UTI prophylaxis prevalence decreased from 3.8% to 2.9% between 2010 and 2016.

Diagnosis of UTI

Diagnosis of UTI should be based on a full clinical assessment. It is acknowledged that this diagnosis can be difficult and without other obvious cause, a trial of treatment may be justified.

✔ Residents may have non-specific signs including confusion, lethargy, decreased oral intake and/or agitation but  dysuria, frequency, urgency, new onset incontinence, fever >38°C, suprapubic tenderness and haematuria are significant indicators of Urinary Tract Infection.

✔ Consider COVID-19 for residents with non-specific signs and symptoms.

✔ Consider acute prostatitis in males >50 years with lower urinary tract symptoms, and referral for specialist opinion is advisable for recurrent UTI in males

✘ Cloudy urine is NOT an indicator of UTI in the absence of symptoms and signs

✘ Foul-smelling urine is NOT an indicator of UTI in the absence of symptoms and signs

Should I do a urine dipstick?

✘ All persons aged 65 years and older: The use of dipstick urinalysis in assessing for evidence of a UTI is not a useful guide to management and is not recommended. 

When should I send a urine to the lab for culture?

✔ Send urine to the lab in residents with symptoms

✘ **DO NOT SEND URINE FOR CULTURE IF THERE ARE NO SIGNS/ SYMPTOMS OF UTI**

Antimicrobial Prophylaxis

Should I consider antimicrobial prophylaxis ?

✘ **DO NOT ROUTINELY USE ANTIBIOTIC PROPHYLAXIS TO PREVENT URINARY TRACT INFECTION**

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.

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

Microscopy

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Culture

The following culture results usually indicate UTI in residents with symptoms:

  • 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 

N.B. Positive culture with no symptoms = asymptomatic bacteriuria, not infection, and does not require antibiotic treatment.

Empirical Treatment of UTI in Residents

  1. Only consider empiric antibiotic therapy in SYMPTOMATIC residents while awaiting urine culture result.
  2. Antibiotics (particularly ciprofloxacin and cephalosporins) are associated with C. difficile infection in elderly patients. Give antibiotics only if clinically indicated and avoid these agents where there is an alternative.
  3. Choice of empirical therapy should be guided by local resistance rates where available.
  4. N.B. Check the resident’s previous culture results and do not use an antibiotic empirically if an organism resistant to that antibiotic has recently been cultured (within 12 weeks).
  5. Modify treatment according to culture result when available.
  6. 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.

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*fluoroquinolone warnings 2019 update

Patient Information

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

Safe Prescribing

  • Doses are oral and for adults unless otherwise stated
  • Fluoroquinolone warning
  • Penicillin allergy – tips on prescribing in penicillin allergy
  • Renal impairment dosing table
  • Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
  • Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed November 2020

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