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Improving the Management of Urinary Tract Infections in Nursing Homes: It’s Time to Stop the Tail From Wagging the Dog
Affiliations:
1Division of Infectious Diseases, School of Medicine and Public Health, University of Wisconsin—Madison, Madison, WI
2Medical Service, William S. Middleton Memorial Veterans Hospital, Madison, WI
3Department of Medicine, School of Medicine and Public Health, University of Wisconsin—Madison, Madison, WI
4Division of Geriatrics, Medical College of Wisconsin, Milwaukee, WI
Abstract: Overdiagnosis and overprescription of antibiotic therapy to treat urinary tract infections (UTIs) in long-term care settings is a problem that has recently come under the scrutiny of clinicians, medical directors, policymakers, and regulators. The growing number of nursing homes recently cited with inappropriate antibiotic use highlights a need to revisit the way in which UTIs are identified and managed in these settings. This article addresses some of the reasons why antibiotic therapy is often overprescribed and proposes recommendations for a new stepwise approach to diagnosing UTIs in residents of long-term care facilities, including determining when antibiotic therapy is the appropriate course of action.
Key words: Antibiotic stewardship in long-term care, urinary tract infections.
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Overprescription of antibiotics is a significant problem in nursing homes.1 A urinary tract infection (UTI) is the most common indication for the prescription of antibiotics in long-term care (LTC) settings,2-4 and it is the condition most commonly associated with inappropriate antibiotic use.2,5-7 True cases of UTI undoubtedly occur with some frequency in nursing homes, but there is compelling evidence that UTIs are both overdiagnosed and overtreated in this setting. The rise in antibiotic resistance in LTC facilities8-10 threatens to create what the World Health Organization has called the postantibiotic era, a potential future in which existing antimicrobial therapies fail to treat common, previously treatable infections. Consequently, there is an urgent need to improve antibiotic use in nursing homes. Many hospitals have begun to implement antibiotic stewardship programs in an effort to reduce overuse and misuse of antibiotics in this setting. In contrast, efforts to stem inappropriate antibiotic use in LTC facilities have been far more limited. As Nicolle11 concluded in a recent systematic review, widespread implementation of antibiotic stewardship programs has been hindered by a lack of standardization of program components, implementation strategies, and evaluation methods. Additionally, institutional attitudes toward delayed or withheld prescribing can be a barrier to judicious prescribing of antibiotics.
Recently, the failure to proactively address this problem has drawn the attention of government surveyors, with an increasing number of nursing homes cited for inappropriate antibiotic use per the Centers for Medicare & Medicaid Services Unnecessary Drug Surveyor Guidelines (F-Tag 329). In many of these instances, inappropriate antibiotic use has been identified based on surveillance definitions. These definitions, often referred to as the McGeer criteria, were first published in 199112 and most recently updated in 2012.13 However, the McGeer criteria were intended to provide standardized guidance for infection surveillance purposes, and not for clinical decision-making. Surveillance definitions play an important role in tracking and benchmarking UTI rates across facilities as part of an active infection prevention program, but may not be sensitive enough for application in the care of individual residents. We believe their integration as minimum criteria for starting antibiotics may have detrimental consequences. Therefore, we propose in this article an alternative approach that providers should consider implementing as part of ongoing quality improvement efforts in nursing homes. This article includes an algorithm that is based on published guidelines but also incorporates our suggested inclusions for the minimum criteria needed to diagnose a UTI and start antibiotic therapy.
Urinalysis and the Antibiotic Cascade
Frail elderly persons with serious infections may present with atypical manifestations of illness.14 Sensitization to such atypical symptoms has created a generation of providers who interpret any change in condition as indicative of an underlying infection. In addition, the ease with which urine diagnostics can be obtained relative to tests for other types of infections further precipitates overdiagnosis of UTIs in these groups. Due to difficulties in their collection,15 sputum cultures are usually only obtained when residents have severe localizing respiratory symptoms and then usually only after they have been transferred to the emergency department. In contrast, it is not uncommon for nursing staff to perform a urine dipstick and urine culture in response to any change in a resident’s condition, no matter how nonspecific the symptoms.16,17 This seemingly innocuous practice initiates a cascade of events that often culminates in the prescription of an antibiotic. While a normal urinalysis virtually rules out a UTI, the positive predictive value of an abnormal dipstick (eg, positive leukocyte esterase or nitrite) in the nursing home population has been shown to be as low as 20% in some studies.18-20 Moreover, there is no evidence that bacteriuria is associated with the presence of localizing urinary symptoms in this particular patient population.21 Consequently, these tests have limited power to discriminate between residents with asymptomatic bacteriuria/colonization and those with a symptomatic infection.18-20 Nevertheless, many providers feel compelled to prescribe antibiotics when the results of urine tests are abnormal, regardless of clinical circumstances.16,22 Quality improvement efforts focused on standardizing the resident assessment process and restricting use of the urinalysis and culture to residents with a reasonable likelihood of a UTI will go a long way toward reducing the frequency of the antibiotic cascade seen in LTC facilities.
Overtreatment of UTIs is influenced only partly by overdiagnosis; it is further amplified by an imbalance in the manner by which providers weigh immediate versus delayed consequences when deciding to prescribe antibiotics. Providers would be appropriately concerned about the short-term consequences of withholding antibiotics from a frail older patient who may have an infection. However, these same providers rarely consider the delayed adverse consequences of antibiotic therapy. In one cohort study of Massachusetts nursing homes, up to 20% of all adverse drug reactions in these facilities were attributable to receipt of an antibiotic.23 Abundant antibiotic use in recent years has been convincingly linked to antibiotic resistance and development of antibiotic-resistant infections at the individual and institutional level.24-26 Moreover, several studies have now shown that Clostridium difficile infection commonly is preceded by inappropriate antibiotic use.27,28 It is time to strike a better balance between appreciation for the immediate goals and consideration of the potential adverse long-term consequences of antibiotic use.
The management of UTIs in nursing homes is driven by institutional attitudes, and therefore efforts to change practice will likely face resistance.29 To overcome this challenge, nursing homes can employ two strategies: standardizing the way we evaluate the health status of nursing home residents and changing our antibiotic decision-making processes to be both condition-based and criterion-based.
The Framework for a New Approach
The Infectious Diseases Society of America (IDSA) recently updated its guidelines for the evaluation of fever in LTC facilities.30 The guidelines recommend a standardized process for the initial evaluation of a resident with suspected infection and establish explicit thresholds for identifying the presence of fever as well as for recommending additional diagnostic testing based on the specifics of the resident’s presentation. Notably, a complete cell count, including peripheral white blood cell count and differential cell counts, is the only diagnostic test recommended in all residents with suspected infection, as absence of fever, leukocytosis, and focal findings substantially reduces the probability of serious bacterial infections. Based on the IDSA guidelines, additional diagnostic testing is indicated only if the resident’s presentation suggests the involvement of a specific organ system.
Although standardization of evaluation processes can certainly lead to reductions in unnecessary antibiotic use in nursing homes, the overall impact is likely to be small in the absence of other changes to practice. Clinicians in nursing homes must begin to embrace the idea of withholding antibiotics from residents who have a low probability of bacterial infection. The diagnosis of UTI is based on clinical grounds—not laboratory test results.31 The urine culture, while important for tailoring subsequent antibiotic regimens and development of an institutional antibiogram,32 should have a limited role in the provider’s decision to initiate antibiotic therapy unless it is negative. That the vast majority of antibiotics in nursing homes are initiated only after urinary diagnostic test results become available suggests that laboratory results unduly influence the clinical decision-making process (ie, “the tail wagging the dog”).33
Given this current state of affairs, how can progress be made? The Choosing Wisely campaign, a new joint initiative of the American Geriatrics Society and the American Board of Internal Medicine, supports withholding antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.34 Minimum criteria for initiation of antibiotics in nursing homes were published over a decade ago by Loeb and colleagues,12 and the efficacy of their application in the treatment of nursing home residents with a suspected UTI has been demonstrated in several clinical studies.35,36 These criteria are summarized in the Table.12,30,35,36 It must be emphasized that these represent minimum criteria. We believe delirium in the absence of localizing symptoms or other systemic signs (eg, fever, rigors, unstable vital signs, leukocytosis) is an uncommon presentation of UTIs in nursing homes, especially in the absence of a urinary catheter.12,30 Nevertheless, even if one includes isolated delirium as an indication for empirical treatment of UTIs in residents with or without a catheter, more than half of nursing home residents prescribed an antibiotic for a UTI indication do not satisfy these minimum criteria.12,33
Explicit incorporation of these criteria into antibiotic decision-making would enable clinicians to stratify residents into two categories: one in which immediate initiation of empirical antibiotic therapy is indicated and another in which watchful waiting is the more prudent option. In noncatheterized residents capable of reporting symptoms, restricting immediate empirical antibiotic therapy to residents with symptoms that are clearly localized to the urinary tract appears safe as long as the resident does not manifest signs suggestive of severe systemic inflammation (eg, unstable vital signs).35 Nonverbal residents or those unable to report symptoms for other reasons do pose a challenge for clinical decision-making. In these residents, fever or leukocytosis alone may be adequate evidence to justify initiation of antibiotics targeted at the urinary tract as long as signs do not point to infection at another body location (eg, new cough, change in pulse oximetry).37
It may even be reasonable to withhold antibiotics from residents whose isolated urinary symptoms (eg, dysuria, new incontinence) are mild pending the results of cultures, as long as these individuals do not display more concerning symptoms (eg, fever, functional decline). Delayed prescribing of antibiotics is a strategy that has been used with some success in the outpatient setting,38 and we have seen many residents with isolated localizing urinary symptoms improve spontaneously without antibiotics while awaiting the results of cultures.
Our Proposed Algorithm
Based on the limitations of current antibiotic guidelines, we present our unified algorithm to synthesize diagnostic and treatment decision activities (Figure). The four levels of the algorithm provide recommendations for the clinical evaluation and treatment of residents with a change in condition potentially attributable to a UTI. In the first level of the assessment, clinicians should evaluate the resident for the presence of signs or symptoms that localize to the urinary tract. Urine cultures should not be ordered without further evaluation in residents who do not exhibit these signs/symptoms. In the second level, clinicians should determine whether the resident shows symptoms suggestive of infection at an alternative location (eg, cough, other respiratory symptoms). Urine cultures should not be ordered for individuals whose symptoms are localized to an extraurinary source. In the third level of assessment, it is appropriate to initiate empirical antibiotic therapy for a UTI in the presence of systemic warning signs (eg, fever, clear-cut delirium, rigors, hemodynamic instability), assuming no other obvious source of infection is present. The fourth level indicates that residents who do not meet any of these criteria may be safely observed and reassessed after 48 hours.
Nursing staff using this approach would only obtain a urinalysis and urine culture for a resident who presents with signs and symptoms localizing to the urinary tract or for an individual who presents with one or more systemic warning signs and an absence of signs and symptoms of infection at an extraurinary site. Observation without administration of antibiotics is the preferred strategy for residents who experience a change in condition but do not have localizing urinary symptoms or any of the aforementioned systemic warning signs. Reducing the reflexive performance of urinalysis and urine culture in this manner will help to reduce the pressure to prescribe. Importantly, it may still be appropriate to initiate antibiotic therapy for infection at another anatomic location (eg, pneumonia) in those residents who manifest appropriate extraurinary signs and symptoms. Finally, empirical antibiotic therapy for a suspected UTI should never be initiated without obtaining a urine culture first. Culture results should be reviewed at 48 to 72 hours and therapy targeted to the results to avoid unnecessarily broad therapy (eg, failing to narrow therapy from ciprofloxacin to nitrofurantoin).
Conclusion
We feel strongly that nursing homes that implement this or a similar algorithm will observe substantial reductions in the rates of unnecessary antibiotic use at their facilities. Advances in diagnostic testing (eg, point-of-care C-reactive protein, procalcitonin testing) may create opportunities to further enhance the antibiotic decision-making process. We also recognize that pathways will never be able to fully account for the diverse range of resident presentations encountered in the nursing home setting. Pathways are not intended to replace clinical intuition, however, the wide variation in antibiotic use across LTC settings suggests that a significant proportion of prescriptions are responses to nonclinical factors. Implementing the strategies proposed in this article can help reduce this unwanted variation. We are at the precipice of the postantibiotic era in many nursing homes. It is time to tackle the management of UTIs in these settings.
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Disclosures: The authors report no relevant financial relationships.
Address correspondence to: Christopher Crnich, MD, PhD, Associate Professor of Medicine, Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, 5217 MFCB, Madison, WI 53705; cjc@medicine.wisc.edu
