nursing case study on uti

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Urinary tract infection in an older patient: a case study and review

Advanced Nurse Practitioner, Primary Care

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Gerri Mortimore

Senior lecturer in advanced practice, department of health and social care, University of Derby

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This article will discuss and reflect on a case study involving the prescribing of nitrofurantoin, by a non-medical prescriber, for a suspected symptomatic uncomplicated urinary tract infection in a patient living in a care home. The focus will be around the consultation and decision-making process of prescribing and the difficulties faced when dealing with frail, uncommunicative patients. This article will explore and critique the evidence-base, local and national guidelines, and primary research around the pharmacokinetics and pharmacodynamics of nitrofurantoin, a commonly prescribed medication. Consideration of the legal, ethical and professional issues when prescribing in a non-medical capacity will also be sought, concluding with a review of the continuing professional development required to influence future prescribing decisions relating to the case study.

Urinary tract infections are common in older people. Haley Read and Gerri Mortimore describe the decision making process in the case of an older patient with a UTI

One of the growing community healthcare delivery agendas is that of the advanced nurse practitioner (ANP) role to improve access to timely, appropriate assessment and treatment of patients, in an attempt to avoid unnecessary health deterioration and/or hospitalisation ( O'Neill et al, 2021 ). The Core Capabilities Framework for Advanced Clinical Practice (Nurses) Working in General Practice/Primary Care in England recognises the application of essential skills, including sound consultation and clinical decision making for prescribing appropriate treatment ( Health Education England [HEE], 2020 ). This article will discuss and reflect on a case study involving the prescribing of nitrofurantoin by a ANP for a suspected symptomatic uncomplicated urinary tract infection (UTI), in a patient living in a care home. Focus will be around the consultation and decision-making process of non-medical prescribing and will explore and critique the evidence-base, examining the local and national guidelines and primary research around the pharmacokinetics and pharmacodynamics of nitrofurantoin. Consideration of the legal, ethical and professional issues when prescribing in a non-medical capacity will also be sought, concluding with review of the continuing professional development required to influence future prescribing decisions relating to the case study.

Mrs M, an 87-year-old lady living in a nursing home, was referred to the community ANP by the senior carer. The presenting complaint was reported as dark, cloudy, foul-smelling urine, with new confusion and night-time hallucinations. The carer reported a history of disturbed night sleep, with hallucinations of spiders crawling in bed, followed by agitation, lethargy and poor oral intake the next morning. The SBAR (situation, background, assessment, recommendation) tool was adopted, ensuring structured and relevant communication was obtained ( NHS England and NHS Improvement, 2021 ). The National Institute for Health and Care Excellence ( NICE, 2021 ) recognises that cloudy, foul-smelling urine may indicate UTI. Other symptoms include increased frequency or pressure to pass urine, dysuria, haematuria or dark coloured urine, mild fever, night-time urination, and increased sweats or chills, with lower abdominal/loin pain suggesting severe infection. NICE (2021) highlight that patients with confusion may not report UTI symptoms. This is supported by Gupta and Gupta (2019) , who recognise new confusion as hyper-delirium, which can be attributed to several causative factors including infection, dehydration, constipation and medication, among others.

UTIs are one of the most common infections worldwide ( O'Grady et al, 2019 ). Lajiness and Lajiness (2019) define UTI as a presence of colonising bacteria that cause a multitude of symptoms affecting either the upper or lower urinary tract. NICE (2021) further classifies UTIs as either uncomplicated or complicated, with complicated involving other systemic conditions or pre-existing diseases. Geerts et al (2013) postulate around 30% of females will develop a UTI at least once in their life. The incidence increases with age, with those over 65 years of age being five times more likely to develop a UTI at any point. Further increased prevalence is found in patients who live in a care home, with up to 60% of all infections caused by UTI ( Bardsley, 2017 ).

Greener (2011) reported that symptoms of UTIs are often underestimated by clinicians. A study cited by Greener (2011) found over half of GPs did not record the UTI symptoms that the patient had reported. It is, therefore, essential during the consultation to use open-ended questions, listening to the terminology of the patient or carers to clarify the symptoms and creating an objective history ( Taylor, 2016 ).

In this case, the carer highlighted that Mrs M had been treated for suspected UTI twice in the last 12 months. Greener (2011) , in their literature review of 8 Cochrane review papers and 1 systematic review, which looked at recurrent UTI incidences in general practice, found 48% of women went on to have a further episode within 12 months.

Mrs M's past medical history reviewed via the GP electronic notes included:

• Hypertension
• Diverticular disease
• Basal cell carcinoma of scalp
• Retinal vein occlusion
• Severe frailty
• Fracture of proximal end of femur
• Total left hip replacement
• Previous indwelling urinary catheter
• Chronic kidney disease (CKD) stage 2
• Urinary and faecal incontinence
• And, most recently, vesicovaginal fistula.

Bardsley (2017) identified further UTI risk factors including postmenopausal females, frailty, co-morbidity, incontinence and use of urethral catheterisation. Vesicovaginal fistulas also predispose to recurrent UTIs, due to the increase in urinary incontinence ( Stamatokos et al, 2014 ). Moreover, UTIs are common in older females living in a care home ( Bradley and Sheeran, 2017 ). They can cause severe risks to the patient if left untreated, leading to complications such as pyelonephritis or sepsis ( Ahmed et al, 2018 ).

Mrs M's medication included:

• Paracetamol 1 g as required
• Lactulose 10 ml twice daily
• Docusate 200 mg twice daily
• Epimax cream
• Colecalciferol 400 units daily
• Alendronic acid 70 mg weekly.

She did not take any herbal or over the counter preparations. Her records reported no known drug allergies; however, she was allergic to Elastoplast. A vital part of clinical history involves reviewing current prescribed and non-prescribed medications, herbal remedies and drug allergies, to prevent contraindications or reactions with potential prescribed medication ( Royal Pharmaceutical Society, 2019 ). Several authors, including Malcolm et al (2018) , indicate polypharmacy as a common cause of adverse drug reactions (ADRs), worsening health and affecting a person's quality of life. NICE (2015) only recommends review of patients who are on four or more medications on each new clinical intervention, not taking into account individual drug interactions.

Due to Mrs M's lack of capacity, her social history was obtained via the electronic record and the carer. She moved to the care home 3 years ago, following respite care after her fall and hip replacement. She had never smoked or drank alcohol. Documented family history revealed stroke, ischaemic heart disease and breast cancer. Taylor (2016) reports a good thorough clinical history can equate to 90% of the working diagnosis before examination, potentially reducing unnecessary tests and investigations. This can prove challenging when the patient has confusion. It takes a more investigative approach, gaining access to medical/nursing care notes, and using family or carers to provide further collateral history ( Gupta and Gupta, 2019 ).

As per NICE (2021) guidelines, a physical examination of Mrs M was carried out. On examination it was noted that Mrs M had mild pallor with normal capillary refill time, no signs of peripheral or central cyanosis, and no clinical stigmata to note. Her heart rate was elevated at 112 beats per minute and regular, she had a normal respiration rate of 17 breaths per minute, oxygen saturations (SpO 2 ) were 98% on room air and blood pressure was 116/70 mm/Hg. Her temperature was 37.3oC. According to Doyle and Schortgen (2016) , there is no agreed level of fever; however, it becomes significant when above 38.3oC. Bardsley (2017) adds that older patients do not always present with pyrexia in UTI because of an impaired immune response.

Heart and chest sounds were normal, with no peripheral oedema. The abdomen was non-distended, soft and non-tender on palpation, with no reports of nausea, vomiting, supra-pubic tenderness or loin pain. Loin pain or suprapubic tenderness can indicate pyelonephritis ( Bardsley, 2017 ). Tachycardia, fever, confusion, drowsiness, nausea/vomiting or tachypnoea are strong predictive signs of sepsis ( NICE, 2021 ).

During the consultation, confusion and restlessness were evident. Therefore, it was difficult to ask direct questions to Mrs M regarding pain, nausea and dizziness. Non-verbal cues were considered, as changes in behaviour and restlessness can potentially highlight discomfort or pain ( Swift, 2018 ).

Mrs M's most recent blood tests indicated CKD stage 2, based on an estimated glomerular filtration rate (eGFR) of 82 ml/minute/1.73m 2 . The degree of renal function is vital to establish prior to any prescribing decision, because of the potential increased risk of drug toxicity ( Doogue and Polasek, 2013 ). The agreed level of mild renal impairment is when eGFR is <60 ml/minute/1.73 m 2 , with chronic renal impairment established when eGFR levels are sustained over a 3-month period ( Ahmed et al, 2018 ).

Previous urine samples of Mrs M grew Escherichia coli bacteria, sensitive to nitrofurantoin but resistant to trimethoprim. A consensus of papers, including Lajiness and Lajiness (2019) , highlight the most common pathogen for UTI as E. coli. Fransen et al (2016) indicates that increased use of empirical antibiotics has led to a prevalence of extended spectrum beta lactamase positive (ESBL+) bacteria that are resistant to many current antibiotics. This is not taken into account by the NICE guidelines (2021) ; however, it is discussed in local guidelines ( Barnsley Hospital NHS FT/Rotherham NHS FT, 2022 ).

Mrs M was unable to provide an uncontaminated urine sample due to incontinence. NICE (2021) advocate urine culture as a definitive diagnostic tool for UTIs; however, do not highlight how to objectively obtain this. Bardsley (2017) recognises the benefit of an uncontaminated urinalysis in symptomatic patients, stating that alongside other clinical signs, nitrates and leucocytes strongly predict the possibility of UTI. O'Grady et al (2019) points out that although NICE emphasise urine culture collection, it omits the use of urinalysis as part of the assessment.

Based on Ms M's clinical history and physical examination, a working diagnosis of suspected symptomatic uncomplicated UTI was hypothesised. A decision was made, based on the local antibiotic prescribing guidelines, as well as the NICE (2021) guidelines, to treat empirically with nitrofurantoin modified release (MR), 100 mg twice daily for 3 days, to avoid further health or systemic complications. The use of electronic prescribing was adopted as per local organisational policy and the Royal Pharmaceutical Society (2019) . Electronic prescribing is essential for legibility and sharing of prescribing information. It also acts as an audit on prescribing practices, providing a contemporaneous history for any potential litigation ( Lovatt, 2010 ).

Pharmacokinetics and pharmacodynamics

Lajiness and Lajiness (2019) reflect on the origins of nitrofurantoin back to the 1950s, following high penicillin usage leading to resistance of Gram-negative bacteria. Nitrofurantoin has been the first-line empirical treatment for UTIs internationally since 2010, despite other antibacterial agents being discovered ( Wijma et al, 2020 ). Mckinell et al (2011) highlight that a surge in bacterial resistance brought about interest in nitrofurantoin as a first-line option. Their systematic review of the literature indicated through a cost and efficacy decision analysis that nitrofurantoin was a low resistance and low cost risk; therefore, an effective alternative to trimethoprim or fluoroquinolones. The weakness of this paper is the lack of data on nitrofurantoin cure rates and resistance studies, demonstrating an inability to predict complete superiority of nitrofurantoin over other antibiotics. This could be down to the reduced use of nitrofurantoin treatment at the time.

Fransen et al (2016) reported that minimal pharmacodynamic knowledge of nitrofurantoin exists, despite its strong evidence-based results against most common urinary pathogens, and being around for the last 70 years. Wijma et al (2018) hypothesised this was because of the lack of drug approval requirements in the era when nitrofurantoin was first produced, and the growing incidence of antibiotic resistance. Pharmacokinetics and pharmacodynamics are clinically important to guide effective drug therapy and avoid potential ADRs. Focus on the absorption, distribution, metabolism and excretion (ADME) of nitrofurantoin is needed to evaluate the correct choice for an individual patient, based on a holistic assessment ( Doogue and Polasek, 2013 ).

Nitrofurantoin is structurally made up of 4 carbon and 1 oxygen atoms forming a furan ring, connected to a nitrogroup (–NO 2 ). Its mode of action is predominantly bacteriostatic, with some bactericidal tendencies in high concentration levels ( Wijma et al, 2018 ). It works by inhibiting bacterial cell growth, breaking down its strands of DNA ( Komp Lindgren et al, 2015 ). Hoang and Salbu (2016) add that nitrofurantoin causes bacterial flavoproteins to create reactive medians that halt bacterial ribosomal proteins, rendering DNA/RNA cell wall synthesis inactive.

Nitrofurantoin is administered orally via capsules or liquid. Greener (2011) highlights the different formulations, which originally included microcrystalline tablets and now include macro-crystalline capsules. The increased size of crystals was found to slow absorption rates down ( Hoang and Salbu, 2016 ). Nitrofurantoin is predominantly absorbed via the gastro-intestinal tract, enhanced by an acidic environment. It is advised to take nitrofurantoin with food, to slow down gastric emptying ( Wijma et al, 2018 ). The maximum blood concentration of nitrofurantoin is said to be <0.6 mg/l. Lower plasma concentration equates to lower toxicity risk; therefore, nitrofurantoin is favourable over fluoroquinolones ( Komp Lindgren et al, 2015 ). Wijma et al (2020) found a reduced effect on gut flora compared to fluoroquinolones.

Distribution of nitrofurantoin is mainly via the renal medulla, with a renal bioavailability of 38.8–44%; therefore, it is specific for urinary action ( Hoang and Salbu, 2016 ). Haasum et al (2013) highlight the inability for nitrofurantoin to penetrate the prostate where bacteria concentration levels can be present. Therefore, they do not advocate the use of nitrofurantoin to treat males with UTIs, because of the risk of treatment failure and further complications of systemic infection. This did not appear to be addressed by local guidelines.

The metabolism of nitrofurantoin is not completely understood; however, Wijma et al (2018) indicate several potential metabolic antibacterial actions. Around 0.8–1.8% is metabolised into aminofurantoin, with 80.9% other unknown metabolites ( medicines.org, 2022 ). Wijma et al (2020) calls for further study into the metabolism of nitrofurantoin to aid understanding of the pharmacodynamics.

Excretion of nitrofurantoin is predominantly via urine, with a peak time of 4–5 hours, and 27–50% excreted unchanged in urine ( medicines.org, 2022 ). Komp Lindgren et al (2015) equates the fast rates of renal availability and excretion to lower toxicity risks and targeted treatment for UTI pathogens. Wijma et al (2018) found high plasma concentration levels of nitrofurantoin in renal impairment. Singh et al (2015) indicate that nitrofurantoin is mainly eliminated via glomerular filtration; therefore, its impairment presents the potential risks of treatment failure and increased ADRs. Early guidelines stipulated the need to avoid nitrofurantoin in patients with mild renal impairment, indicating the need for an eGFR of >60 ml/min due to this toxicity risk. This was based on several small studies, cited by Hoang and Salbu (2016) , looking at concentration levels rather than focused on patient treatment outcomes.

Primary research by Geerts et al (2013) involving treatment outcomes in a large cohort study, led to guidelines changing the limit to mild to moderate impairment or eGFR >45 ml/min. However, the risk of ADRs, including pulmonary fibrosis and hepatic changes, were increased in renal insufficiency with prolonged use. The study participants had a mean age of 47.8 years; therefore, the study did not indicate the effects on older patients. Singh et al (2015) presented a Canadian study, looking at treatment success with nitrofurantoin in older females, with a mean age of 79 years. It indicated effective treatment despite mild/moderate renal impairment. It did not address the levels of ADRs or hospitalisation. Ahmed et al (2018) conducted a large, UK-based, retrospective cohort study favouring use of empirical nitrofurantoin in the older population with increased risk of UTI-related hospitalisation and mild/moderate renal impairment. It concluded not treating could increase mortality and morbidity. This led to guidelines to support empirical treatment of symptomatic older patients with nitrofurantoin.

Dosing is highly variable between the local and national guidelines. Greener (2011) highlights that product information for the macro-crystalline capsules recommends 50–100 mg 4 times a day for 7 days when treating acute uncomplicated UTI. Local guidelines from Barnsley Hospital NHS FT/Rotherham NHS FT Adult antimicrobial guide (2022) stipulate 50–100 mg 4 times daily for 3 days for women, whereas NICE (2021) recommends a MR version of 100 mg twice daily for 3 days.

In a systematic literature review on the pharmacokinetics of nitrofurantoin, Wijma et al (2018) found that use of a 5–7 day course had similar strong efficacy rates, whereas 3 days did not, potentially causing treatment failure, equating to poor patient outcomes and resistant behaviour. Deresinski (2018) conducted a small, randomised controlled trial involving 377 patients either on nitrofurantoin MR 100 mg three times a day for 5 days or fosfomycin single dose treatment after urinalysis and culture. It looked at response to treatment after 28 days. Nitrofurantoin was found to have a 78% cure rate compared to 50% with fosfomycin. Therefore, these studies directly contradict current NICE and local guidelines on treatment dosing of UTI in women. More robust studies on dosing regimens are therefore required.

Fransen et al (2016) conducted a non-human pharmacodynamics study looking at time of action to treat on 11 strains of common UTI bacteria including two ESBL+. It demonstrated the kill rate for E. coli was 16–24 hours, slower than Enterobacter cloacae (6–8 hours) and Klebsiella pneumoniae (8 hours). The findings also indicated that nitrofurantoin appeared effective against ESBL+. Dosing and urine concentrations were measured, and found that 100 mg every 6 hours kept the urine concentration levels significant enough to reach peak levels. This study directly contradicted the findings of Lindgren et al (2015) , who conducted similar non-human kinetic style kill rate studies, and found nitrofurantoin's dynamic action to be within 6 hours for E. coli. Both studies have limitations in that they did not take into account human immune response effects.

Wijma et al (2020) highlighted inconsistent dosing regimens in their retrospective audit involving 150 patients treated for UTIs across three Australian secondary care facilities. The predominant dosing of nitrofurantoin was 100 mg twice daily for 5 days for women and 7 days for males. Although a small audit-based paper, it creates debate regarding the lack of clarity around the correct dosing, leaving it open to error. It therefore requires primary research into the follow up of cure rates on guideline prescribing regimens. Dose and timing remains an important issue to reduce treatment failure. It indicates the need for bacteria-dependant dosing, which currently NICE (2021) does not discuss.

Haasum et al (2013) found poor adherence to guidelines for choice and dosing in elderly patients in their Swedish register-based large population study. It highlighted high use of trimethoprim in frail older care home residents, despite guidelines recommending nitrofurantoin as first-line. A recent retrospective, observational, quantitative study by Langner et al (2021) involving 44.9 million women treated for a UTI in the USA across primary and secondary care, found an overuse of fluoroquinolones and underuse of nitrofurantoin and trimethoprim, especially by primary care physicians for older Asian and socio-economically deprived patients. Both these studies did not seek a true qualitative rationale for choices of antibiotics; therefore, limiting the findings.

Legal and ethical considerations

NMP regulation of best practice is set by the Royal Pharmaceutical Society framework (2019) , incorporating several acts of law including the medicines act 1968, and medicinal products prescribed by the Nurses Act (1992). As per Nursing Midwifery Council (2021) Code of Conduct and Health Education England (2020), ANPs have a duty of care to patients, ensuring that they work within their area of competence and recognise any limitations, demonstrating accountability for decisions made ( Lovatt, 2010 ).

Empirical treatment of UTIs is debated in the literature. O'Grady et al (2019) summarises that empirical treatment can reduce further UTI complications that can lead to acute health needs and hospitalisation, without increased risk of antibiotic resistance. Greener (2011) states that uncomplicated UTIs can be self-limiting; therefore, not always warranting antibiotic treatment if sound self-care advice is adopted. Chardavoyne and Kasmire (2020) discuss delayed prescribing, involving putting the onus on the patient and carers, which was not advisable in the case of Mrs M. Bradley and Sheeran (2017) found that three quarters of antibiotics in care home residents were prescribed inaccurately, hence recommended a watch and wait approach to treatment in the older care home resident, following implementation of a risk reduction strategy.

Taylor (2016) recommended an individual, holistic approach, incorporating ethical considerations such as choice, level of concordance, understanding and agreement of treatment choice. This can prove difficult in a case such as Mrs M. If a patient is deemed to lack capacity, a decision to act in the patient's best interest should be applied ( Gupta and Gupta, 2019 ). Therefore, understanding a patient's beliefs and values via family or carers should be explored, balancing the needs and possible outcomes. The principle of non-maleficence should be adopted, looking at risks versus benefits on prescribing the antibiotic to the individual patient ( Royal Pharmaceutical Society, 2019 ).

Non-pharmacological advice was provided to the carers to ensure that Mrs M maintained good fluid intake of 2 litres in 24 hours. NICE (2021) advocates the use of written self-care advice leaflets that have been produced to educate patients and/or carers on non-pharmacological actions, supporting recovery and improving outcomes. The use of paracetamol for symptoms of fever and/or pain was also recommended for Mrs M. Prevention strategies proposed by Lajiness and Lajiness (2019) included looking at the benefits of oestrogen cream in post-menopausal women in reducing the incidence of UTIs. Cranberry juice, probiotics and vitamin C ingestion are not supported by any strong evidence base.

There is a duty of care to ensure that follow up of the patient during and after treatment is delivered by the NMP ( Chardavoyne and Kasmire, 2020 ). Clinical safety netting advice was discussed with the carers to monitor Mrs M for any deterioration, and to seek further clinical review urgently. Particular attention to signs of ADRs and sepsis, and the need for 999 response if these occurred, was advocated. A treatment plan was also sent to the GP to ensure sound communication and continuation of safe care ( Taylor, 2016 ).

Professional development issues

The extended role of prescribing brings additional responsibility, with onus on both the NMP and the employer vicariously, to ensure key skills are updated. This is where continued professional development involving research, training and knowledge is sought and applied, using evidence-based, up-to-date practice ( HEE, 2020 ). Adoption of antibiotic stewardship is highlighted by several papers including Lajiness and Lajiness (2019) . They advise nine points to consider, to increase knowledge around the actions and consequences of the drug by the prescriber. Despite no acknowledgment in NICE (2021) guidance, previous results of infections and sensitivities are also proposed as vital in antibiotic stewardship.

The use of decision support tools, proposed by Malcolm et al (2018) , involves an audit approach looking at antibiograms, that highlight local microbiology resistance patterns to aid antibiotic choices, alongside a risk reduction team strategy. Bradley and Sheeran (2017) looked at improving antibiotic use for UTI treatment in a care home in Pennsylvania. They employed a programme of monitoring and educating clinical staff, patients, carers and relatives in evidence-based self-care and clinical assessment skills over a 30-month period. It demonstrated a reduction in inappropriate antibiotic prescribing, and an improvement in monitoring symptoms and self-care practices, creating better patient outcomes. It was evaluated highly by nursing staff, who reported a sense of autonomy and confidence involving team work. Langner et al (2021) calls for further education and feedback to prescribers, involving pharmacists and microbiology data to identify and understand patterns of prescribing.

UTIs can be misdiagnosed and under- or over-treated, despite the presence of local and national guidelines. Continued monitoring of nitrofurantoin use requires priority, due to its first-line treatment status internationally, as this may increase reliance and overuse of the drug, with potential for resistant strains of bacteria becoming prevalent.

Diligent clinical assessment skills and prescribing of appropriate treatment is paramount to ensure risk of serious complications, hospitalisation and mortality are reduced, while quality of life is maintained. The use of competent clinical practice, up-to-date evidence-based knowledge, good communication and understanding of individual patient needs, and concordance are essential to make sound prescribing choices to avoid harm. As well as the prescribing of medications, the education, monitoring and follow-up of the patient and prescribing practices are equally a vital part of the autonomous role of the NMP.

KEY POINTS:

• Urinary tract infections (UTIs) can be misdiagnosed and under- or over-treated, despite the presence of local and national guidelines
• The incidence of UTI increases with age, with those over 65 years of age being five times more likely to develop a UTI at any point
• Nitrofurantoin has been the first-line empirical treatment for UTIs internationally since 2010. Its mode of action is predominantly bacteriostatic, with some bactericidal tendencies in high concentration levels
• Diligent clinical assessment skills and prescribing of appropriate treatment is paramount to ensure risk of serious complications, hospitalisation and mortality are reduced, while quality of life is maintained

CPD REFLECTIVE PRACTICE:

• How can a good clinical history be gained if the patient lacks capacity?
• What factors need to be considered when safety netting in cases like this?
• What non-pharmacological advice would you give to a patient with a urinary tract infection (or their carers)?
• How will this article change your clinical practice?

Urinary Tract Infection

Urinary Tract Infections (UTIs) stand as one of the most prevalent and burdensome healthcare challenges affecting millions of individuals worldwide. As nurses, our frontline role in patient care places us at the forefront of detecting, managing, and preventing UTIs. It is imperative that we possess a thorough understanding of this common condition to deliver efficient, evidence-based care and contribute to improved patient outcomes .

This study guide aims to provide nurses with a comprehensive guide to UTI management, encompassing the pathophysiology, risk factors, clinical manifestations, and evidence-based interventions to combat this significant healthcare concern.

Table of Contents

• What is Urinary Tract Infection? 

Classification

Pathophysiology, statistics & epidemiology, clinical manifestations, complications, assessment and diagnostic findings, medical management, nursing assessment, nursing diagnosis, nursing care planning & goals, nursing interventions, discharge and home care guidelines, documentation guidelines, what is urinary tract infection.

The urinary system is responsible for providing the route for drainage of urine formed by the kidneys, and these should be fully functional because the damage could easily affect other body systems.

• Urinary tract infections (UTIs) are caused by pathogenic microorganisms in the urinary tract.
• The normal urinary tract is sterile above the urethra .
• UTIs are infections involving the upper or lower urinary tract and can be uncomplicated or complicated depending on other patient-related conditions.

UTIs are classified by location and are further classified according to other factors and conditions.

• Lower UTIs. Lower UTIs include bacterial cystitis , prostatitis, and urethritis .
• Upper UTIs. Upper UTIs are much less common and include acute and chronic pyelonephritis , interstitial nephritis, and renal nephritis .
• Uncomplicated Lower or Upper UTIs. Most uncomplicated UTIs are community-acquired and are common in young women but not usually recurrent.
• Complicated Lower or Upper UTIs. Complicated UTIs usually occur in people with urologic abnormalities or recent catheterization and are often acquired during hospitalization .

For infection to occur, bacteria must gain access to the system.

• Access. Infection occurs first as the bacteria gains access inside the urinary tract.
• Attachment. The bacteria attach to the epithelium of the urinary tract and colonize it to avoid being washed out with voiding.
• Evasion. The defense mechanisms are then evaded by the host.
• Inflammation. As the defense mechanisms react to the bacteria, inflammation starts to set in as well as other signs of infection.

Urinary tract infection cases are widespread around the world and affect both the young and the old.

• UTI is the second most common infection in the body.
• Most cases of UTI occur among women ; one out of five women in the United States will develop UTI during her lifetime.
• The urinary tract is the most common site of infection, accounting for greater than 40% of the total number reported by hospitals.
• UTI affects about 600, 000 patients each year.
• More than 250, 000 cases of acute pyelonephritis occur in the United States each year, with 100, 000 requiring hospitalization.
• Approximately 11.3 million women are diagnosed with UTIs in the United States annually.
• The expenditure in direct healthcare costs amounts to $1.6 billion.

UTIs are primarily caused by bacteria that have invaded the urinary tract.

• Inability or failure to empty the bladder completely. Stasis of urine inside the urinary bladder attracts bacteria into entering the tract.
• Instrumentation of the urinary tract. Catheterization or  cystoscopy  procedures could introduce bacteria into the urinary tract.
• Obstructed urinary flow. Abnormalities in the structure of the urinary tract could obstruct the flow of urine and result in an inability to empty the bladder completely.
• Decreased natural host defenses. Immunosuppression, or the inability of the body to produce the body’s defenses, predisposes the patient to UTI.

A variety of signs and symptoms are associated with UTI.

• Burning on urination . The patient may feel pain during urinating and describe it as a burning sensation.
• Frequency. The patient voids more than the usual every 3 hours.
• Nocturia . Awakening at night to urinate is also a sign of UTI.
• Suprapubic or pelvic pain . The patient may report pain at the suprapubic site or on the pelvic area.
• Urgency. There is also a feeling that the patient would not be able to contain the urge anymore and would rush just to excrete it.

Luckily. UTI is a preventable disease mainly focusing on the hygienic practices of the individual.

• Avoid bath tubs . Shower rather than bathe in a tub because bacteria in the bath water may enter the urethra.
• Perineal hygiene . After each bowel movement , clean the perineum and urethral meatus from front to back to reduce concentrations of pathogens at the urethral opening.
• Increase fluid intake. Drink liberal amounts of fluids daily to flush out bacteria.
• Avoid urinary tract irritants. Beverages such as coffee, tea, colas, alcohol, and others contribute to UTI.
• Voiding habit. Void at least every 2 to 3 hours during the day and completely empty the bladder.
• Medications. Take medications exactly as prescribed.

Early recognition of UTI and prompt treatment are essential to prevent recurrent infection and the possibility of complications.

• Renal failure. UTIs that are not treated promptly could spread in the entire urinary system and become the cause of renal failure .
• Urosepsis. The bacteria may invade the urinary system and result in sepsis .

Results of various tests help confirm the diagnosis of UTI.

• Urine cultures. Urine cultures are useful in identifying the organism present and are the definitive diagnostic test for UTI.
• STD tests. Tests for STDs may be performed because there are UTIs transmitted sexually.
• CT scan . A CT scan may detect pyelonephritis or abscesses.
• Ultrasonography. Ultrasound is extremely sensitive for detecting obstruction, abscesses, tumors, and cysts.

Management of UTIs typically involves pharmacologic therapy and patient education .

• Acute pharmacologic therapy. The ideal medication for the treatment of UTI is an antibacterial agent that eradicates bacteria from the urinary tract with minimal effects on fecal and vaginal flora.
• Long-term pharmacologic therapy. Reinfection with new bacteria is the reason for recurrence, and these patients with recurrence are instructed to begin treatment on their own whenever symptoms occur, to contact their physician only when symptoms persist.

Nursing Management

Nursing care of the patient with UTI focuses on treating the underlying infection and preventing its recurrence.

A history of signs and symptoms related to UTI is obtained from the patient with a suspected UTI.

• Assess changes in urinary pattern such as frequency, urgency, or hesitancy.
• Assess the patient’s knowledge about antimicrobials and preventive health care measures.
• Assess the characteristics of the patient’s urine such as the color, concentration, odor, volume, and cloudiness.

Based on the assessment data, the nursing diagnoses may include the following:

• Acute pain related to infection within the urinary tract.
• Deficient knowledge related to lack of information regarding predisposing factors and prevention of the disease.

Main article:   6 Urinary Tract Infection Nursing Care Plans

Major goals for the patient may include:

• Relief of pain and discomfort.
• Increased knowledge of preventive measures and treatment modalities.
• Absence of complications.

Nurses care for patients with urinary tract infection in all settings.

• Relieve pain. Antispasmodic agents may relieve bladder irritability and analgesics and application of heat help relieve pain and spasm.
• Fluids. The nurse should encourage the patient to drink liberal amounts of fluids to promote renal blood flow and to flush bacteria from the urinary tract.
• Voiding. Encourage frequent voiding every 2 to 3 hours to empty the bladder completely because this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection.
• Irritants. Avoid urinary irritants such as coffee, tea, colas, and alcohol.

Expected outcomes may include:

• Experiences relief of pain.
• Explains UTI and their treatment.
• Experiences no complications.

Care of the patient with UTI must continue until at home because it has a high recurrence rate.

• Personal hygiene . The nurse should instruct the female patient to wash the perineal area from front to back and wear only cotton underwear.
• Fluid intake. Increase and fluid intake is the number one intervention that could stop UTI from recurring.
• Therapy. Strictly adhere to the antibiotic regimen prescribed by the physician.

The focus of documentation should include:

• Individual assessment findings, including client’s description and response to pain, expectations of pain management , and acceptable level of pain.
• Prior medication use.
• Plan of care and those involved in planning .
• Teaching plan.
• Response to interventions, teaching, and actions performed.
• Attainment or progress toward desired outcomes .
• Modifications to plan of care.

Posts related to Urinary Tract Infection:

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4 thoughts on “Urinary Tract Infection”

Very nice. Thanks

The role of oestrogen in perimenopasue, menopause, breastfeeding women, is grossly overlooked as a cause, and providing vaginal oestrogen is a very cheap and safe way of preventing UTI’s in these women.

Thank You for this Comprehensive Content 😊

Thank you so much for helping me

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Uncomplicated urinary tract infections (nursing).

Michael J. Bono ; Stephen W. Leslie ; Wanda C. Reygaert ; Chaddie Doerr .

Affiliations

Last Update: November 13, 2023 .

• Learning Outcome
• List the causes of urinary tract infections
• Describe the presentation of urinary tract infections
• Summarize the treatment of urinary tract infections
• Recall the role of the nurse in the management of a patient with a urinary tract infection
• Introduction

Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. These are patients with no structural abnormality and no comorbidities, such as diabetes, immunocompromised, or pregnant. Uncomplicated UTI is also known as cystitis or lower UTI. Forty percent of women in the United States will develop a UTI during their lifetime, making it one of the most common infections in women. UTI is uncommon in circumcised males, and by definition, any male UTI is considered complicated. Many cases of uncomplicated UTI will resolve spontaneously, without treatment, but many patients seek treatment for symptoms. Treatment is aimed at preventing spread to the kidneys or developing into upper tract disease/pyelonephritis, which can cause the destruction of the delicate structures in the nephrons and lead to hypertension. [1] [2] [3]

• Nursing Diagnosis
• Impaired urine elimination
• Deficiency in knowledge
• Altered sleep

Pathogenic bacteria ascend from the perineum, causing UTI. Women have shorter urethras than men and therefore are more susceptible to UTI. Very few uncomplicated UTIs are caused by blood-borne bacteria. Escherichia coli is the most common organism in uncomplicated UTI by a large margin. [4]

• Risk Factors

Urinary tract infections are very frequent bacterial infection in women. They usually occur between the ages of 16 and 35 years, with 10% of women getting an infection yearly and more than 40% to 60% having an infection at least once in their lives. Recurrences are common, with nearly half getting a second infection within a year. Urinary tract infections occur four times more frequently in females than males. [5] [6]

Symptoms of uncomplicated UTI are a pain on urination (dysuria), frequent urination (frequency), inability to start the urine stream (hesitation), sudden onset of the need to urinate (urgency), and blood in the urine (hematuria). Usually, patients with uncomplicated UTI do not have fever, chills, nausea, vomiting, or back pain, which are signs of kidney involvement or upper tract disease/pyelonephritis. Clinical symptoms can overlap, and in some cases, it is hard to distinguish uncomplicated UTI from a kidney infection. When in doubt, treat aggressively for possible upper renal tract disease. Diagnosis is a combination of signs, symptoms, and urinalysis. Be careful of literature that is based on the results of urinalysis of asymptomatic patients.

A good, clean, urinalysis (UA) specimen is vital to the workup. A clean-catch specimen in nonobese women is preferred. Most obese women cannot give a clean specimen, and epithelial cells in the UA means the urine sample was exposed to the genital surface and did not come directly out of the urethra. Get a clean sample, with very few epithelial cells. In-and-out catheterization of the bladder will cause UTI in uninfected women 1% of the time. Men should start the urine stream to clean the urethra and then obtain a midstream sample. Urine should be sent to the lab immediately or refrigerated because bacteria grow rapidly when a sample is left at room temperature, causing an overestimate of the infection's severity. [7] [8]

Do not base the diagnosis upon visual inspection of the urine. Cloudy urine can be aseptic; the cloudiness can come from protein in the sample, not necessarily infection. Crystal clear urine can be grossly infected. All urines undergo dipstick testing, which can be done at the bedside. Helpful values are pH, nitrites, leukocyte esterase, and blood. Remember that in patients with symptoms of UTI, a negative dipstick does not rule out UTI, but positive findings can help make the diagnosis. Look for the presence of bacteria and/or white blood cells (WBC) in the urine.

Normal urine pH is slightly acidic, with usual values of 6.0 to 7.5, but the normal range is 4.5 to 8.0. A urine pH of 8.5 or 9.0 is indicative of a urea-splitting organism, such as  Proteus , Klebsiella , or Ureaplasma urealyticum; therefore, an asymptomatic patient with a high pH means UTI regardless of the other urine test results. Alkaline pH also can signify struvite kidney stones, which are also known as “infection stones.”

The most accurate dipstick test is the nitrite test because bacteria must be present in the urine to convert nitrates to nitrites. This takes 6 hours. This is why urologists request the first-morning urine, particularly in males. The specificity of this test is greater than 90%. This is direct confirmation of bacteria in the urine, which is UTI by definition in patients with symptoms. Several bacteria do not convert the nitrates to nitrites, but those are usually involved in complicated UTIs, such as those involving  Enterococcus, Pseudomonas , and Acinetobacter .

Leukocyte esterase (LE) identifies the presence of WBCs in the urine. The WBCs release the LE, presumably in response to bacteria in the urine. This is why LE is a subsequent test with a specificity of only 55% for UTI. LE is good at detecting WBCs in the urine, but WBCs can be in the bladder for other reasons, like inflammatory disorders.

Hematuria can be helpful because bacterial infection of the transitional cell lining of the bladder can cause bleeding. This helps distinguish UTI from vaginitis and urethritis which do not cause blood in the urine.

In many labs, the presence of nitrites or leukocyte esterase will automatically trigger a microscopic evaluation of the urine for bacteria, WBCs, and RBCs. On microscopy, there should be no bacteria in uninfected urine, so any bacteria on a gram-stained urine under microscopy is highly correlated to UTI. A good urine sample with greater than 5 to 10 WBC/HPF is abnormal and highly suggestive of UTI in symptomatic patients.

Urine cultures are not needed in uncomplicated UTI. Urine should be cultured in all men and patients with diabetes mellitus, who are immunosuppressed, and women who are pregnant. Classic teaching on urine culture sets the gold standard for infected urine at greater than 10 colony forming units (CFU). Recent literature states that a patient who presents with symptoms and greater than 10 CFU is diagnostic of infection. Urine cultures rarely help in the emergency department, except with recurrent UTI.

• Medical Management

Treatment has varied historically from 3 days to 6 weeks. There are excellent rates with “mini-dose therapy” which involves three days of treatment. E. coli resistance to common antimicrobials varies in different areas of the country, and if the resistance rate is greater than 50% choose another drug.

Trimethoprim/Sulfamethoxazole for 3 days is good mini-dose therapy, but resistance rates are high in many areas. First generation cephalosporins are good choices for mini-dose therapy. Nitrofurantoin is a good choice for uncomplicated UTI, but it is bacteriostatic, not bacteriocidal, and must be used for 5 to 7 days. Fluoroquinolones have high resistance but are a favorite of urologists for some reason. Recent precautions from the FDA about fluoroquinolone side effects should be heeded. [9] [10] [11]

• Nursing Management
• Assess the symptoms of UTI
• Encourage patient to drink fluids
• Administer antibiotic as ordered
• Encourage patient to void frequently
• Educate patient on proper wiping (from front to the back)
• Educate patient on drinking acidic juices which help deter growth of bacteria
• Take antibiotics as prescribed
• Void as soon as possible after sexual intercourse
• When To Seek Help

Flank pain (think pyelonephritis)

• Outcome Identification

The majority of women with a UTI have an excellent outcome. Following treatment with an antibiotic, the duration of symptoms is 2-4 days. Unfortunately, nearly 30% of women will have a recurrence of the infection. Morbidity is usually seen in older debilitated patients, those with renal calculi and in patients. Other factors linked to recurrence include the presence of diabetes, underlying malignancy, chemotherapy and chronic catheterization of the bladder. The mortality after a UTI is close to zero, but the infection does have a significant impact on finance. Women often have to miss work, see the physician and purchase the antibiotic. [12] [13] (Level V)

• Coordination of Care

UTI is best managed in a multidisciplinary fashion, and besides physicians, most nurses will encounter a patient with a UTI. The key to preventing recurrences is the education of the patient. Once a UTI has been diagnosed the patient should drink more fluids. Sexually active women should try to void right after sexual intercourse as this can help flush the bacteria out of the bladder. Some women with recurrent UTIs may benefit from prophylactic use of antibiotics. Several other non-medical remedies may help some women with UTI. Anecdotal reports indicate that the use of cranberry juice and probiotics may help reduce the severity and frequency of UTI in some women. [14] [15] (Level V)

• Pearls and Other issues

Although there is no proof of prevention, women should urinate after sexual intercourse because bacteria in the bladder can increase by ten-fold after intercourse. After urination, women should wipe from front to back, not from the anal area forward, which seems to drag pathogenic organisms nearer to the urethra. Vigorous urine flow is helpful to prevention.

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Disclosure: Michael Bono declares no relevant financial relationships with ineligible companies.

Disclosure: Stephen Leslie declares no relevant financial relationships with ineligible companies.

Disclosure: Wanda Reygaert declares no relevant financial relationships with ineligible companies.

Disclosure: Chaddie Doerr declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Bono MJ, Leslie SW, Reygaert WC, et al. Uncomplicated Urinary Tract Infections (Nursing) [Updated 2023 Nov 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Review Clinical Presentations and Epidemiology of Urinary Tract Infections. [Microbiol Spectr. 2016] Review Clinical Presentations and Epidemiology of Urinary Tract Infections. Geerlings SE. Microbiol Spectr. 2016 Oct; 4(5).
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Urinary tract infections in long-term care

Improving outcomes through evidence-based practice.

Wimmer, Brenda DNP, RN, CHPN, CNL

Brenda Wimmer is an assistant professor of graduate nursing at Morningside University at Sioux City, Iowa.

The author and planners have disclosed no potential conflicts of interest, financial or otherwise.

Urinary tract infections (UTI) are the most common infections in long-term care (LTC) facilities, yet clinical judgment rather than evidence is most often used in evaluation and treatment. This article recounts the implementation of an evidence-based practice evaluation and treatment protocol at an LTC facility to reduce the number of residents with a UTI.

Urinary tract infections (UTI) are the most common infections in long-term care (LTC) facilities. This article recounts the implementation of an evidence-based practice evaluation and treatment protocol at an LTC facility to reduce cases of UTI.

Urinary tract infections (UTIs) are the most common infections found in residents in long-term care (LTC) facilities. However, no universal evaluation or treatment is available for a UTI. Often, it is determined by clinical judgment rather than diagnosing via evidence-based practice (EBP). 1 It is common in healthcare to “check a urine” when a patient's health declines or an unexplainable event occurs. This strategy can lead to inappropriate evaluation and treatment of UTIs.

Data demonstrated that the percentage of residents in a rural, Midwestern LTC facility who had a UTI was 11.1%, which was 3.3 times greater than the state average of 3.3 % and 4.1 times greater than the national average of 2.7%. 2 However, the UTI rate was exaggerated due to the number of discrepancies between UTIs evaluated by best practice and those identified through clinical judgment. 3

This article recounts the implementation of an EBP evaluation and treatment protocol at an LTC facility to reduce the percentage of residents with a UTI.

Quality outcomes

The lack of best practices has facility and patient consequences. Facility consequences may be financially related to quality outcome scores. Nursing Home Compare, now known as Care Compare (CC), was initiated in 1998 by the Centers for Medicare and Medicaid Services (CMS) to educate consumers on LTC quality of care. 2 Quality scores are calculated based on individual LTC facility statistics derived from the CMS health inspection database, the national database on resident clinical information, the Minimum Data Set retrieved from individual resident assessments, Medicare claims data, and nursing staff hours. Data on rehospitalizations, ED visits, pain, pressure injuries, and UTIs are included in CC quality outcomes. The UTI quality measure is the percentage of residents with a UTI in the previous 30 days. This is an important quality measure as it reflects the LTC facility's cleanliness, nutrition services, and personal care services. 2

All data are combined to give each LTC facility a star rating: a five-star rating is the highest, and a one-star rating is the lowest. Data are publicly reported and compare individual facility star ratings to state and national ratings. Consumers can review star ratings to judge an LTC facility's quality of care. Higher facility star ratings can increase resident referrals and admissions, increasing revenue and facility solvency. Conversely, lower ratings may lead to fewer referrals and admissions, decreasing revenue and facility solvency. 2

A lack of best practices in UTI evaluation and treatment may negatively impact residents in LTC facilities. Poor practices may cause unnecessary lab testing procedures, adverse drug events, opportunistic infections, antimicrobial resistance, and additional expenses, such as medications and testing. 1,4 . Residents in LTC, if misdiagnosed and inappropriately treated with antibiotics, are more likely to develop drug resistance and subsequently require the use of alternative, expensive antibiotics. 4

UTI approaches

Uti evaluation and treatment.

The McGeer Criteria for Urinary Tract Infection Surveillance was developed in 1991 for infection surveillance and guidance in LTC facilities. 5 The Criteria require that all signs and symptoms be new or acutely worse, alternative noninfectious signs and symptom causes be ruled out, and clinical presentation and microbiologic findings be present to diagnose infections. 5

As of 2012, The McGeer Criteria may no longer apply to new types of LTC facilities, such as LTC hospitals, acute inpatient rehabilitation facilities, and pediatric LTC centers. These types of LTC facilities may have greater technologic resources, such as on-site lab facilities, and serve more diverse, acutely ill residents than traditional LTC facilities.

Stone's 5 Revised McGeer Criteria embraced McGeer's three important criteria but also considered the low probability of UTIs in asymptomatic residents without indwelling urinary catheters. Furthermore, Stone's revised criteria require a microbiologic confirmation for a UTI diagnosis, localizing genitourinary signs and symptoms, and a positive urine culture. The revised definitions noted only a positive blood culture with the same organism as from the urine culture can diagnose a UTI without the presence of symptoms. 5

Loeb 6 outlined a proactive approach involving UTI evaluation and treatment algorithms for residents living in LTC facilities, Loeb's Minimum Criteria for Initiating Antibiotic Therapy. The three important conditions of the original McGeer criteria were retained; however, the Loeb criteria determine if a urine culture should be performed based on assessment findings such as fever, urinary symptoms, pain, new delirium, and the presence of an indwelling urinary catheter. If a urine culture is obtained, the treatment algorithm assesses if a positive urine culture, indwelling urinary catheter, or other urinary symptoms are present, thus advising if an antibiotic should be prescribed. 6

“Watchful waiting” is a skilled cornerstone of nursing care that is recommended if a urine culture is not advised. “Watchful waiting” is not an absence of action but an observation and monitoring protocol that supports frequent resident assessments and communication of change in condition. 1

Loeb's 6 algorithms reduced antimicrobial prescriptions for suspected UTI events in residents in LTC facilities. Residents in LTC facilities were often diagnosed with UTIs based on a positive urine culture which only implies the presence of bacteriuria, not a symptomatic UTI. The prevalence of asymptomatic bacteriuria (ASB) ranges from 25% to 50% in females and 15% to 40% in males. ASB can also coincide with signs and symptoms unrelated to UTIs. It is not unusual to seek a urine culture for self-limiting, inappropriate symptoms rather than following best practices. 7

Antibiotic stewardship

Antibiotic overuse is a national health concern. For residents who live in an LTC facility for at least 6 months, 75% receive an antibiotic, of which over half are unnecessary. 8 Nearly 75% of antibiotics prescribed for UTIs in LTC facilities do not meet the minimum UTI criteria. 8

There are extra financial and quality-of-life costs related to unnecessary antibiotics, including opportunistic infections and adverse drug reactions. 9 Antibiotic-resistant organisms develop with the misuse of antibiotics and require alternative, sometimes more expensive, treatments to eradicate. 4 Furthermore, unnecessary lab tests and medications can lead to wasted healthcare dollars and poor-quality patient experiences.

In the US, family preferences profoundly influence prescriber antibiotic decision-making, as do off-site prescription processes. 1 Families often pressure LTC staff and providers to “do something” even if best practice does not support the “something.” 1

If a urine culture is completed, an antibiotic will likely be prescribed, with or without an EBP UTI diagnosis. 1 According to a narrative review, providers spent less than 2 hours per week in LTC facilities and relied on individual nurses to recognize and communicate changes. A standardized assessment and communication intervention leads to lower antibiotic prescription rates. 9

Interventions, education

A national quality improvement assessment found that only 36.1% of licensed personnel recognized that pyuria does not equal a UTI. 10 The Agency for Healthcare Research and Quality (AHRQ) provided multiple tools for LTC facilities, such as assessments to determine if the LTC facility has the right staff and resources and areas for quality improvement related antimicrobial stewardship. 11 The toolkit assists LTC facilities in the team creation, readiness assessments, implantation plans, and the introduction of new policies and procedures for an antimicrobial stewardship plan. 11

The Cooper Urinary Surveillance Tool was developed using consensus evaluation and treatment criteria from McGeer, Stone, and Loeb. 5,6 Nurses were educated on best-practice identification of UTI signs and symptoms and appropriate versus inappropriate UTI diagnosis via the tool. After 3 months, the number of UTIs decreased significantly, and there was a 97% reduction in urinalysis (UA) testing. 4

In a pilot program, the use of the AHRQ antimicrobial stewardship toolkit resulted in a reduction of unnecessary antibiotic use by 30%. 11 In another study, an evidence-based education program and a knowledge evaluation instrument were presented to 42 healthcare personnel at an LTC, and the participants' knowledge was measured both before and following the presentation. Results showed that knowledge of UTI diagnosis significantly improved. 12

EBP intervention

In September 2019, an EBP project was developed at a facility in a rural, Midwestern state the US, starting with an organizational and problem assessment. In March 2020, a protocol was created based on the stakeholder assessment, best-practice evidence, the Loeb's Minimum Criteria for Initiating Antibiotic Therapy, 6 and the AHRQ antimicrobial toolkit 11 (see UTI Evaluation/Treatment Worksheet ). The protocol was printed, and an educational intervention was planned for March 18, 2020.

First, a pretest was to be completed by participants and an informational packet and copy of the UTI Evaluation/Treatment Worksheet were to be provided. Then, a 30-minute formal educational program was to be provided to all nursing staff at a scheduled staff meeting. Next, participants would engage in a hands-on activity involving simulated urine and resident signs and symptoms to practice using the worksheet. Education reinforcement was to occur weekly through posters, data displays, and improvement huddles. However, plans changed with the COVID-19 pandemic.

On March 13, 2020, the target facility closed to visitors due to the COVID-19 pandemic. The pretests were eliminated due to the transmission concerns of paper copies. Email was not an option as the facility only had dedicated email accounts for administrative nurses. The project was modified with social distancing regulations, a virtual presentation instead of a staff meeting, and virtual education.

Any staff absent from the virtual education meeting viewed the recorded presentation later. After the educational intervention, the worksheet was placed in the Nurse Communication Books. In the initial stages of the pandemic, follow-up was conducted via email and text messaging. Facility access increased as the COVID-19 tests and vaccinations were released, permitting informal follow-up and education on the EBP process, at most, every 2 weeks.

Data were studied from the CC dataset, UTI Evaluation and Treatment Worksheets, and facility infection control logs. The project participants included facility residents and LTC nurses. Fifteen facility residents required UTI evaluation and treatment. Eighteen LTC facility nurses participated in the UTI evaluation and treatment process and viewed the virtual presentation. Additionally, 24 certified nurse aides viewed the virtual presentation but did not complete the evaluation and treatment process.

National, State, and Facility UTI rate means were analyzed from 2018 to 2020 (see 2018-2020 Yearly UTI Rates ). The National and State means remained steady from 2.6% to 2.7% and 3.2% to 4.1%, respectively. The Facility means varied widely. The 2018 Facility UTI rate mean was 8.4%, 2019 was 11.1%, and 2020 was 3.1%. Thus, the goal of Facility UTI rate at or below National and State averages by May 2021 was partially met. During the project period (September 2019-December 2020), the Facility was at or below the National and State averages for 10 of 16 months.

Facility documentation audits noted that most UTIs during June-September 2020 did not meet EBP criteria. UAs were obtained due to residents' failure to thrive, and antibiotics were prescribed. Most failure-to-thrive residents died.

Outcomes evaluation indicated the use of an EBP protocol was associated with a decreased incidence of inappropriate UTI evaluation and treatment compared with the nonuse of an EBP protocol over 12 months.

Potential quality and financial benefits

If a urine culture is obtained, an antibiotic will likely be prescribed, with or without a UTI diagnosis (see UTIs appropriately treated with antibiotics ). 1 This suggests that using the EBP protocol could deter unnecessary urine testing and unnecessary antibiotic treatment. The reduction of antibiotic-related consequences for the facility residents was not monitored and is an area for future consideration.

The treatment of inappropriately diagnosed UTIs unnecessarily increased costs. The exact medication costs are unknown as the medications were directly billed to the residents. The cost of each UTI treatment course was estimated for the three most commonly prescribed antibiotics in the facility. An informal facility assessment revealed the three most frequently prescribed UTI antibiotics were ciprofloxacin, cephalexin, and nitrofurantoin. The average cost of each medication treatment course was calculated using estimated medication costs from three local pharmacies. This average cost, multiplied by the number of inappropriately diagnosed UTIs equaled a potential antibiotic cost savings (see Estimated cost savings if inappropriately diagnosed UTIs were not prescribed antibiotics ).

If urinary signs and symptoms do not meet the EBP criteria and a UA is obtained, there is potential for unnecessary expense. The cost per UA in the facility was reported as $49 (see Estimated UA cost savings if inappropriately diagnosed UTIs had no UA order ). Facility average daily census (ADC) is included as the declining census may partially affect the data. There also is a potential quality outcome cost. The process of collecting a UA is stressful and unpleasant for older adults, especially those that are cognitively impaired. By not collecting unnecessary specimens, anxiety and loss of dignity can be avoided.

Limitations

The COVID-19 pandemic affected the project. LTC facility priorities turned to resident and staff safety. The educational intervention was delayed and continued only through facility support. One limitation was the lack of data on preintervention versus postintervention knowledge. The pretests were not conducted as the educational intervention was done virtually due to social distancing requirements and transmission concerns with the planned paper tests. Email could not be used due to lack of facility access.

Early in the pandemic, March-December 2020, all outside materials were isolated for 72 hours before being brought into the LTC facility. Therefore, a decision was made not to use posters and data displays in the facility. For an already stressed and exhausted staff, the added burden of retrieving outside materials for distribution was replaced with text messaging and electronic mail contact to relay updates to administrative nurses for distribution.

Another limitation was the small size of the facility and the decreased ADC over the evaluation period. It is unknown if the decline in UTI rates would have naturally occurred with the decline in the census. The project could be repeated with greater population sizes in other LTC facilities.

Recommendations

The findings suggest that an EBP protocol is useful in diagnosing, evaluating, and treating UTIs in residents in LTC facilities. Additional projects to support the EBP on evaluating and treating UTIs in residents in LTC facilities are needed to expand the body of knowledge. Greater focus on patient and prescriber preferences is necessary as these stakeholders affect the UTI evaluation and treatment process. As previously described, family preferences profoundly influence prescriber antibiotic decision-making, as do off-site prescription processes. 1 Families often pressure LTC staff and providers to “do something” even if best practice does not support the “something,” 1 and this deserves further consideration.

The COVID-19 pandemic altered aspects of LTC facilities, including the care and communication of the EBP project. Visual management such as posters and data displays should be used in future studies. Improvement huddles should also be implemented to share successes and improvement strategies.

Nursing implications

UTIs are the most common infections found in residents in LTC facilities, and EBP nursing interventions can improve quality outcomes. Careful analysis and application of assessment findings empower nurses to make EBP evaluation and treatment clinical decisions at the bedside. The nurse is responsible for educating other nurses and ancillary staff on best practices, and sensitive and measured communication is required during treatment decisions with residents and families. Nurses are ethically responsible for addressing antibiotic stewardship and healthcare costs at every opportunity.

UTI evaluation and treatment rooted in EBP can improve outcomes in LTC facilities. Additional projects to support EBP in evaluating and treating UTIs in residents in LTC facilities are needed to expand the body of knowledge. Further focus on patient and prescriber preferences is necessary as these stakeholders affect the UTI evaluation and treatment process.

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extended care; long-term care; urinary tract infection; UTI

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• 1 Eastern Virginia Medical School
• 2 Creighton University School of Medicine
• 3 Oakland Un William Beaumont Sch of Med
• 4 University of Louisville
• PMID: 33760460
• Bookshelf ID: NBK568701

Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. These are patients with no structural abnormality and no comorbidities, such as diabetes, immunocompromised, or pregnant. Uncomplicated UTI is also known as cystitis or lower UTI. Forty percent of women in the United States will develop a UTI during their lifetime, making it one of the most common infections in women. UTI is uncommon in circumcised males, and by definition, any male UTI is considered complicated. Many cases of uncomplicated UTI will resolve spontaneously, without treatment, but many patients seek treatment for symptoms. Treatment is aimed at preventing spread to the kidneys or developing into upper tract disease/pyelonephritis, which can cause the destruction of the delicate structures in the nephrons and lead to hypertension.

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Conflict of interest statement

Disclosure: Michael Bono declares no relevant financial relationships with ineligible companies.

Disclosure: Stephen Leslie declares no relevant financial relationships with ineligible companies.

Disclosure: Wanda Reygaert declares no relevant financial relationships with ineligible companies.

Disclosure: Chaddie Doerr declares no relevant financial relationships with ineligible companies.

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