Urinary Tract Infections:
LTC Facilities
Robert M. Palmer, MD, MPH
Director of the Glennan Center for
Geriatrics and Gerontology
gy
Eastern Virginia Medical School
November 2, 2011
Urinary Tract Infection (UTI):
Definition
O “Clinically
Clinically detectable condition
associated with invasion by disease
causing microorganism of some part of
the urinary tract.
O ‘Urosepsis’
Urosepsis is systemic inflammatory
response to infection (sepsis).”
--CMS F315 June 28, 2005
https://www.cms.gov/transmittals/downloads/r8som.pdf
1
Classification of UTI
Upper tract
UTI
Lower tract
UTI
Epidemiology: Bacteriuria in
Elderly
Asymptomatic Positive Urine Culture (%)
POPULATION Women Men
Community >70 yrs 10-18 4-7
Long-Term Care 25-55 15-37
Chronic Catheter >90% >90%
Symptomatic Nicolle LE. UTI
in Hazzard’s
1-2.4 / 1000 resident days LTC Geriatric
Medicine 6th ed.
0.6 / 1000 with standardized criteria 2009
2
Risk Factors in LTC
O Age
O Urinary incontinence
O Prior UTI (women)
O BPH (men)
O Dementia
O Mobility limitations
O Bladder dysfunction (DM, PD, CVA)
Buhr GT et al.
Clin Geriatr Med 2011; 27:229
Pathophysiology
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Infecting Bacteria:
Asymptomatic LTC
Women Men
O E coli (47-77%) O Proteus mirabilis (30-
O Proteus mirabilis (2-27%) 36%)
O Klebisella pneum (7-11%) O E coli (11-27%)
O Pseudomonas (5-9%) O Klebsiella pneum (6-9%)
O Enterococcus (5-8%) O E t b t (2-9%)
Enterobacter (2 9%)
O Enterococcus (5-24%)
Nicolle LE. UTI in Hazzard’s Geriatric
Medicine 6th ed. 2009
Common Clinical Features
O Lower urinary tract O Systemic symptoms
symptoms
t – Nausea/vomiting
– Dysuria – Fever/chills
– Urgency – Flank pain
– Frequency – Delirium
– Suprapubic – Functional decline
pain/tenderness
– Hematuria
– Cloudy urine
4
Diagnosis
O Asymptomatic bacteriuria: Urine Culture
– > 105 cfu/mL on 2 voided consecutive
specimens (women)
– > 105 cfu/mL on 1 clean-catch urine
specimen (men)
– > 102 cfu/mL
f / L on 1 catheterized
h i d urine
i
specimen
Nicolle LE et al. IDSA Guidelines.
Clin Infect Dis 2005: 40:643
Diagnosis
O Symptomatic bacteriuria: Urine Culture
– > 104 cfu/mL (pyelonephritis or fever with
local GU symptoms)
– > 103 cfu/mL (acute lower urinary tract
symptoms)
– > 105 cfu/mL ((external catheter in men))
– > 103 cfu/mL (aspirated indwelling
catheter)
Nicolle LE. UTI in Hazzard’s
Geriatric Medicine 6th ed. 2009
5
F315 Indications to Treat Symptomatic UTI:
residents without catheter (>3)
O Fever (increase of > 2° 2 F; rectal temp > 100
100°F)
F)
O New or increased burning, pain on urination,
frequency or urgency
O New flank or suprapubic pain/tenderness
O Change in character of urine (new bloody urine, foul
smell or amount of sediment) or lab report of + result
(nitrite +, pyuria, microhematuria)
O Worsening of mental or functional status (confusion,
lethargy, unexplained falls, recent onset of
Incontinence, decreased activity or appetite)
https://www.cms.gov/transmittals/downloads/r8som.pdf
F315 Indications to Treat
Catheter-associated UTI: (>2)
O Fever or chills
O New flank pain or suprapubic tenderness
O Change in character of urine (new bloody urine, foul
smell, increased sediment or lab report of +pyuria,
microscopic hematuria)
O Worsening of mental or functional status
https://www.cms.gov/transmittals/downloads/r8som.pdf
6
What is the CMS/F315
guidance for indwelling (Foley)
catheters/incontinence?
CMS/F315
O F315 released by CMS in June 28
28, 2005
O Intent of F315
– incontinent resident to maintain as normal
urine function as possible (assess/manage)
– Indwelling urinary catheter Is not justified
without medical indication
– Prevent UTI through appropriate care
https://www.cms.gov/transmittals/downloads/r8som.pdf
7
Indications for Catheters
O Urinary retention that cannot be treated
or corrected medically or surgically
– PVR >200 ml
– Inability to manage retention/incontinence
with intermittent caths
– Persistent overflow incontinence, SUTI,
renal dysfunction
https://www.cms.gov/transmittals/downloads/r8som.pdf
Indications for Catheters
O Contamination of stage 3 or 4 pressure
ulcers when urine impedes healing
despite appropriate care for the UI
O Terminal illness or severe impairment
(uncomfortable or intractable pain)
https://www.cms.gov/transmittals/downloads/r8som.pdf
8
Risks of Indwelling urinary
Catheters
O UTI (with or without symptoms): biofilm
O Obstruction due to encrustations,
kinking
O Bladder spasms
O Urinary leakage
O Urethral erosion, infection
O Sepsis
Compliance with F315:
Urinary Incontinence and UTI
O Recognize
g and assess factors affecting
g
urinary function and risk of UTI
O Attempt correction of underlying causes
of UI
O Monitor response to preventive efforts
and interventions
O Revise approaches as appropriate
https://www.cms.gov/transmittals/downloads/r8som.pdf
9
Discuss management of the
resident with dementia and a
suspected urinary tract infection.
Dementia and UTI
O Dementia is risk factor in LTC for UTI
O Symptoms of UTI might not be reported
O No practice guideline: F315 criteria apply
O Monitor for symptoms/signs of UTI
– Fever
– Clinical deterioration
– Check suprapubic/flank tenderness
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How can recurrent urinary
tract infections be managed?
Recurrent UTI
O Recurrent: 2 or more infections in 6
months
– Relapse
– Reinfection
O Might
g indicate structural abnormality
y
(obstructive uropathy)
– Check PVR
– If catheter: check perineal hygiene technique
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Preventing Recurrent UTI
O Eliminate chronic indwelling
g catheter
– Condom catheter in non-demented men
O Improve resident walking, transfers, bed
mobility
O Replace chronic with intermittent caths
O Vaginal estrogen for women?
O Cranberry juice or tablets?
O Abx? Not shown to be effective in LTC
Buhr GT et al. Clin Geriatr Med 2011; 27:229
Discuss urinary tract infection
prevention strategies in the
catheterized and non-
catheterized resident.
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Best Practice: UTI Prevention
O Adequate fluid intake
– Cranberry juice 10 ounces/extract 300-400 mg daily
O Promote complete bladder emptying
– Every 3-4 hours
O Perform daily perineal skin care
– Prevent excessive skin wetness, contact with urine/feces
– “front-to back” cleaning
O Appropriate incontinence products
– super absorbent polymer Newman DK. Ostomy/wound
management 2006;52:34
Avoiding CAUTI
O Limiting
g unnecessaryy catheterization
O Discontinuation of catheter
O Strategies to consider before catheter
– Education and training of staff
O Alternatives to indwelling
g catheters
– Condon caths in men (effectiveness?)
– Intermittent caths
Hooten TM et al. IDSA
– Suprapubic caths Guidelines. Clin Infect Dis
2010;50:625
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Prevention of CAUTI:
Society for Healthcare
Epidemiology of America (SHEA)
Catheter Insertion Catheter Maintenance
O Clean technique for O Closed drainage system
Intermittent cath O Replace catheter for break
O Secure cath to prevent in aseptic technique
movement/urethral traction O Keep collecting bag below
O Perform cath at regular bladder level
intervals O Use clean collecting
O Check PVR to avoid container to empty bag
unneeded cath insertion O Routine hygiene for meatal
Gould CV et al. Infect control hosp managment care
2010: 31:319
Keeping Seniors Healthy
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