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We already know that up to 40% or more of residents without an indwelling catheter,
have asymptomatic colonization of the urinary tract, and
that a positive culture is a common and expected finding at any time.
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When localizing and systemic symptoms or signs such as fever or
shaking chills, painful urination, blood in urine, pain or
tenderness along the urinary tract and a new or increased frequency, urgency or
incontinence are also present, diagnosis and treatment of a UTI is appropriate.
In residents without any signs or symptoms who have a positive urinalysis and
positive culture, there are often benign findings and
should not be treated, as this can be harmful to the resident.
Prescribing antibiotics is the subject of increased scrutiny due to the overuse of
antibiotics, and resulting resistance to antibiotics that many organisms develop.
The upward trend of C Difficile diarrhea cases and
increasing antibiotic resistance has led to the positive practice
of shifting from broad to narrow spectrum antibiotics.
The use of narrow spectrum antibiotics is based on the need for
accurate diagnosis, and the importance of obtaining cultures
in the elderly population before starting antibiotics.
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When clinicians are selecting antibiotics for treating UTIs,
they should follow evidence-based clinical guidelines, such as those published by
the Infectious Disease Society of America, or other professional societies.
Clinicians faced with the decision to treat with antibiotics or employ monitor
and observe, often opt for antibiotics due to the concerns over missing an infection,
delaying treatment, or not meeting a resident's or family's expectations.
In doing so, physicians overvalue the benefits of antibiotic therapy,
while undervaluing the strong likelihood of negative outcomes related to treating
asymptomatic bacterial colonization such as Clostridium difficile,
adverse drug events, and antibiotic resistance.
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The appropriate choice is to monitor and
observe the resident, which is called watchful waiting.
The example observation order set,
shown here, ensures that the resident is receiving supportive care,
provides reassurance that the resident is being adequately cared for, and
emphasizes prompt communication for changes in condition.
The goal of treatment for
UTI is to alleviate symptoms, not to create a sterile bladder.
If the resident appears to be responding to the therapy,
it is not necessary to re-culture after a course of antibiotics.
Polymicrobial bacteriuria often persists after a course of antibiotics and
does not mean the treatment has failed.
A urine test alone does not provide sufficient information.
Increases the risk of treating asymptomatic bacteriuria,
as well as the risk of adverse drug events, C difficile infection, and
antimicrobial resistance.
To sum up, a positive urinalysis and or urine culture only tells you that bacteria
are present in the bladder, and does not necessarily indicate an infection.
For a UTI to be present, the resident must have systemic and or
local signs and symptoms and a positive culture.
Only then should an infection be treated.
Evelyn CookAssociate Director
