INFECTION CONTROL NEWSLETTER

November 1996
written by and for Long Term Care Infection Control Nurses

Broad Street Solutions
James Marx, RN, MS, CIC Editor
PO Box 16557
San Diego, CA 92176
(619)563-0274 Voice/FAX
jmarx@concentric.net

Focus on Urinary Tract Infection:
Catheterized and Non-Catheterized residents

Urinary Tract Infection (UTI) is the most frequently occurring infection in skilled nursing facilities. Research on the cause and prevention of UTI's in both the community and the institutional settings have been done. The following is a summary of what is currently known about UTI's.

TERMS

Bacteriuria or UTI- presence of > 100,000 colony-forming units of a uropathogen per milliliter of urine without regard to clinical symptoms.
Asymptomatic bacteriuria- UTI without clinical symptoms.
Complicated UTI- infections that fails to resolve completely or recurs after standard therapy.
Recurrent UTI- three or more episodes of symptomatic bacteriuria with 1 year. A recurrent UTI is classified as either relapse or reinfection.
Relapse UTI- bacteriuria within 2 weeks of antibiotic therapy. In men with chronic bacterial prostatitis, treatment with long-term (at least 4 weeks) oral antimicrobial agents such a quinolone, carbenicillin, or trimethoprim-sulfamethoxazole is recommended.
Reinfection UTI- bacteriuria occurs 4 or more weeks after previous infection has been cured. It can be with the same or a different organism.

FACTS

In the community, 5 to 10% of women older than age 60 are bacteriuric. This increases to 20 to 30% in women over age 80. In men age 70 and older, the prevalence is 5 to 10%.

In institutionalized populations, bacteriuria in women ranges from 17 to 55% and 15 to 31 % in men.

Because of the diversity of uropathogens in older persons with UTI, it is important to obtain properly collected urine cultures in persons with suspected UTI.

Most older women with uncomplicated lower tract UTI should be treated with antibiotics for 10 days; older men are generally treated for 14 days. Upper tract UTI in both man and women requires 14 days of therapy.

Reinfection UTI may be treated be giving Vitamin C and drinking citrus fruit juice to acidify the urine (which inhibits bacterial growth), or perhaps cranberry juice (which limits microbial adherence to bladder epithelium).

In non-catheterized female residents with asymptomatic bacteriuria, E. coli is the most frequently isolated organism. For male residents, P. mirabilis is identified as frequently or more frequently than E. coli .

Infection with more than one organism is identified in 10 to 25% of institutionalized bacteriuria residents.

The use of pyuria to differentiate "colonization" from infection has not been shown to have clinical relevance. More than 90% of older adults with asymptomatic bacteriuria have pyuria; however up to 30% of non-bacteriuric institutionalized adults have pyruia.

There is little evidence that asymptomatic bacteriuria by itself leads to other complications.

There are no benefits to treating asymptomatic bacteriuria. In fact, there is a potential to develop antimicrobial resistant microorganisms. More than 50% of female residents with asymptomatic bacteriuria develop recurrent bacteriuria within 4 weeks of discontinuing antimicrobial therapy.

All residents with a urinary catheter greater than 30 days will have bacteriuria.

Changing urinary catheter bags monthly does not decrease UTI.

Some experts advise removing the catheter and replacing it with a new one before obtaining urine cultures for residents with clinical symptoms of a UTI.

Current data does not support treatment of asymptomatic bacteriuria for residents with urinary catheters.

Symptomatic UTI in a resident with a catheters should be treated with a narrow spectrum agent, based on culture and sensitivity reports for 5 to 14 days or longer.

REFERENCES ARE AVAILABLE ON REQUEST

Indications for use of a urinary catheter

Urinary retention that cannot be managed by surgical or medical treatment, condom or intermittent catheterization

where incontinence interfers with wound healing

care of the terminally ill or severely impaired where frequent changing of clothes or linen would be very uncomfortable

preference of the resident who has not responded to specific incontinence treatments