Management of urinary tract infections in elderly patients: Strategies for improvement

Abstract

Urinary tract infection (UTI) is one of the most common infections affecting the elderly. However, UTI is overdiagnosed and overtreated in this group. This project aimed to look into strategies for improving the management of UTI in elderly medical inpatients. A retrospective audit was performed on the case notes of medical inpatients in a district general hospital from December 2012 to April 2013. The target measures for improvement include increasing adherence to SIGN guidelines in the diagnosis of UTI, increasing the frequency and timeliness of urinary culture collection in suspected UTI, and increasing use of urine culture sensitivities to tailor antimicrobial treatments.Initial baseline measurement revealed 16 patients treated for UTI. 31.3% of these fulfilled SIGN criteria for UTI. 68.5% had urine cultures performed. 60% of patients with positive urine cultures had correct antibiotic therapy after sensitivity results. The mean time from the diagnosis of UTI to urine collection for culture was 4 days.Three further cycles were performed. Following each cycle, improvement measures were implemented to raise the awareness of medical staff about the management of UTI in the elderly. These comprised presentations to junior doctors at local teaching sessions; emails to ward managers with results of the previous audit cycle broken down by ward; and prominent display of guidelines on medical wards and ensuring availability of ‘Newcastle pads’ for taking sterile urine cultures from incontinent patients.In the final cycle, 19 patients were diagnosed with UTI. 42.1% of these fulfilled SIGN criteria for diagnosis of UTI. 89.5% had urine cultures sent. 86.7% of patients with a positive urine culture were treated with appropriate antibiotics after sensitivities became available. Mean time from UTI diagnosis to culture collection improved to zero days.In conclusion, continuous educational measures, performance feedback, and increased availability of specialist equipment are imperative for improving management of UTIs in the elderly.

The Antibiotic Prescribing Pathway for Presumed Urinary Tract Infections in Nursing Home Residents

“…36 Outpatient treatment guidelines for UTIs in the United Kingdom explicitly state that antibiotics should be discontinued if a culture yields no bacterial count. 28,37 Yet our providers discontinued antibiotics in only 4 of 6 cases with no bacterial growth. Standing orders for antibiotic cessation when urine cultures are negative may reduce antibiotic use.…”

“…Even when faced with negative cultures, providers apparently failed to reexamine their diagnosis and discontinue antibiotics–despite the fact that discontinuing antibiotics, when no infection is present, reduces antibiotic resistance . Outpatient treatment guidelines for UTIs in the United Kingdom explicitly state that antibiotics should be discontinued if a culture yields no bacterial count . Yet our providers discontinued antibiotics in only 4 of 6 cases with no bacterial growth.…”

“…One of the early components of the prescribing pathway, namely signs and symptoms of the presenting illness, may represent an important area for intervention. Despite the existence of evidence‐based guidelines for more than a decade, we continue to see that most presumed UTIs fail to meet minimum requirements for appropriate antibiotic initiation . Admittedly, one possible explanation for apparent inappropriate prescribing may be the lack of documentation in NH charts.…”

“…Despite the existence of evidence-based guidelines for more than a decade, 21 we continue to see that most presumed UTIs fail to meet minimum requirements for appropriate antibiotic initiation. 10,18,27,28 Admittedly, one possible explanation for apparent inappropriate prescribing may be the lack of documentation in NH charts. Even when symptoms were documented, however, non-specific signs and symptoms such as confusion or agitation (which have shown little to no association with UTIs 29 ) were documented most frequently.…”

Urinary Tract Infection Treatment Pattern of Elderly Patients in a Tertiary Hospital Setup in South India: A Prospective Study

“…1 Due to their anatomy and reproductive physiology, women are more susceptible. 2,3 However, between females and males, the ratio varies from geriatrics (50:1) to younger (2:1) population.…”