Hydration and UTI Management

As we enter summer, reports of UTIs increase. Hydration is a crucial factor that should not be overlooked. This blog focuses on optimising hydration and managing urinary tract infections (UTIs), particularly in aged care settings in Australia and New Zealand, especially during warmer months. The text emphasises that dehydration is a significant risk factor for UTIs and other serious health issues like delirium and heatstroke in older adults. To address this, there are innovative, structured strategies to encourage residents to meet their daily fluid targets, such as scheduling regular rounds and incorporating fluid-rich foods. Importantly, the current national guidelines strongly discourage the routine use of urine dipstick tests to diagnose UTIs, as these often result in unnecessary antibiotic treatment of Asymptomatic Bacteriuria (ASB). Instead, best practice suggests focusing on aggressive hydration, pain relief, and diagnosing UTIs based solely on the presence of new or worsening clinical urinary symptoms.

We review best practice guidelines from Australia and New Zealand, highlighting innovative hydration approaches, the important shift away from outdated diagnostic tests, and effective non-antibiotic methods for managing UTIs. By implementing these evidence-based practices, we can enhance resident outcomes, minimise unnecessary antibiotic use, and promote antimicrobial stewardship.

Hydration is essential for a healthy mind and body. For older adults, maintaining enough f luid intake is not just about comfort; it is vital in preventing a range of health issues. Dehydration can have a serious impact on an older person's health, directly impairing brain function and leading to critical medical events. Conversely, staying well-hydrated can boost endurance, lower the heart rate, speed up recovery, and lift mood. Why are residents in aged care so vulnerable to dehydration?

Adults can lose nearly 2.5 litres of water daily through normal activities, making regular

• Reduced Thirst Sensation: It’s important to remember that when an older person feels thirsty, their body is already dehydrated. Their natural thirst response is less sensitive.
• Cognitive and Mobility Limitations: Residents with cognitive impairments like dementia may forget to drink, while those with mobility issues might be unable to get a drink themselves.
• Medication Side Effects: Common medications, like diuretics, can lead to increased fluid loss.
• Decreased Appetite and Activity: As appetite and physical activity often decline with age, so can the motivation and routine of drinking fluids.
• Poor Hydration Literacy: A 2017 study found that many older Australians lack essential knowledge about hydration health literacy. They often overestimate the amount of fluid loss required to cause symptoms and underestimate the amount of fluid that needs to be replaced. Additionally, they may not recognise the signs of dehydration in themselves.
  

Early identification is essential. Care staff should remain alert for the common signs of dehydration, which include:

Residents living with dementia face an increased risk of dehydration. Water is crucial for this group to help prevent behavioural changes, delirium, and depression. However, specific challenges include:

The aim for most residents is a daily fluid intake of at least 1.5 to 2.0 litres, unless they are on a fluid restriction prescribed by a doctor. Moving beyond simply asking, "Would you like a drink?" is essential. Here are evidence-based strategies to reach this target:

2. Think Beyond the Water Jug:

• Fluid-Rich Foods: A large part of fluid intake can come from food. Regularly offer high fluid options such as:

◦ Ice blocks, ice cream, jelly, and fruit juice blocks. A homemade ice block can be a wonderful afternoon treat that doubles as a hydrating trick.
◦ Thin custard and yoghurt.
◦ Water-rich fruits and vegetables such as watermelon, cucumber, grapes, tomatoes, spinach and broccoli.

◦ Soups and broths, served at the resident's preferred temperature.

3. Ensure Accessibility and Support

4. Monitor Carefully

Urinary tract infections are a common concern in aged care, but our approach to diagnosing and treating them must align with current best practices to prevent the significant harms of over-treatment.

This marks a crucial change in aged care practice. Clinical pathways at the national and state levels in Australia and New Zealand strongly advocate against routinely using urine dipstick tests for suspected UTIs in aged care residents.

The clear message is: Do NOT use a urine dipstick test to diagnose a UTI in an aged care resident.

Why is this so critical? The reason lies in a condition called Asymptomatic Bacteriuria (ASB).

• What is ASB? ASB is the presence of bacteria in the urine without any clinical symptoms of infection. It is a normal, harmless colonisation of bacteria that does not require antibiotic treatment.
• How common is it? ASB is very prevalent among older adults. Up to 50% of older women and a notable number of older men experience it.
• The Dipstick Problem: A positive dipstick result (showing nitrites or leukocyte esterase) cannot differentiate between a genuine, symptomatic UTI and harmless ASB. This often results in the misdiagnosis and unnecessary treatment of ASB.

Treating ASB exposes residents to unnecessary antibiotics, increasing their risk of Clostridioides difficile infection and worsening the antimicrobial resistance (AMR) public health crisis. Additionally, treating ASB does not prevent future symptomatic UTIs and often causes more harm than good.

The focus should move from pursuing a positive test result to performing a comprehensive clinical assessment. A suspected UTI diagnosis must rely on new or worsening localised urinary symptoms.

Symptoms that are NOT sufficient for a UTI diagnosis:

• A shift in behaviour
• A fall
• A general decline in condition
• Cloudy or foul-smelling urine

These vague symptoms are usually caused by other issues, with dehydration being a common cause. Cloudy or foul-smelling urine is most often a sign of dehydration or a reaction to certain foods or medications, not an infection.

Before prescribing an antibiotic, especially in mild cases or when symptoms are vague, concentrate on these important non-pharmacological interventions:

1. Aggressive Hydration: This is the crucial first step. Addressing dehydration can often relieve mild urinary symptoms, such as painful urination (dysuria), and may be the only treatment needed to resolve the resident's condition.

2. Symptom and Pain Relief: Relieve discomfort with simple analgesics like paracetamol (if suitable for the resident). Urinary alkalisers can also help in easing symptoms, although they do not treat the underlying infection.

3. Perineal Hygiene: Practice regular and correct perineal cleaning, especially after toileting and incontinence episodes, to lower the bacterial load locally.

4. Topical Oestrogen: For postmenopausal women experiencing recurrent UTIs, intravaginal oestrogen (available as a cream or pessary) can be highly effective. It works by restoring healthy vaginal flora, which considerably reduces the occurrence of UTIs.

5. Catheter Management: For residents with an indwelling catheter, strict adherence to catheter care bundles is essential. If a UTI is suspected clinically, the catheter should ideally be removed or replaced before collecting a urine sample for culture (MC&S) to prevent contamination.

Managing hydration and UTIs effectively in the summer months doesn't have to mean an automatic spike in antibiotic prescribing. By rigorously prioritising hydration, avoiding routine dipstick testing, and ensuring all diagnostic decisions are based on strong clinical assessment and current national guidelines, we can greatly enhance the quality of life for our residents. This approach not only delivers better, safer care but also positions our facilities as leaders in antimicrobial stewardship.

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