Dec 11

UTI's in a Nutshell

Diagnosis and Treatment

This outline provides guidelines for identifying and managing urinary tract infections (UTIs), the most common bacterial infections in aged care settings and a leading cause of serious complications. It highlights the importance of differentiating true infections from asymptomatic bacteriuria (ASB), the frequent presence of bacteria in the urine of older people without associated illness. Therefore, the emphasis is on diagnosis based on specific criteria and the presence of clear symptoms, which vary depending on whether the resident has a urinary catheter, and on avoiding the use of unreliable urine dipsticks. Proper treatment involves collecting a sterile urine sample for culture testing, an essential step for supporting antimicrobial stewardship and selecting the safest antibiotic. The guide concludes with management strategies, such as encouraging fluid intake and ensuring the full course of antibiotics is completed to prevent more serious infections.
Introduction
Urinary Tract Infections (UTIs) are the most common bacterial infection among older people in Australia and New Zealand. Providing clear, concise information on UTIs is essential for effective infection control and resident care. This guide concentrates on key clinical assessment and antimicrobial stewardship principles relevant to the Aged Care sector.

Understanding the Infection

A UTI is a bacterial infection that affects any part of the urinary system, including the kidneys, ureters, bladder, or urethra. Usually, bacteria from the person's own bowel, such as Escherichia coli, enter the urinary tract and cause the infection.

  • Symptomatic UTI: This refers to a bacterial presence along with clinical signs of infection, usually needing assessment and treatment.
  • Asymptomatic Bacteriuria (ASB): This refers to bacteria in the urine without any signs or symptoms of infection.


* ASB is very common among aged care residents; about 50% of older people and all those with an indwelling catheter have bacteria in their urine without showing symptoms.

*ASB seldom requires antibiotic treatment.

Recognising Atypical Signs

Classic UTI symptoms, such as dysuria, frequency, or urgency, are often absent in older adults. Caregivers need to recognise atypical signs, as they could be mistaken for other conditions or behaviour changes.

Crucial Signs and Symptoms (S&S) in Older Adults:

1. Systemic Changes – which should prompt a full medical workup:
  • Sudden change in mental state, confusion, or delirium.
  • Lethargy, excessive sleepiness, dizziness, or a higher risk of falls.
  • A temperature below 36 °c or above 38 °c or experiencing shivering or chills.
  • New or worsening confusion or agitation.

2. Local Changes:
  • New or worsening urinary incontinence. 
  • New or worsening pain or tenderness above the pubic bone (suprapubic area) or in the flank/lower back.
  • Presence of new or visible blood in the urine.


Unreliable Indicators: Note that cloudy or foul-smelling urine alone is not a reliable indicator of a UTI.

Diagnosis and Specimen Collection

Accurate diagnosis relies on clinical assessment, often following criteria such as the McGeer definition. Nurses should prioritise the resident's clinical signs as the primary guide to diagnosis and initiating treatment.

  • Symptoms are Essential: Using symptoms provides a more accurate way to assess whether a resident might have a UTI.
  • The Dipstick Problem: Urine dipsticks are not very effective in diagnosing UTIs in older people because the high prevalence of ASB can lead staff to mistakenly believe an infection is present, resulting in unnecessary antibiotic use.
  • When to Collect a Urine Sample: A specimen for full urine culture and sensitivity as per lab results (C&S) is indicated only if the resident shows new or worsening symptoms suggestive of a UTI.
  • When NOT to Screen: Avoid screening for a UTI or sending a urine specimen for routine culture in asymptomatic residents, as this leads to inappropriate antibiotic use (for treating ASB).
  • Best Practice Collection:
       The best practice is a midstream clean-catch (MSU) or a specimen from a newly inserted catheter.
      The sample must be immediately sent to the pathology lab for microbiological testing. If transport is delayed, the sample must be refrigerated to prevent rapid bacterial growth that may skew results.
  • Ural: Use with caution, urine is already alkaline, and Ural can increase alkalinity.

Treatment and Antimicrobial Stewardship

The central principle for infection control is to: Treat the patient, not the lab results. Unnecessary testing of asymptomatic residents is a significant cause of inappropriate antibiotic use and contributes to antimicrobial resistance (AMR).

1. When to Treat (Symptomatic UTI):
  • If a symptomatic resident is diagnosed with a UTI, antibiotics are usually prescribed based on the C&S results.
  • Nurses must ensure the correct antibiotic is administered and monitor for adverse drug reactions, such as an increased risk of C. difficile infection.
  • The antibiotic course must be finished, even if the symptoms are no longer there, this is to ensure all the bacteria is eliminated and avoid complications.
  • Untreated UTIs can spread to the kidneys (pyelonephritis), potentially causing kidney damage, sepsis, septic shock, and the need for hospitalisation with intravenous antibiotics.

2. When NOT to Treat (ASB): 
  • Do not use antibiotics to treat asymptomatic bacteriuria (ASB), regardless of the bacterial count in the culture.
  • The general exception for treating ASB applies only before invasive urological procedures.

Prevention and Infection Control

Focusing on modifiable risk factors is essential for prevention.

  • Hydration: Promote sufficient fluid intake to flush the urinary tract.
  • Hygiene: Ensure thorough perineal hygiene by wiping from front to back after voiding or bowel movements.
  • Incontinence Management: Change incontinence pads or aids promptly when they are wet.
  • Bladder Emptying: Encourage the resident to empty the bladder completely and void frequently.
  • Catheter Care: Strictly follow Aseptic Non-Touch Technique (ANTT) for insertion and maintenance of catheters; minimise catheter use and remove them at the earliest suitable time.

Conclusion

Continuously monitor the resident's clinical symptoms, especially noting any sudden changes in their mental state or physical health, to guide your assessment. By carefully avoiding unnecessary testing and treatment of asymptomatic bacteriuria, nurses make a significant contribution to antimicrobial stewardship and help prevent the emergence of antimicrobial resistance in aged care settings. Early detection of atypical signs and appropriate management are crucial to avoiding serious complications such as sepsis.
Short note on hydration:

Think of novel ways to keep a resident hydrated in summer.

  • Most people love ice blocks – make your own from cordial, fruit juice, or lemonade.
  • Conduct regular water rounds and encourage residents to have a drink instead of leaving the water jug to gather dust.
  • A small facility? How about an ice cream for special occasions?
  • Catering staff can identify those not drinking enough fluids.

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