Ann Longterm Care. 2021;29(1):11-17. DOI: 10/25270/ALTC.2020.3.00001 Received August 21, 2019; accepted November 7, 2019. Published online March 10, 2020.
Morgan C Johnson, DNP, FNP-BC
Tennessee Valley Healthcare System
1310 24th Avenue South
Nashville, TN 37209
Phone: (615) 489-2072 Fax: (615) 873-7981 Email: firstname.lastname@example.org
The authors have no relevant financial relationships to disclose.
1Tennessee Valley Healthcare System, Nashville, TN
2Vanderbilt University School of Nursing, Nashville, TN
3Belmont University, Nashville, TN
This project reports on the results of a doctorate of nursing practice project at Belmont University, Nashville, TN. The assistance of Dr. Elizabeth Morse, Dr. Leslie Higgins, Dr. Linda Wofford, and Dr. Steven Schaeffer Spires is acknowledged. Funding was provided by Belmont University.
Misdiagnosis of asymptomatic bacteriuria (ASB) contributes to antibiotic overuse. Due to the growing population of older adults in long-term care facilities (LTCFs), these institutions can play a critical role in antimicrobial stewardship. A retrospective review of 152 urinalyses was conducted in one LTCF to assess the management of urinary tract infections (UTI). Chi-square analysis was used to assess for associations between cognitive impairment, meeting symptoms criteria, and receiving empiric antibiotic treatment. Overall, 13% of urinalyses met diagnostic criteria and 56% met all components of treatment criteria. There was a weak association between cognitive impairment and not meeting symptomatic criteria, indicating that symptoms are less likely to be met for cognitively impaired patients. No relationship was identified between cognitive impairment and empiric treatment. LTCFs should target management of suspected UTIs to improve antibiotic use and educate on newly published guidelines for ASB in older persons with cognitive impairment.
Key words: urinary tract infections, older adults, diagnosis, treatment, treatment guidelines, algorithm
By 2030, one-fifth of the US population is projected to be aged 65 years or older.1 Older persons are at greater risk for infections due to factors such as impaired immune function, comorbidities, alteration in mucosal linings, and institutionalization.2,3 Urinary tract infections (UTI) account for 20% to 30% of all infections within long-term care facilities (LTCFs) and have been an area of inappropriate antibiotic prescribing.4,5 The management of UTIs in older LTCF residents is challenging due to these health factors and comorbidities. The complexity of care in older adults has limited the ability to create universal standards for diagnosis and treatment of UTIs.6,7 One complicating factor is asymptomatic bacteriuria (ASB), which is common in older adults and defined as colonization of bacteria in the urinary tract with a positive urine culture while lacking specific signs and symptoms of an infection.8,9 Screening for and treating ASB in institutionalized older adults increases the risk for antimicrobial resistance and adverse effects from antibiotics such as Clostridioides difficile infections and is therefore not recommended.10-12 Despite this recommendation, misdiagnosis and inappropriate treatment of ASB still occur at a high rate.13-15
The Society for Healthcare Epidemiology of America (SHEA) updated its guidelines in 2012 due to the low sensitivity of correctly identifying a true UTI in its previous version.16,17 However, these guidelines are directed toward the general population, making application to older adults problematic. A proposed diagnostic and treatment algorithm with further evidence-based modifications to the 2012 guidelines sought to increase specificity for UTI diagnosis in older adults in the LTCF setting.7 In reviewing the literature, no evidence on the use of the proposed diagnostic and treatment algorithm could be found to support its use in LTCFs.
Older adults may not present with the same signs of an infection as younger persons. For example, older adults are less likely to exhibit a fever with an infection than the general population.1,18 Nonspecific symptoms such as mental status change or delirium have been mistakenly presumed to be secondary to UTIs. However, a recent systematic review could not validate a significant relationship between delirium and UTIs.19,20 Determining whether nonspecific symptoms such as delirium are related to an infection along with identifying the origin of a possible infection is especially challenging, increasing the risk of diagnostic errors.12,18 Furthermore, diagnosis can be complex in cognitively impaired older adults who are unable to describe their symptoms, yet still have a positive urine culture.21 Older adults in LTCFs with dementia frequently do not meet criteria for diagnosis of an UTI, accentuating the possibility that: (1) those who do not meet symptoms criteria have ASB and are overtreated due to providers’ caution with this vulnerable population; or (2) those with cognitive impairment do not meet diagnostic criteria due to cognitive deficits and communication barriers, but still produce urine specimens consistent with a UTI.21-24 In 2019, the Infectious Diseases Society of America (IDSA) disseminated ASB guidelines and strongly recommended against obtaining a urinalysis (UA) for cognitively impaired older persons with delirium or falls without localized genitourinary symptoms due to the likelihood of a positive result without a true UTI.12
Treatment decisions for UTIs include initiation and selection of an antibiotic along with dosage and duration. Treatment for UTIs may differ between men and women, and men are often diagnosed with complicated UTIs.25 Although current guidelines for treatment of uncomplicated UTIs in women recommend sulfamethoxazole/trimethoprim, nitrofurantoin, and fosfomycin, broad-spectrum fluoroquinolones are often prescribed for uncomplicated UTIs for women in primary care and LTCF settings.25-28 Watchful waiting defers antimicrobial treatment and is a recommended course of action that improves antibiotic prescribing by delaying antimicrobial use until confirmation of a UTI through diagnostic workup.6,7,12,25
Recommendations regarding antibiotic duration vary. Although SHEA recommends women with symptomatic lower UTIs should be treated for 3 to 7 days, a more recent guideline by the IDSA suggests 3 to 5 days of antibiotics is sufficient.26,29 There is no consensus on an appropriate duration for treatment of UTIs in older patients.7
The purpose of this study was to compare diagnostic and treatment practices for UTIs in women aged 65 years and older at one LTCF with a proposed evidence-based algorithm. The guiding questions were: (1) How do current practices within the LTCF compare to Rowe and Juthani-Mehta’s7 proposed algorithm for diagnosis and treatment of UTIs as it relates to cognitively and noncognitively impaired older adult females; (2) is there an association between cognitive status and meeting symptoms criteria for diagnosis in this sample; and (3) is there an association between cognitive status and decisions to treat empirically for a UTI in this sample?
The LTCF was a 131-bed urban facility in a southeastern state, with 24 beds allocated for assisted-living and 107 beds available for skilled nursing residents. The 2016-2017 average census within the LTCF was 95% occupancy at any given time.
The project population consisted of female residents for whom a requisition for a UA was sent for a suspected UTI over a 1-year period. Urinalyses associated with a resident meeting the following criteria were excluded: males, residents younger than 65 years, those with urinary catheters within the previous 48 hours before the urine specimen was collected, those receiving antibiotics at the time of the UA, those who did not utilize the facility’s providers as primary care providers, hospice care residents, those with suspected or diagnosed pyelonephritis, or UAs collected that specified reasons other than a UTI.
The review utilized a retrospective cohort design to compare a UTI algorithm with current diagnostic and treatment practices at one urban LTCF. The review included cases of residents with a documented UA or UA with culture and sensitivity from July 1, 2016, to June 30, 2017. A total of 152 cases of suspected UTIs related to residents’ urine specimens were included in the analysis. The project was approved by the Belmont University Institutional Review Board.
Based on the literature review and chosen algorithm, the Appropriateness of Antibiotics for Urinary Tract Infections instrument from the Centers for Disease Control and Prevention was adapted for the project.7,30 A list of UA results was obtained from the LTCF’s laboratories and used to evaluate medical records and determine if the cases met inclusion criteria (Figure 1). The project defined a positive UA and urine culture with the algorithm’s definition for urine specimens collected via clean catch and straight in-and-out catheterization methods.7 Two reviewers placed cases into groups based on diagnostic components and treatment. If a culture or UA result was missing from the chart, two independent experts reviewed the case and determined the category using the data collected. All cases were agreed upon by the two experts.
Article continues after Figure 1
Treatment course was assessed using criteria outlined in Rowe and Juthani-Mehta’s algorithm.7 To discern rationale for antibiotic choice, factors including drug allergies and renal function were considered. Creatinine clearance measured renal function and was calculated using creatinine level, weight, height, and age with the Cockcroft-Gault equation.31 Published guidelines were used to assess renal dosing.7,32
A laboratory requisition list was reviewed for all collected UAs with or without a culture and sensitivity from the two commercial labs utilized during the study period. Data abstracted from the medical record included vital signs, documented signs and symptoms related to the UA, culture orders and results, medication orders, and administrations. Comorbid conditions were identified and defined by ICD-10 diagnosis categories. Cognitive impairment included codes related to dementia, metastatic cancer of the brain, or deficits related to cerebrovascular accidents such as aphasia or dysarthria. Immunosuppression was determined through reviewing current medications associated with immunosuppression (eg, methotrexate for rheumatoid arthritis) or an ICD-10 code related to cancer or HIV. Additionally, codes associated with incontinence and chronic kidney disease were included. Data were de-identified for purposes of data collection.
Information from the Appropriateness of Antibiotics for Urinary Tract Infections instrument was transferred into Excel and analyzed in IBM Statistical Packages for Social Sciences (SPSS) 24.0 software. Descriptive statistics were used to depict current practices compared to evidence-based practice recommendations including symptomatology, UA results, culture results, and treatment data including antibiotic selection, dosage, duration, and frequency. Demographic data and comorbidities were reported in aggregate. To assess the relationship between cognitively impaired older women and (1) meeting symptoms criteria for diagnosis and (2) receiving empiric treatment, Chi-square tests of independence with the use of Phi-coefficients were utilized. A level of P < .05 was used to assess significance.33
Among the 325 total UAs collected in the specified timeframe, 152 from 111 LTCF residents met inclusion criteria. Demographic characteristics including age, gender, history, and comorbidities are provided in Table 1. Notably, 49% (n = 79) had received an antibiotic in the last 3 months, of which 73% (n = 58) had a previous antibiotic prescription for a UTI.
Thirty-four percent (n = 51) of cases met the symptoms component of the algorithm and warranted additional laboratory diagnostics for diagnosis of a UTI consistent with the algorithm. The most common symptoms documented for the suspected UTI cases were change in mental status (37%, n = 56), increased urinary frequency (35.5%, n = 54), and change of character in urine (34.2%, n = 52).
Of the 152 UAs, 67.7% (n = 103) were positive, 30.9% (n = 47) negative, and 1.3% (n = 2) were missing from the chart. Among the positive UAs and symptoms criteria, 65% (n = 67) were classified as ASB and 35% (n = 36) were symptomatic bacteriuria. Of 152 total UAs, cultures were positive in 34.9% (n = 53), negative in 53.9% (n = 82), and missing in 10.5% (n = 16). After review of all 152 UAs and cultures, 44.1% (n = 67) of UAs were categorized as ASB, 15.1% (n = 23) were true UTIs, and 40.8% (n = 62) had negative UA and/or culture results.
All cases were evaluated as to whether the treatment criteria were met. Stepwise evaluation of guideline-driven treatment was derived from treatment components as designated by the algorithm.7 Table 2 provides results regarding cases that met treatment criteria.
The majority of cases deferred treatment while culture results were pending (55.9%, n = 85), and 44.1% (n = 67) received empiric treatment before culture results were available. Of these 67 cases, 40.3% (n = 27) had treatment selections that aligned with algorithm guidelines. Over half of cases (55.9%, n = 85) met the treatment criteria in the algorithm, all of which received deferred treatment. Overall, none of the cases met both diagnostic and treatment criteria.
Associations Between Cognitive Impairment, UTI Symptoms, and Treatment
The first Chi-square test was performed to assess the association of meeting symptoms criteria and cognitive impairment. A significant association (P = .05) of meeting symptoms criteria and cognitive impairment was found (χ2 [1, N = 152] = 4.4524; P = .033). Noncognitively impaired patients were 1.449 times more likely to meet symptoms criteria than cognitively impaired patients (95% CI, 1.043-2.014). The phi-coefficient (P = -.173) indicates a weak association between cognitive impairment and meeting symptoms criteria. 33
The second Chi-square test of independence was performed to assess the association of empiric treatment and cognitive impairment. No significant association (P = .05) was found (χ2 [1, N = 152] = 0.053; P = .818), indicating that older women with cognitive impairment were not more likely to receive empiric treatment.
The results of this review show that UTI diagnostic criteria were often not met among older female LTCF residents, which is consistent with reports in the literature.34,35 Reported reasons that clinicians were influenced to prescribe antibiotics for older women were (1) concerns about missing an infection and (2) concerns for critically ill or immunocompromised patients.23 These clinician rationales may be congruent with those at the LTCF. The most common symptoms documented for suspected UTI in this study were change of character in urine and mental status change, which was consistent with a previous finding of symptoms triggering UTI treatment.35 Additional information related to clinicians’ mental models and perception of nonspecific symptoms as it relates to guidelines in this area could be useful to inform translational research and help identify behavioral interventions that may improve guideline concordant care.
Confirming an association between cognitive impairment and meeting symptoms concurs with findings suggesting that providers in LTCFs may not utilize guidelines to assess residents with cognitive impairment.21 Moreover, these findings are supported by D’Agata et al, who found within a sample of patients with advanced dementia that only 16% met the diagnostic criteria necessary for antibiotic treatment.22 Guidelines have recently been updated to address cognitively impaired older persons in the LTCF setting, stating that UAs should not be obtained without localized symptoms, even for cognitively impaired older persons.12 Ryan et al reported discrepancies between guidelines and clinical application with only 5.9% of suspected UTIs in two LTCFs meeting criteria, likely representing overprescribing for ASB.35 Furthermore, a prospective study of delirious patients with ASB found those treated with antibiotics had poorer outcomes than those without treatment, providing additional evidence of the adverse effects of treatment.36
Some authors postulate that the association found in the current study between cognitive impairment and not meeting symptoms criteria is a function of clinicians’ concern for overlooking an infection, leading clinicians to obtain an unwarranted UA. This is supported by finding no association between cognitive impairment and empiric treatment, highlighting that even though clinicians obtain UAs, they do not consider patients acutely ill enough to need empiric treatment. A recent retrospective study of 591 LTCFs in Canada found that resident characteristics did not influence antibiotic prescribing. Rather, facility characteristics influenced antibiotic prescribing, but facility characteristics did, highlighting the potential for clinicians’ mental models to be incongruent with guidelines.37 Additionally, the LTCFs experienced diagnostic cascade effects, meaning LTCFs with higher rates of urine cultures also experienced higher rates of antibiotic prescribing and C difficile infections.37 However, this was not confirmed in the study because only empiric treatment was evaluated and not the general administration of an antibiotic. Future research is warranted to validate guidelines for cognitively impaired older persons, prevent overtreatment of ASB in this complex population, and minimize the potential for cascade effects of unnecessary urine cultures.
A higher frequency of positive UAs compared to positive cultures was found in this study. Several studies have found the positive predictive value of a UA is low, ranging from 31% to 45%, thus highlighting why deferred treatment is a beneficial strategy for antimicrobial stewardship.38,39 Rowe and Juthani-Mehta recommend deferred treatment for patients with nonspecific symptoms during the diagnostic workup.7 The majority of cases in this review were concordant with guidelines, having treatment deferred while culture results were pending. In this audit review, 40.5% of cases associated with patients who received antibiotics had a negative culture. These findings reinforce deferred treatment as a beneficial approach for residents with nonspecific symptoms who are not acutely ill while awaiting UA and culture results.
In less than half (39.7%) of cases in our study, an antibiotic choice was in accordance with Rowe and Juthani-Mehta’s algorithm.7 Although IDSA guidelines recommend sulfamethoxazole/trimethoprim and nitrofurantoin as empiric therapies for uncomplicated cystitis, certain experts have not categorized postmenopausal women with UTIs as uncomplicated UTIs.26 Furthermore, Hooton and Gupta note that the definition of uncomplicated cystitis varies.40 While cases with chronic kidney disease and immunosuppression were included in this review and considered to be uncomplicated cystitis, Hooton and Gupta categorized chronic kidney disease and immunosuppression as complicated cystitis.40 This inconsistency in the literature highlights the difficulty of distinguishing between uncomplicated and complicated cystitis as well as the challenge clinicians may experience when managing older women with comorbidities.
The finding that no antibiotic course met guideline recommendations for antibiotic selection, duration, and dosage based on renal function is comparable to the low adherence rates to all components of the IDSA’s treatment guidelines for community-dwelling women with uncomplicated cystitis in the United States, as well as several European countries.41,42
Implications for Practice
Most UAs in this review were considered unnecessary because they did not meet symptomatic criteria. When symptoms are insufficient to meet diagnostic criteria, there is evidence for deferring treatment until culture results are available if the patient is not acutely ill.6,7,25,43 This approach mitigates the risk of unnecessary treatment with broad-spectrum antibiotics, representing an important step toward improved antimicrobial stewardship.
The majority of cases receiving antibiotics did not meet the symptoms component of the algorithm. This finding resembles other reports in the literature which found 32% to 41% of patients received antibiotics despite not meeting diagnostic guidelines.5,28 Several factors could have influenced clinicians to prescribe antibiotics, including cognitive impairment and other comorbidities such as immunocompromise, which can complicate clinicians’ abilities to accurately diagnose and treat infections.20,23,25 Furthermore, the overall complexity of the LTCF population could have influenced clinician decision-making; however, limited documentation existed to provide clinician rationale for decisions to prescribe antibiotics.
Implications of this review for clinical practice include the need for diagnostic guidelines to be adapted for implementation to the older adult population in LTCFs. Since the completion of this review, a new decision tool was created to aid in decision-making for empirically treating older adults with suspected UTIs.43 Like Rowe and Juthani-Mehta’s algorithm, Nace et al determined that dysuria must be present with one of three other signs to suspect cystitis; however, mental status change and other atypical symptoms are not addressed in Nace and colleagues’ diagnostic algorithm because consensus could not be reached regarding its inclusion.43 In this project, clinicians commonly reported altered mental status as a reason for suspected UTI, stressing the discord in clinical diagnostic decision-making and increasing the likelihood that ASB could be mistakenly diagnosed as an UTI. Studies comparing Rowe and Juthani-Mehta’s diagnostic algorithm to the new consensus guidelines created by Nace et al could provide insight into use of guidelines for older women in LTCFs.12,43
Besides increasing accuracy in the diagnosis of UTIs, antimicrobial stewardship can also be accomplished through interventions aimed at treatment. The relative risk of watchful waiting is well established in the literature for children with otitis media, but the reflection of this evidence in clinician decision-making and clinical practice is less evident.44 Improving clinicians’ confidence to defer antibiotics will require better dissemination of quality evidence to the practice setting that reinforces the harm of empiric treatment in the absence of symptoms. Additionally, qualitative studies on clinicians’ mental models and risk-assessment of older adults may be warranted to further explore the rationale for urine specimen collection from patients who do not meet the symptoms component of the diagnostic criteria to limit the potential cascade effect associated with urine culturing.
Limitations of this project include the possibility that documentation may not accurately reflect the clinical process and individuality within each case. Residents noted as immunosuppressed were kept within the sample, although this information may have prompted clinicians to respond differently and may have altered results of the review. Additionally, some residents were overrepresented in the sample due to multiple cases with suspected UTIs, which may have skewed sample characteristics. Clinicians’ rationale for treatment choices were not known and treatment choices may have been based on a multitude of factors.
Diagnosis and treatment of UTIs in the LTCF population is complex. Additional resources to guide clinicians’ decision-making are needed. Further studies could assess the necessity of guideline adjustment to enhance UTI diagnosis in older women in LTCFs, including the newly proposed algorithm by Nace et al.43 Small-scale changes at LTCFs could include encouragement of ASB guidelines to minimize the culture cascade, increased use of watchful waiting, and improved use of treatment guidelines.
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