Diagnosis&ManagementofUrinaryTractInfection(UTI)
inLongTermCareResidents>65years
KEYMESSAGES
DiagnosisofUTIinresidents>65yearsrequiresacombinationofreliableclinicalsignsandsymptoms
ANDapositiveurinecultureresult.
[Link]
performurinedipsticktestingorsendurineforculturesolelyonthebasisofurineodourorappearance
Residents in long term care facilities have high rates of abnormal dipstick and urine test results
WITHOUT infection necessarily being present. Antibiotic therapy in these cases does not reduce
mortality or prevent symptomatic episodes, rather it increases side effects and leads to antibiotic
resistance.
DONOTROUTINELYUSEANTIBIOTICPROPHYLAXISTOPREVENTURINARYTRACTINFECTION
1:SIGNSANDSYMPTOMSOFUTI
DiagnosisofUTIshouldbebasedonafullclinicalassessment.
Symptoms&signssuggestiveofurinarytractinfectioninclude:
Dysuria FrequencyUrgency Newonsetincontinence
Fever>38CSuprapubictendernessHaematuria
Inpatientswithaurinarycatheterloinpainandfever>38CaresignificantindicatorsofaUTI.
***DONOTSENDURINEFORCULTUREIFTHEREARENOSIGNSANDSYMPTOMSOFUTI***
[Link]
patientsareasymptomaticorifaurinarycatheterispresentasfalsepositiveswilloccur.
[Link]
besenttothemicrobiologylaboratoryforcultureandantimicrobialsusceptibilitytestinginthesecases.
Apositiveurinedipstickresultinanasymptomaticpatientisnotsignificantandshouldnotbetreated.
2:HOWTOINTERPRETURINECULTURERESULTSINRESIDENTSWITHOUTAURINECATHETER
Microscopy
WhiteCells Nowhitecellspresentindicatenoinflammationthereforecultureresultisunlikely
toindicateUTI.
Whitecells100/lareconsideredtorepresentinflammation.
Epithelialcells/mixed Presenceindicatesperinealcontaminationandthereforecultureresultisunlikelyto
growth indicateUTI
Redcells MaybepresentinUTI,patientswithpersistenthamaturiapostUTIshouldbe
referred
Culture
Singleorganism10,000(104)colonyformingunits(CFU)/mLOR
5
100,000(10 ) mixedgrowthwithonepredominantorganismOR UsuallyindicatesUTIbutonlyin
3 patientswithsymptoms
EscherichiacoliorStaphylococcussaprophyticus1,000(10 )CFU/mL
Positive culture/microscopy result and no symptoms = bacteriuria, not infection
and does not require antibiotic treatment.
3:HOWTOINTERPRETAURINECULTURERESULTINRESIDENTSWITHAURINARYCATHETER
LaboratorymicroscopyshouldnotbeusedtodiagnoseUTIincatheterisedpatientsasurinewhitecellsare
oftenelevatedduetothepresenceofthecatheter
If the urine culture result is positive (see section 2) treat only if the resident has symptoms or signs
suggestiveofUTIandnoothersourceisidentified.
Inthepresenceofaurinarycatheterantibioticswillnoteradicatebacteriuria
4:EMPIRICALTREATMENTOFUTIINRESIDENTS
OnlyconsiderempiricantibiotictherapyinSYMPTOMATICpatientspendingurinecultureresult.
Choiceofempiricaltherapyshouldbeguidedbylocalresistancerateswhereavailable.
Modifytreatmentaccordingtocultureresultwhenavailable.
FortreatmentofuncomplicatedUTIinpatients<65,pleaserefertopage9oftheNationalGuidelinesfor
AntimicrobialPrescribinginPrimaryCareinIreland(2011)1
4a:EMPIRICALTREATMENTOFUTIINRESIDENTSWITHOUTAURINARYCATHETER
[Link],first Acutepyelonephritis
presentations/lowriskofresistantorganisms
Coamoxiclav500/125mgTDSfor14days
Trimethoprim200mgBD ORCiprofloxacin500mgBDfor7days
ORNitrofurantoin*50100mgQDS
(*Avoidinrenalimpairment) Ifnoresponsewithin24hoursconsiderhospital
For7days referral
UseofCephalexin500mgBDorCoamoxiclav
500/125mgTDSmayalsobeconsideredbasedon
local resistance rates
4b:EMPIRICALTREATMENTOFUTIINRESIDENTSWITHAURINARYCATHETER
Firstpresentations/lowriskofresistantorganismsPreviousresistanceto,orriskof,trimethoprimor
nitrofurantoinresistance
Trimethoprim200mgBD Cephalexin500mgBD
OR OR
Nitrofurantoin50100mgQDS* Coamoxiclav500/125mgTDS
(*Avoidinrenalimpairment) (Considerbasedonlocalresistancerates)
Durationoftherapy
Promptresolutionofsymptoms:7days
Delayedresponse(regardlessofwhetherpatientremainscatheterisedornot):1014days
Ifanindwellingcatheterhasbeeninplacefor>2weeksattheonsetofUTIandisstillindicated,thecatheter
shouldbereplaced.
5:ANTIBIOTICPROPHYLAXIS
DONOTROUTINELYUSEANTIBIOTICPROPHYLAXISTOPREVENTURINARYTRACTINFECTION
AntibioticprophylaxisisnotrecommendedforthepreventionofsymptomaticUTIincatheterisedpatients.
Antibioticprophylaxisisnotrecommendedforurinarycatheterchangesunlessthereisadefinitehistoryofsymptomatic
UTIsduetocatheterchange.
Antimicrobialprophylaxismaybeconsideredinpatientsforwhomthenumberofurinaryinfectionsareofsuchfrequency
orseveritythattheychronicallyimpingeonfunctionandwellbeing.
1:Availableat[Link]
REFERENCES
AbrutynE,MosseyJ,BerlinJA,BosciaJ,LevisonM,PitsakisP,[Link]
mortalityanddoesantimicrobialtreatmentreducemortalityinelderlyambulatorywomen?AnnIntMed1994:827
33.
Diagnosis,Prevention,andTreatmentofCatheterAssociatedUrinaryTractInfectioninAdults:2009International
ClinicalPracticeGuidelinesfromtheInfectiousDiseasesSocietyofAmericaClinicalInfectiousDiseases2010;
50:625663
[Link],FlogazziG,GantV,[Link],GuderWG
ScandJClinLabInvest2000;60:196.
[Link].NationalStandardMethodBSOP41.2009[Link]
[Link]/documents/bsop/pdf/[Link](Accessed6thAugust2011)
[Link]
[Link]
[Link]&BritishAssociationof
UrologicalSurgeons.July2008.
NicolleLE,[Link]
asymptomaticbacteriuriaininstitutionalizedelderlywomen.TheAmericanJournalofMedicine1987;83:2733.
SARI.GuidelinesforAntimicrobialPrescribinginPrimaryCareinIreland2011[Link]
Z/MicrobiologyAntimicrobialResistance/StrategyforthecontrolofAntimicrobialResistanceinIrelandSARI/Communityan
tibioticstewardship/File,3334,[Link](Accessed6thAugust2011)
[Link]:[Link]
IntercollegiateGuidelinesNetwork.2006[Link]
August2011)
