MDS Alert

These strategies can halt a resident's recurrent UTIs.

As a first step toward avoiding unnecessary care, "facilities need to see if they have a nursing culture where they assume too quickly that a change in condition means the person has a UTI -- so they get a urinalysis and potentially over-treat," says Charles Crecelius, MD, CMD, PhD, a medical director in St. Louis, Mo.

Crecelius thinks that "in 90 to 99 percent of cases, facilities should only treat people who meet the McGeer criteria" (see page 90 to review the criteria). There is, however, "always that exception where a person has a history of urosepsis, etc."

Assume not: "Look for other pelvic reasons that a person with dementia may be agitated," which doesn't have to be cystitis, Crecelius advises. Other possibilities include musculoskeletal problems, constipation or fecal impaction, or colitis, he adds.

As for the significance of the bacterial count in the urine: That's "really only important if there are white cells or other evidence of infection in the urine. Asymptomatic bacteriuria is common in nursing residents," Crecelius explains. If the urine shows "significant numbers of white cells and bacteria," then you have to carefully consider the "strength of the clinical evidence" for the person having a UTI.

A concentrated urine with an odor is usually due to dehydration which you can resolve with hydration, Crecelius adds. He thus doesn't advise obtaining a urinalysis for that complaint. In the facilities where Crecelius serves as medical director, "nursing staff use dipsticks that detect WBCs and leukocytes (esterase) and/ or nitrates, which result from the bacteria breakdown."

Crecelius advises "waiting for the culture before starting treatment. That way you don't have to switch to another antibiotic." But "if the person has an obvious UTI (with pyuria and blood in the urine), you can go ahead and treat" empirically. Then make sure the microorganism is susceptible to the antibiotic when you get the culture and sensitivity results, he adds.

For treating a UTI, he recommends starting with "simpler antibiotics first, such as ampicillin or sulfa drugs." That decision, however, "depends on the facility's sensitivity patterns, which is another reason to obtain cultures," he adds, noting that "the majority of UTIs are caused by E. coli followed by Proteus."

Crecelius doesn't recommend obtaining a repeat UA once the patient completes his antibiotics, "if the person is clinically better. You might repeat the UA, however, if you're treating a highly resistant bacteria."

QA tip: Since Masonic Village initiated a "a more aggressive protocol to reduce the inappropriate use of antibiotics for UTIs," which is modeled on the McGeer criteria, the facility has "started to see less E. coli resistance to Cipro and Septra," reports Kenneth Brubaker, MD, CMD, medical director for the facility in Lancaster, Pa.

If the person has recurrent UTIs, says Crecelius, "there's nothing wrong with getting a urology consult," including for people with dementia. "The person may have a stone or cystocele, for example," he points out.

"If E. coli or other gastrointestinal bacteria are the cause of the UTI, pay close attention to perineal care. In our facilities, we do random audits where the DON pops in to observe how CNAs are doing perineal care," Crecelius says.

For recurring UTIs, "you can use agents that acidify the urine, such as methenamine." Crecelius says he has also prescribed cranberry extract to prevent recurrent UTI. (See the recent study on cranberry cocktail and UTIs in the news brief section of this issue.)

"You can also try prophylactic antibiotics but you're going to increase the risk of resistant organisms, which is why I advise using ampicillin or sulfa drugs for that purpose."

Does pushing fluids help reduce UTIs? "Adequate hydration is good for the person for a lot of reasons,"

Crecelius says, "but the study showing that it decreased UTI was observational. The researchers didn't look at whether those who didn't drink fluids well were sicker overall."

Clinical tips: "The nurse should remind the ordering clinician that the patient is on warfarin [Coumadin], as a number of antibiotics can interact with that medication." You should also know the person's renal function, which affects antibiotic dosing, Crecelius stresses.