Antimicrobial Stewardship Strategies in Nursing Homes: Urinary Tract Infections

Abstract

Deciding if a nursing home resident should receive an antimicrobial for a suspected urinary tract infection is challenging. One of the most frequently reported reasons nursing home staff suspect presence of a urinary tract infection (UTI) is change in a resident’s mental status. However, a change in mental status may be due to numerous causes, such as presence of underlying conditions like dementia, or reaction to a new medication. The evaluation for a UTI when a resident experiences change in mental status is further confounded by the high prevalence of asymptomatic bacteriuria, which leads to positive urine cultures in nursing home residents. Various organizations recommend testing and/or treating residents for UTIs only when they have presence of localizing signs and symptoms in order to reduce prescribing antimicrobials to residents with asymptomatic bacteriuria. Unnecessary antimicrobial use is contributing to the emergence of multidrug-resistant organisms and the increase in Clostridium difficile infections. Antimicrobial stewardship programs take measures to reduce inappropriate antimicrobial use including monitoring antibiotic use for residents with suspected urinary tract infections and reviewing the use of diagnostic tests as a driver for antibiotic use. Furthermore, additional methods such as educating nursing home staff on hand hygiene, urinary catheter use, and criteria for identifying signs and symptoms of a urinary tract infection along with discussing and including antimicrobial use in end-of-life goals may also aid in reducing antimicrobial use for UTIs. However, determining when a resident should be treated for a urinary tract infection is difficult, and more research is needed to help clinicians distinguish nursing home residents who have bacteriuria from the residents who have true urinary tract infections.