Urinary tract infection (UTI)

ONLY check for a UTI if the resident has either:

1. Acute onset of dysuria (burning or stinging when passing urine) OR
2. The resident has two or more criteria for a UTI (at least one of which is a major criterion) or if the resident has an IDC or SPC at least one criteria of:
   • Major criteria:
     • Fever (where this is defined as a single oral temperature of > 38 degrees Celsius or an increase in temperature > 1.5 degrees Celsius over resident’s baseline temperature).  Note - fever may be absent in frail older persons or immunocompromised persons
     • Delirium without another cause
   • Minor criteria:
     • New or worsening urgency or frequency
     • Suprapubic or flank pain or tenderness
     • Gross haematuria (blood stained urine) without another cause
     • New or worsening urinary incontinence
     • Rigors (uncontrollable shivering or shaking)

** Urine odour and appearance are not predictive of UTI

** Do not screen urine in asymptomatic residents because residents in aged care facilities have high rates of abnormal dipsticks without UTI necessarily being present

** Do not screen urine based on an isolated episode of behavioural change

** Multiple randomised trials have shown no benefit by treating asymptomatic bacteriuria

Assessment of resident with suspected UTI involves assessment to:

1. Confirm meets clinical criteria to test for UTI (see above practice point 1 - When to suspect UTI)
2. Identify sepsis or unstable vital signs
3. Determine type of UTI:
   • Assess for underlying functional or anatomical abnormality:
     • Uncomplicated UTI is a UTI with no underlying abnormality of the urinary tract
     • Complicated UTI is a UTI with functional or anatomical abnormality of the urinary tract e.g. bladder or ureteric stones, neurogenic bladder, prostatic hypertrophy, phimosis or paraphimosis with associated obstruction of flow
   • Assess for location of UTI:
     • Cystitis = infection localised to bladder
     • Pyelonephritis = infection involves kidney
     • Prostatitis = infection involves prostate gland
4. Identify and treat precipitants (see below practice point 6 - Prevention of UTI)

• In males and females midstream urine collection should involve prior cleansing of the genitalia
• Females should be instructed to hold labia apart during sampling
• Use of catheterisation is associated with lower rates of contaminated urines on microscopy and culture but may cause harm and distress - use of catheterisation should be limited to those with significant cognitive impairment who are not able to undertake a midstream urine
• Catheter insertion for purposes of urine sample collection should be restricted to an in-out catheter unless there is concurrent acute urinary retention
• For residents with a long-term indwelling catheter (urethral or suprapubic), it is important to remove the catheter and insert a new catheter prior to collection of urine from the new catheter via the sampling port to test for UTI

Supportive care of residents with UTI is critical to optimising resident outcomes and should include:

1. Identification and treatment of direct complications of infection, particularly development of sepsis (infection with end-organ dysfunction)
   • Arrange medical review of residents by GP
   • Institute regular monitoring of vital signs (minimum four times a day for 72 hours) - notify GP or at GP discretion, the HHS RaSS team if vital signs suggest clinical deterioration (review Recognition of the deteriorating resident)
2. Anticipate, prevent or treat destabilisation of chronic diseases with examples of actions including:
   • Enact diabetes sick-day plan- refer to National Diabetes Service Scheme Diabetes management in aged care handbook
   • Monitor blood glucose levels closely in diabetics, chronic liver disease or in those with reduced oral intake
   • Attention to fluid balance in those with congestive cardiac failure or renal disease
   • Review medications and with-hold where indicated e.g. consider with-holding diuretics and SGLT- 2 inhibitors if clinically dehydrated
3. Prevent, identify and treat health-care related complications of acute illness
   • Implement strategies to prevent, identify and treat delirium
   • Institute falls risk management strategies
   • Encourage oral fluids to minimise dehydration
   • Institute turns once every 2 hours and individualised skin care regimen where mobility is reduced
   • Ensure mobility is maintained (with physiotherapy support if indicated) where clinically appropriate

Review Fever / suspected infection pathway for principles of prescribing

Modify empirical antibiotic therapy based on urine culture results

If diagnostic criteria for UTI met and there are no features of pyelonephritis or prostatitis suspect CYSTITIS:

• For empirical therapy of uncomplicated cystitis:
  • Nitrofurantoin 100mg orally with food or milk to reduce nausea, 6 hourly for 5 days in females or for 7 days in males
    • Cautious, short-term use of nitrofurantoin may be considered in residents with mild renal impairment and an estimated glomerular filtration rate (eGFR) of 30 to 60mL / minute
    • Avoid in those using concurrent urinary alkalising agents (e.g. URAL), which may reduce effectiveness of nitrofurantoin
• Where nitrofurantoin cannot be used, use:
  • Cefalexin 500mg orally every 12 hours for 5 days in females or for 7 days in males
• If there is catheter-associated UTI, change catheter and use 7 days of antibiotics or if symptoms slow to respond, treat for 10 to 14 days

If diagnostic criteria for UTI are accompanied by flank tenderness, suspect PYELONEPHRITIS:

• For  empirical therapy of non-severe pyelonephritis:
  • If NO penicillin allergy use:
    • Amoxicillin and clavulanate 875mg + 125mg orally every 12 hours for 14 days (give with food to improve absorption)
  • If penicillin hypersensitivity use:
    • Ciprofloxacin 500mg orally every 12 hours for 7 days - if eGFR < 30mL / min review Therapeutic Guidelines: antibiotic for dosing guidance
    • Note: ciprofloxacin is absorbed best if taken 1 hour before or 2 hours after meals; residents should drink plenty of fluids where clinically appropriate while taking ciprofloxacin
    • Avoid urinary alkalising agents (e.g. URAL) due to increased risk of crystalluria
    • Avoid dairy products, iron, zinc or calcium supplements and aluminium or magnesium-containing antacids as these may reduce absorption of ciprofloxacin

In males, if diagnostic criteria for UTI are accompanied by systemic features and either perineal pressure or prostate tenderness on gentle rectal examination, suspect PROSTATITIS:

• For empirical therapy of non-severe acute bacterial prostatitis:
  • Trimethoprim 300mg orally daily for 14 days - if eGFR < 30mL /min review Therapeutic Guidelines: antibiotic for dosing guidance
    • Note - if resident has had trimethoprim in prior 3 months or if history of trimethoprim-resistant E.coli, instead use:
    • Cefalexin 500mg orally every 6 hours for 14 days

• Avoid condom catheters
• Review the indication for indwelling catheters regularly and remove for trial of void where no longer indicated 
  Note - there is no indication for prophylactic antibiotics administered with IDC change
• Topical vaginal oestrogen may decrease incidence of UTI in post-menopausal women
• Where UTIs are recurrent, arrange a ultrasound of the bladder and renal tract to exclude bladder stones, incomplete bladder emptying or other structural or functional abnormality and seek urological or infectious diseases opinion as indicated
• Seek pharmacy review to identify any potential medications that could increase the risk of UTI e.g. SGLT2 inhibitors
• Where clinically appropriate, encourage residents to increase fluid intake and avoid dehydration

History:

• Symptoms:
  • Uncontrolled pain
  • Vomiting
  • Anuria (or failure to pass urine)
• Comorbidities that require stabilisation or presence of:
  • Immunocompromise
  • Renal failure

Examination:

• Vital signs: unstable vital signs and / or altered mental status (different to usual), where goals of care are active (review Recognition of the deteriorating resident)
• Rigors (uncontrollable shivering)
• Failure to respond to oral antibiotics within 72 hours

QH has developed a learning module to support clinicians in learning about management of the deteriorating resident. The learning module is available via QHs iLearn portal - RACF clinicians practicing in public or private RACFs in Queensland can access the  module free of charge. You will simply need to register to create an iLearn account - find the link to register at the bottom of the  iLearn account page - if you already have a log-in simply log into your iLearn account.

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