From the Guidelines
For nursing home residents with suspected urinary tract infections (UTIs), prompt empiric treatment with nitrofurantoin 100 mg orally twice daily for 7 days is often necessary for uncomplicated cases, as recommended by the most recent guidelines 1. When managing UTIs in this population, it's essential to differentiate between asymptomatic bacteriuria, which is common and doesn't require treatment, and symptomatic UTIs. Look for specific symptoms like:
- Fever
- New onset confusion
- Localized urinary symptoms
- Dysuria Avoid treating based solely on cloudy or smelly urine, as the specificity of urine dipstick tests ranges from 20% to 70% in the elderly 1. For prevention, ensure:
- Proper hydration
- Regular toileting
- Good perineal hygiene Avoid unnecessary catheterization, and if catheters are needed, use proper insertion techniques and remove them as soon as possible, as catheter-associated UTIs require the same treatment principles as non-catheter-associated UTIs 1. The recommended treatment targets common uropathogens in this setting, including E. coli and other gram-negative bacteria. The 7-day duration balances effective treatment with minimizing antibiotic exposure. Regular monitoring of local antibiotic resistance patterns is essential to guide empiric therapy choices, and after culture results are available, narrow the antibiotic spectrum if possible to reduce the risk of developing resistant organisms 1. In residents with long-term indwelling urethral catheters, evaluation is indicated if there is suspected urosepsis, and catheters should be changed prior to specimen collection and institution of antibiotic therapy 1.
From the FDA Drug Label
Ciprofloxacin Tablets USP, 250 mg, 500 mg and 750 mg is indicated for the treatment of infections caused by susceptible strains of the designated microorganisms in the conditions and patient populations listed below. Adult Patients: Urinary Tract Infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, Proteus mirabilis, Providencia rettgeri, Morganella morganii, Citrobacter diversus, Citrobacter freundii, Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus epidermidis, Staphylococcus saprophyticus, or Enterococcus faecalis Amoxicillin and clavulanate potassium tablets USP is a combination penicillin-class antibacterial and beta-lactamase inhibitor indicated in the treatment of infections due to susceptible isolates of the designated bacteria in the conditions listed below*: 1.5 Urinary Tract Infections – caused by beta-lactamase–producing isolates of E. coli, Klebsiella species, and Enterobacter species.
The causes of Urinary Tract Infections (UTI) in nursing home residents are not directly stated in the provided drug labels. The management of UTI in nursing home residents may involve the use of antibiotics such as ciprofloxacin 2 or amoxicillin-clavulanate 3, depending on the susceptibility of the causative microorganism.
- Ciprofloxacin 2 is indicated for the treatment of UTIs caused by susceptible strains of microorganisms such as Escherichia coli, Klebsiella pneumoniae, and others.
- Amoxicillin-clavulanate 3 is indicated for the treatment of UTIs caused by beta-lactamase–producing isolates of E. coli, Klebsiella species, and Enterobacter species. However, the FDA drug labels do not provide information on the specific management of UTIs in nursing home residents.
From the Research
Causes of Urinary Tract Infections (UTI) in Nursing Home Residents
- Immobility and the use of bedpans instead of commodes contribute to decreased bladder emptying and an increased potential for UTI 4
- Poor perineal hygiene in many females in nursing homes also increases the potential for UTI 4
- Asymptomatic bacteriuria is common in nursing home residents, with a prevalence of 20 to 50% in those without bladder catheters and 100% in those with chronic catheterization 5
- The presence of an indwelling urinary catheter is a powerful predictor of antibiotic treatment for asymptomatic bacteriuria (ASB) 6
Management of Urinary Tract Infections (UTI) in Nursing Home Residents
- Symptomatic UTI requires treatment, but symptoms may be nonspecific, such as acute deterioration in functional ability or mental status 4
- Complicated UTI is more common in nursing home residents than in other populations, and treatment may involve oral or parenteral antibiotics 4, 5
- Diagnostic tests for nursing home patients with suspected UTI include urinalysis, urine culture, and sensitivity testing 5
- Adherence to a simple algorithm can prevent unnecessary antibiotic courses without compromising resident safety 7
- Efforts to improve antibiotic stewardship in nursing homes must address clinical decision-making solely on the basis of diagnostic testing in the absence of signs or symptoms of a UTI 6
Diagnosis of Urinary Tract Infections (UTI) in Nursing Home Residents
- Diagnosing UTIs in residents is challenging due to the high prevalence of asymptomatic bacteriuria and nonspecific urinary tract signs and symptoms among those with suspected UTIs 7
- Various decision tools and algorithms aim to aid in UTI diagnosis and the initiation of antibiotic therapy for residents, but these tools vary widely and can be complex 7, 8
- Urine dipsticks should not be recommended for geriatric patients, and patients who do not meet the minimum diagnostic criteria for UTIs should be evaluated for alternative conditions 7