What are appropriate provider orders for treating a urinary tract infection (UTI) in an assisted living facility?

Provider Orders for UTI Treatment in Assisted Living Facilities

For patients with suspected UTI in assisted living facilities, the recommended provider orders should include appropriate diagnostic testing followed by culture-directed antibiotic therapy for as short a course as reasonable, generally 3-7 days depending on the antibiotic selected.

Initial Assessment and Diagnosis

• A three-tiered clinical evaluation approach should be implemented involving a certified nursing assistant (CNA), on-site nurse, and physician/advanced practice provider 1
• CNAs should measure vital signs (temperature, heart rate, blood pressure, respiratory rate) and immediately report residents with fever (>100°F/37.8°C, ≥2 readings >99°F/37.2°C, or increase of 2°F/1.1°C over baseline) to the on-site nurse 1
• Initial clinical evaluation by the on-site nurse should assess for UTI symptoms including dysuria, frequency, urgency, gross hematuria, new or worsening urinary incontinence, and/or fever 1
• Avoid testing or treating asymptomatic bacteriuria as this contributes to antimicrobial resistance 1

Diagnostic Testing Orders

• Order urinalysis for determination of leukocyte esterase and nitrite level by dipstick and microscopic examination for WBCs 1
• Only order urine culture with antimicrobial susceptibility testing if pyuria (≥10 WBCs/high-power field) or positive leukocyte esterase or nitrite test is present 1
• For suspected urosepsis, order urine and paired blood specimens for culture and antimicrobial susceptibility testing, and Gram stain of uncentrifuged urine 1
• For residents with long-term indwelling urethral catheters and suspected urosepsis, order catheter change prior to specimen collection and initiation of antibiotic therapy 1

Antibiotic Orders

• First-line antibiotic options for uncomplicated UTIs:

  • Nitrofurantoin 100 mg PO every 12 hours for 5 days 2, 3
  • Fosfomycin 3 g PO as a single dose 2, 3
  • Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg (one DS tablet) PO twice daily for 3 days (if local resistance rates are <20%) 2, 4

• For complicated UTIs or pyelonephritis:

  • Culture-directed therapy for 7-14 days 1, 2
  • Consider parenteral antibiotics for resistant organisms or severe illness 1

Monitoring Orders

• Order reassessment of symptoms after 48-72 hours of antibiotic therapy 1
• For residents with indwelling catheters, order monitoring for signs of catheter obstruction or need for change 1
• Avoid surveillance urine testing in asymptomatic patients with recurrent UTIs 1

Antibiotic Stewardship Considerations

• Document the specific indication for antibiotic therapy, planned duration, and criteria for discontinuation 1
• Consider antibiotic prophylaxis only after discussing risks, benefits, and alternatives for residents with frequent recurrent UTIs 1
• Implement a diagnostic and treatment algorithm specific to the facility to reduce inappropriate antibiotic use 1

Common Pitfalls to Avoid

• Avoid treating asymptomatic bacteriuria, which is common in elderly residents and does not require treatment 1, 2
• Avoid using fluoroquinolones (e.g., ciprofloxacin) as first-line agents due to increasing resistance rates and risk of adverse effects 2, 5
• Avoid prolonged antibiotic courses beyond what is necessary for symptom resolution, as this increases risk of resistance 1, 2
• Do not rely solely on nonspecific symptoms (confusion, falls, anorexia) for UTI diagnosis without specific urinary symptoms 1