Impact of a decision-making aid for suspected urinary tract infections on antibiotic overuse in nursing homes.

BACKGROUND: Antibiotics are highly utilized in nursing homes. The aim of the study was to test the effectiveness of a decision-making aid for urinary tract infection management on reducing antibiotic prescriptions for suspected bacteriuria in the urine without symptoms, known as asymptomatic bacteriuria (ASB) in twelve nursing homes in Texas. METHOD: A pre- and post-test with comparison group design was used. The data was collected through retrospective chart review. The study sample included 669 antibiotic prescriptions for suspected urinary tract infections ordered for 547 nursing home residents. The main measurement for the outcome variable was whether an antibiotic was prescribed for suspected urinary tract infections with no symptoms present. RESULTS: Most of the prescriptions for antibiotics UTIs were written without documented symptoms - thus for asymptomatic bacteuria (ASB) (71 % during the pre-intervention period). Exposure to the decision-making aid decreased the number of prescriptions written for ASB (from 78 % to 65 % in the low-intensity homes and from 65 % to 57 % in the high-intensity homes), and decreased odds of a prescription being written for ASB (OR = 0.63, 95 % CI = 0.25 - 1.60 for low-intensity homes; OR = 0.79, 95 % CI = 0.33 - 1.88 for high-intensity homes). The odds of a prescription being written for ASB decreased significantly in homes that succeeded in implementing the decision-making aid (OR = 0.35, 95 % CI = 0.16-0.76), compared to homes with no fidelity. CONCLUSIONS: The decision-making aid improved antibiotic stewardship in nursing homes.

Urinary tract infections and asymptomatic bacteriuria in older adults.

Overuse of urinalysis in older adults to investigate vague changes in condition such as confusion, lethargy, and anorexia, has led to overtreatment of asymptomatic bacteriuria and associated antibiotic resistance.

Catheter-associated bladder pain: it's not always infection.

This article is a case study examining the diagnosis and management of bladder dysfunction and catheter-associated pain in an older woman with diabetes and a hypotonic bladder. The incidence of diabetes has reached epidemic proportions. Although people with diabetes frequently develop lower urinary tract symptoms and voiding difficulties, this is often an unrecognised problem. As the incidence of diabetes grows, the incidence of diabetes-related bladder dysfunction will also increase. It is important that community nurses are aware of how diabetes affects bladder function and how to enable people with diabetes to manage bladder dysfunction well.

Criteria for urinary tract infection in the elderly: variables that challenge nursing assessment.

Urinary tract infections (UTIs) are common in the elderly, yet there is much disagreement in the literature regarding many aspects of this condition. To assist the nurse in developing optimum care strategies, UTI criteria in the elderly are discussed. Using the most recent knowledge to guide clinical assessment and intervention skills, the longterm care facility nurse and nurses who care for the elderly can influence positive outcomes in this challenging population.

Urinary tract infections. Does the smell really tell?

Asymptomatic bacteriuria is considered a transient and benign condition in the geriatric population. Before a diagnosis of a urinary tract infection (UTI) can be made, symptoms and significant bacteriuria must be present. One of these symptoms is malodorous urine. Other symptoms of a UTI, typical in the younger population, have been found to be absent or misleading in the older adult population. Though early detection of UTIs improves outcomes, unnecessary laboratory tests are costly and time-consuming, and may encourage inappropriate antibiotic therapy. The purpose of this study was to determine if urine odor is an accurate predictor of a UTI in the older adult incontinent nursing home population. Ninety-seven recently wet incontinence pads of residents in six Midwestern nursing homes were evaluated for odor within 1 hour of voiding. These results were compared to microscopy and culture results of clean-catch urine samples from these individuals. Defining a UTI as either bacteriuria or bacteriuria and pyuria, using urine odor to identify a UTI resulted in error in one third of cases. Results of this study indicate smell of urine in incontinence pads may be an absent or misleading symptom for UTIs in elderly nursing home residents.

A method to minimize indwelling catheter calcification and bladder stones in individuals with spinal cord injury.

Indwelling catheters are a common tool of bladder management in persons with high-level spinal cord injury who are unable to intermittently catheterize their bladders. Indwelling catheters are used to prevent bladder overdistension, which can trigger autonomic dysreflexia in those with injuries at or above T6. Unfortunately, indwelling catheters are prone to encrustation and can lead to the formation of bladder stones that can block the catheter and cause autonomic dysreflexia. We found that weekly catheter changes dramatically reduced catheter encrustation and stones in 2 individuals who had a history of recurrent stones despite various accepted interventions. We describe the clinical course and impact of this method in each case.

Instillation of 3% hydrogen peroxide or distilled vinegar in urethral catheter drainage bag to decrease catheter-associated bacteriuria.

Patients with indwelling catheters acquire urinary tractinfections ata rate of 5% perday. After 30 days of catheterization, there is a 78% to 95% incidence of bacteriuria, despite the use of meticulous catheter care. Research studies on reducing the development of bacteriuria have focused on the propagation of bacteria within the catheter drainage bag. This research proposal sought to determine the effects of instillation of 3% hydrogen peroxide versus distilled vinegar in urethral catheter drainage bags to decrease bacteriuria in 20 long-term catheterized patients. Baseline urine cultures for control and test mediums showed no significant difference in rates of bacteriuria. However, urine cultures obtained at the 48-hour interval showed significant reduction in bacteriuria in urinary bags irrigated with vinegar The implications this study has for nursing practice include a needforfurther research using a larger number of subjects and a need for improvements in the design of the catheter drainage system.

Nursing management of elderly patients with asymptomatic bacteriuria.

Nursing management of elderly patients with asymptomatic bacteriuria encompasses an array of basic and complex nursing observations and interventions to eliminate or reduce those risk factors that contribute to persistent bacteriuria and to identify warning signs of an impending inflammatory response. Selected risk factors, the prevalence of bacteriuria in the elderly population, and nursing management of clients with asymptomatic bacteriuria are discussed.

Asymptomatic bacteriuria in older adults: when is it necessary to screen and treat?

The incidence of asymptomatic bacteriuria increases with age, and thus it is a common finding in older adults, especially the very old and the institutionalized. Bacteriuria in most older adults, while common, is often transient. The clinical significance is generally minor and the treatment yields very little benefit, is expensive, and may cause substantial drug toxicity. Guidelines to help determine which patients may benefit from treatment are included. Primary care providers for older adults in ambulatory, home, hospital, or institutional settings, should recognize asymptomatic bacteriuria and know when and when not to treat. This management decision will become an increasingly important aspect of gerontological health care.

Effective management of urinary discomfort.

Urinary discomfort is the second most common physical complaint affecting women. Although urinary discomfort is commonly a result of inflammation due to bacterial invasion, there are also nonbacterial causes. The development of antimicrobial resistance to bacteria is frequent and costs the patient and the medical community unnecessary time and money. Antimicrobial intervention should be instituted only after the uropathogen is identified through a urine culture. While awaiting the results of the urine culture or other laboratory or radiological tests, the patient's symptoms can be relieved with the use of urinary analgesics or antispasmodics. This conservative approach meets the immediate concern of the patient and better ensures a proper diagnostic workup and successful cure. Along with a conservative diagnostic approach, the patient should be included in all aspects of health care management.

Intermittent catheterization: sterile or clean?

Bacteriuria--asymptomatic and symptomatic--always has the potential to develop into a serious problem when intermittent catheterization is being used. Research on the best method of reducing bacteriuria is inconclusive. Studies have focused on the use of sterile technique, oral or vesical antibiotics, and the frequency of catheterization. This article presents a summary of current research on bacteriuria in the patient requiring intermittent catheterization.

Bacteriuria and urinary incontinence in aged female nursing home residents.

Although urinary incontinence (UI) is identified as a symptom of urinary tract infection (UTI), the incontinent elderly frequently are not treated for UTI unless clinically significant manifestations are present. The purpose of this research was to identify variables that may be associated with bacteriuria in the female person who is already known to be incontinent. A sample of 65 incontinent female nursing home residents was divided into three groups: (1) those with negative urine screens; (2) those with a bacterial count of over 100,000 per ml of urine; and (3) those with a bacterial count of below 100,000 per ml urine. Variables examined were: (1) physical symptoms; (2) physical examination findings; (3) mental status; and (4) functional abilities. Significant group differences were found regarding awareness of the urge to void and ability to hold urine. A near significance finding suggested that the higher the level of cognitive function the less likely the presence of UTI. There was some evidence to suggest the higher the level of independence the less likely the presence of UTI. Recommendations for nursing practice and future nursing research are made.