Download Managing Urinary Tract Infections in the Care Home Setting

Managing Urinary Tract Infections
in the Care Home
Jean Matthews
Primary Care Pharmacist
Aneurin Bevan University Health Board
February 2015
Background
• UTIs are one of the most common complaints in general
practice, especially in the elderly (both male and female)
• UTIs are one of the commonest reasons for prescribing
antibiotics
• Care home residents are exposed to a higher level of
antibiotics
• UTIs are one most frequent causes of hospital admission in
elderly
• In elderly, prevalence increases to 20% in women (compared
to 3-5%), 10% in men (compared to 0.5%)
When would you expect that your
patient has a UTI?
Contamination or Infection?
• Elderly frequently have dysuria, frequency, incontinence with no infection
• Studies suggest 40% ‘misdiagnosed’ or ‘overdiagnosed’
• Asymptomatic bacteruria- no clinical symptoms -in care homes this may
be as high as 50% in women and 40% for men
• Asymptomatic infection frequent in
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patients with cognitive impairment (Alzheimers, PD),
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prostate disease,
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kidney stones,
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urinary/ faecal incontinence,
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diabetics with poor glycaemic control,
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catheters, self-catheterisation
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structural abnormalities
Symptoms
 Symptomatic bacteruria (UTI) requires new symptoms
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Frequency
Urgency
Dysuria
Frank (visible) blood
New incontinence,
High temperature
Lower back, flank or suprapubic tenderness
Worsening of confusion/agitation
Antibiotic treatment – the reality
• Trimethoprim – High drug résistance (80% in 80y +)
• Nitrofurantoin – cant use if severe renal failure
• Cefalexin/ Co-amoxiclav – use restricted due to increased risk
of developing Clostridium difficile (CD) diarrhoea
• Clostridia infections caused by disruption of normal bacterial
flora in intestine
• Risk factors for CD diarrhoea; antibiotic use, repeated
antibiotic use, frail, elderly, hospital admissions, gastric acid
lowering drugs (PPIs and H2 antagonists), laxatives, care
homes
• Instead adequately hydrate the patient and give analgesia to
relieve any pain
• .....informing the GP?
Informing the GP: The SBAR Tool
•
Situation
Identify yourself, your patient and your concerns
• Background
The resident has been here since...
His medical condition and medications
Have fluids been pushed over past 24 hours
Previous treatment for UTI
• Assessment
Vital signs – BP, resps, temperature, stable or deteriorating
Symptoms
Fever and/or pain
Dipstick test (?)
• Recommendations
I’d like you to come and see him
Would you like me to do a dipstick test? collect specimen, put fluids up?
When would you like me to phone you back?
To Dip or Not To Dip: Urinalysis
• Use of dipstick and levels of specimens sent for culture varies between
homes.
• Detect blood, protein, leukocytes, nitrites
• Positive results can suggest likelihood of infection
• Use as negative test ?
• National guidance suggests don’t dip in elderly – send sample for culture
(NB transport sample within1-2 hours or refrigerate)
• The difficulty can be getting an uncontaminated sample in the first place
• Check with your local GPs what they expect
Prevention
• Adequate hydration
minimum of 2 litres/day
( fluid balance charts )
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Good personal hygiene
Avoid feminine hygiene products
Encourage complete bladder emptying
Encourage front to back cleansing
Change incontinence pads frequently
Timer alerts for reminding to use toilet for memory
impaired
Cranberry products
• National guidelines now recommend for prevention of
recurrent infections but..........
• Evidence shows very small trend to UTI reduction over 12m
• Cranberries contain tannins which prevent adherence of
bacteria to bladder wall
• Not available of prescription
• Capsules easier to take than juice
• Interaction with warfarin possible?
• Ask GP for his opinion
Antibiotic Prophylaxis
• Evidence in elderly is limited ( trials not done in
• care home population)
• ABHB suggest using for 6 months then stop and see what
happens. Restart if necessary
• Rotate antibiotics every 3-6 months
• Cause as much harm as good! (oral and vaginal candida, GI
upset)
• And the likelihood of antibiotic resistance increases
Thank you for listening
Any questions?
Any answers ?
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References
Primary Care Guidance: Diagnosing and managing infections
https://www.gov.uk/government/collections/primary-care-guidancediagnosing-and-managing-infections
British Infection Association and Health Protection Agency (2012) Diagnosis of
UTI: Quick Reference Guide for Primary Care (Endorsed by RCGP)
Carbans, N (2012) Chapter 36 in Walker and Whittlesea Clinical Pharmacy and
Therapeutics, 5th edition
Scottish Medicines Consortium (2013) Decision aid for diagnosis and
management of suspected urinary tract infections in older people
http://www.scottishmedicines.org.uk/SAPG/Catheter_associated_urinary_trac
t_infection_CAUTI
Beveridge, Davey, Phillips and McMurdo (2011) Optimal management of urinary
tract infections in older people, Clin Interven Aging , June 22nd, 6, 173-180