Urinary Tract Infection Guideline

Guideline for the Diagnosis and Management of
Urinary Tract Infections in Long Term Care

Issues
Diagnosis of urinary tract infections (UTIs) in older adults relies on clinical judgment.
Non-specific and non-localizing signs and symptoms are seldom due to a UTI in the noncatheterized resident.
Asymptomatic bacteriuria does not require treatment. Routine screening for UTIs is not
necessary.
Age related changes to the urinary tract and associated illnesses predispose older adults to
urinary tract colonization and to the development of UTIs.
Among residents in long term care (LTC), UTIs are the most common source of bacteremia,
a dangerous systemic infection. Bacteremia is 40 times more likely to occur in catheterized
than non-catheterized residents and can lead to significant morbidity and mortality in the
elderly.
Older adults often have decreased renal function, which needs to be considered when selecting
antibiotic therapy for UTI in the elderly.
Inappropriate use of antibiotics may adversely affect resident outcomes and promote antimicrobial resistance.
Inclusions
Long term care applies to any congregate residential setting for older or disabled adults that
have high personal and professional care needs. These are sometimes known as nursing
homes, auxiliary hospitals, chronic care centres, or continuing care centres.
Exclusions
Goals
Prevention
Definitions
Community acquired UTIs

UTIs in acute care
To increase the accuracy of clinical diagnosis of UTIs for residents in LTC

To improve resident outcomes through decreased morbidity and mortality
To optimize the use of testing and laboratory services
To reduce inappropriate prescribing of antibiotics for residents with asymptomatic bacteriuria
To optimize antibiotic therapy for residents with UTIs
Limit use of catheters

Ensure proper hydration
Good perineal hygiene
Urinary Tract Infection

Significant bacterial count (108 cfu/L) present in a clean-catch or midstream urine specimen
accompanied by symptoms of UTI (Table 1) and confirmed by urine culture and sensitivity
(C&S)
The above recommendations are systematically developed

statements to assist practitioner and patient decisions about
appropriate health care for specific clinical circumstances.
They should be used as an adjunct to sound clinical
decision making.

Asymptomatic Bacteriuria
The presence of bacteria in the urine of residents who do not have dysuria, increased urinary
frequency or urgency, fever, flank pain, or other symptoms related to irritation of the urethra,
bladder, or kidney1
Identified by urine cultures on two clean catch specimens that are positive in a resident who
has no urinary tract infection symptoms2
Pyuria
Presence of leukocytes in the urine
Recurrent UTIs
>3 culture confirmed UTIs in 1 year3 with the same or different organisms or
>2 culture confirmed UTIs in 6 months with the same or different organisms
Relapse UTIs
Repeat infection with the same infecting organism, usually occurring within 4 weeks of
previous UTI
Complicated UTIs
UTIs in elderly men are always considered complicated
UTIs in women are considered complicated if associated with:
- Structural abnormalities
- Urinary catheters
- Kidney stones
- Urinary retention
- Renal and perinephric abscess formation
- Diabetes
Signs &
Symptoms
Table 1: Typical Signs and Symptoms of UTI

Sign/Symptom
New or increased urinary
urgency, urinary frequency,
dysuria
Comments
Chronic genitourinary symptoms are common in LTC
facilities and only acute changes in genitourinary symptoms
are relevant for the diagnosis of symptomatic UTI
Incontinence
Functional incontinence is common in LTC but new onset or

exacerbation of incontinence may be a symptom of a UTI
Studies indicate that fever is a marker for serious infection
and is the most important clinical indicator for antibiotics
Elevated temperature,
rigors
Elderly require longer time to present with fever, may not

have an increase in temperature or may even be hypothermic.
A temperature of 38C or an increase of 1.1C above
baseline is significant.
Elderly adults often take medications that lower baseline
temperature.
Caution: lack of identifying fever may delay diagnosis.
Compare temperature with baseline.

New flank/costo-vertebral
angle (CVA) or suprapubic
pain or tenderness
Hematuria
Delirium
Localized pain can indicate UTI

Blood in the urine is not always indicative of infection, but
is an indication of a UTI if other signs and symptoms are
present
In the catheterized resident, new onset of delirium may
indicate a UTI
Table 2: Signs and Symptoms Not Specific for UTI

Sign/Symptom
Comments
Cloudy, milky, or turbid urine Cloudiness can occur in normal urine and is not an indicator of UTI or for antibiotic
treatment.4
Malodorous urine
Worsening or decline in
mental status or functional
status
Increased behavioral and
psychological symptoms of
dementia (BPSD)
Increased falls
Clinical
Management
Indicators
Smelly urine is not a valid indicator of UTI and may be caused by diet or poor
hygiene.
Acute confusional states may be associated with any significant infection including
UTI.
A diagnosis of UTI depends on the presence of typical symptoms.
BPSD is unlikely to be attributable to UTI in the absence of localizing genitourinary
signs or symptoms.
Delirium may impair the ability to report or observe genitourinary signs or symptoms.
Falls indicate a change in functional status and are not a specific indicator of
infection including UTI.5-8
Symptoms
Typical Symptoms with no indwelling catheter

See Table 1 and Clinical Pathway

A suspected UTI, without an indwelling catheter, is indicated by the following criteria: 9,10
- Acute dysuria
OR
- Fever (> 38C), or an increase of 1.1C above baseline on 2 consecutive occasions or
chills PLUS any of the following:
New or increased urinary frequency, urinary urgency, incontinence
New flank/costo-vertebral angle (CVA) or suprapubic pain or tenderness
Hematuria
Typical Symptoms with indwelling catheter

A suspected UTI, with an indwelling catheter, is indicated by any one of the following
criteria:

- Fever (> 38C) , or an increase of 1.1 C above baseline on 2 consecutive occasions

- New flank/costo-vertebral angle (CVA) or suprapubic pain or tenderness

- Rigors

- New onset delirium

Practice Point
Many residents in long term care may be unable to voice symptoms.
Signs and symptoms not specific for a UTI
Any of the following indicate a change in medical status. They do not indicate a UTI unless
typical symptoms develop:
- Worsening of functional status
- Worsening of mental status, increased confusion, delirium or agitation
- Increased falls
Unless there is a rapid decline in medical status, push fluids for 24 hours for residents with
non-specific signs and symptoms and reassess. If typical symptoms develop, treat as for UTI.
If non-specific symptoms continue without evidence of a UTI, consider other diagnoses.
If symptoms resolve, no further intervention is required.
Practice Point
For medically stable residents with non-specific signs and symptoms, there is no evidence
of increased morbidity or mortality associated with waiting 24 hours before initiating
antibiotic therapy. With good hydration, symptoms often resolve.
Asymptomatic bacteriuria is common in the elderly. Age related changes that are associated
with asymptomatic bacteriuria are listed in Table 3
The presence of bacteria in the urine without other symptoms of a UTI does not indicate
infection or the need for treatment with antibiotics
Routine screening for asymptomatic bacteriuria is not needed
Table 3: Age Related Factors Associated with Asymptomatic Bacteriuria11
Laboratory
Anatomical
Pelvic prolapse/cystocele; benign prostatic hypertrophy; urinary tract obstruction;

fecal incontinence/impaction; vaginal atrophy; estrogen deficiency; bladder or
prostate cancer
Functional
Incomplete bladder emptying or neurogenic bladder; CNS disorders (i.e.,

Parkinsons disease, dementia); spinal cord injury; insufficient fluid intake/
dehydration
Metabolic
Diabetes; immunosuppression
Instrumental
Indwelling Foley catheter or urinary catheterization or instrumentation procedures
Gender
In women, a prior history of UTI at a younger age

A urine culture and sensitivity (C&S) should be obtained whenever symptoms suggest a
UTI. If empiric antibiotic therapy is indicated, collect the specimen before any antibiotics
are given.
A positive dipstick test for leukocyte esterase or nitrite is not diagnostic for a UTI. Asymptomatic bacteriuria and pyuria are common in the elderly and do not indicate infection or
the need to treat with antibiotics.12,13

Practice Point
Pyuria is found in >90% of cases of asymptomatic bacteriuria and 100% of symptomatic
UTIs. If pyuria is absent, urinary infection can be ruled out
Pyuria is not sufficient for a diagnosis of a UTI as it does not differentiate between
symptomatic UTI and asymptomatic bacteriuria 14
A positive dipstick for leukocyte esterase or nitrite is not diagnostic for UTI
Electrolytes and serum creatinine testing may be appropriate if fluid status is a concern
A recent calculated creatinine clearance (CrCl) is needed for the appropriate dosing of
antibiotics as decreased renal function is common in the elderly
Repeat C&S after antibiotic therapy is NOT necessary unless typical UTI signs and
symptoms persist
Practice Point
A clean catch or midstream urine sample is the preferred method for collection of urine
specimens.
When a voided specimen cannot be collected, it is acceptable to use:
A freshly applied condom catheter for men if measures are taken to limit contamination
In and out catheterization for women 15,16
For residents with short term in-dwelling catheters, specimens should be obtained by
aspiration of the catheter tubing port. Do not collect the specimen from the drainage
bag where contamination is likely.
For long term catheterized residents, replace the catheter, and then collect the urine
specimen through the freshly placed catheter.
Information to be included on laboratory requisition: clinical symptoms, drug allergies,
name of antibiotic if empiric treatment to be initiated before C&S result is available.
Treatment
See Tables 4 and 5 and Clinical Pathway.

Asymptomatic bacteriuria DOES NOT require treatment.17,18 Note: Inappropriate use of
antibiotics may adversely affect resident outcomes and promote antimicrobial resistance
in bacteria.
Empiric antibiotic selection should be based on local resistance patterns. See Table 4 for
common UTI pathogens and Table 5 for recommended treatment regimens in the elderly.
Select narrow spectrum antibiotics as a first-line to minimize promotion of resistant
organisms
Empiric antimicrobial therapy should be reviewed and altered, if indicated, to specific
therapy once C&S results are available. STOP ANTIBIOTICS if no infection is identified
on C&S result.
Nitrofurantoin has limited usefulness in this population because most elderly residents
have reduced renal function. A calculated CrCl is required to assess renal function.
Nitrofurantoin should not be used if CrCl is less than 60 mL/min.19

Consider alternative causes for symptoms if there is no improvement in 48 hours.20
Referral to acute care should be considered for any of the following:
- Respiratory distress (e.g. respiratory rate over 40)
- Tachycardia (pulse over 125)
- Congestive Heart Failure
- Systolic BP less than 90mmHg
- Signs of impending hemodynamic instability
- Signs of respiratory failure
- Reduced level of consciousness
- Clinical judgment of the attending physician at any time
- Level of acuity that cannot be managed at the facility
- Limited capacity to support the illness at the facility, e.g., oxygen not available
Table 4: Common UTI Pathogens in LTC21

Escherichia coli
Proteus mirabilis
Providencia stuartii
Pseudomonas aeruginosa
Citrobacter spp.
Klebsiella spp.
Enterobacter spp.
Enterococcus spp.
Group B Streptococcus
Coagulase negative Staphylococci
Table 5: Recommended Treatment Regimens for Acute UTIs in the Elderly19

Antibiotic therapy for the treatment of asymptomatic bacteriuria is not needed
Elderly individuals with asymptomatic bacteriuria should receive pre-procedure prophylaxis only if they are to undergo traumatic genitourinary procedures
Asymptomatic bacteriuria is not associated with short or long term negative outcomes, including hypertension,
impaired renal function or decreased survival.
Uncomplicated and Complicated UTls (men, diabetes, symptoms greater than seven days)
TMP/SMX
Or
Trimethoprim
Or
Nitrofurantoin
Alternative
Ciprofloxacin
Or
Norfloxacin
Or
Cefixime
1 DS tab PO bid
7 days
100mg PO bid
7 days
50-100mg PO qid
7 days
250mg PO bid or XL 1g PO
daily
7 days
400mg PO bid
7 days
400mg PO daily
7 days
Pre-treatment urine cultures are

recommended.
Post-treatment cultures are not recommended
unless symptoms persist or recur.
TMP/SMX has no activity against
Enterococcusi spp or Group B Streptococci.
Residents with diabetes are predisposed to
UTI with Group B Streptococci.
Nitrofurantoin should not be used if CrCl
is less than 60 mL/min.19

Chronic Catheterization: Asymptomatic
Antibiotic therapy is not beneficial in this population, may adversely affect resident outcomes, and may
promote the emergence of organisms of increased resistance. Only treat symptomatic episodes of UTI in this
resident population.
Abnormality of the Urinary Tract

Anatomical
Functional
Metabolic
Ciprofloxacin
Alternative
Ampicillin
PLUS
Gentamicin
daily
10-14 days
1g IV/IM q 6h
PLUS
7mg/kg IV q 24h* or 1.5-2mg/
kg IM q 12h*
10-14 days
10-14 days
Pre-treatment urine cultures are recommended.

Because of potential for resistant
organisms, it is important to modify empiric
therapy to most narrow spectrum option based
on C&S results.
* Dosing interval may need to be adjusted
based on renal function
Chronic Catheterization: Symptomatic

Catheter should be changed and urine specimen should be obtained through the newly placed catheter before
starting antibiotics
Cefixime
Or
Ciprofloxacin
Or
Amoxicillinclavulanate
400mg PO daily
10-14 days
Cefixime has no activity against Enterococcus spp.
daily
10-14 days
Ciprofloxacin has unreliable activity against

Enterococcus spp.
875mg PO bid or 500mg PO tid
10-14 days
Cefixime and amoxicillinclavulanate have no

activity against Pseudomonas.
Pyelonephritis: Complicated

In residents with indwelling catheters, 7 days of treatment is recommended if there is a prompt response following
initiation of antimicrobial therapy
Ciprofloxacin
Alternative
Cefixime
Or
Amoxicillinclavulanate
Or
Ampicillin
PLUS
Gentamicin
500mg PO bid
10-14 days
400mg PO daily
10-14 days
875mg PO bid or 500mg PO tid
10-14 days
1g IV/IM q 6h
PLUS
7mg/kg IV q 24h* or 1.5-2mg/
kg IM q 12h*
10-14 days
10-14 days
Pre-treatment urine cultures are recommended.

Urologic investigation recommended if
recurrent or symptoms >72 hours.
Cefixime and amoxicillin-clavulanate have no
activity against Pseudomonas.
If enterococcal bacteremia use ampicillin +
gentamicin.
* Dosing interval may need to be adjusted
based on renal function

Prevention
of Catheter
Associated UTIs
The Centers for Disease Control and Prevention (CDC) have published guidelines for the
prevention of catheter associated UTIs, shown in Table 6.
Table 6: Prevention of Catheter Associated Urinary Tract Infections (CAUTI)22

Insert catheters only for appropriate indications
Minimize urinary catheter use and duration of use
Avoid the use of urinary catheters in residents for the management of incontinence
Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site
Ensure proper training of personnel in the correct technique of aseptic catheter insertion and maintenance
Insert urinary catheters using aseptic techniques and sterile equipment:
- Use sterile gloves, drapes, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and
a single-use packet of lubricant jelly for insertion
- Routine use of antiseptic lubricants is not necessary
Properly secure indwelling catheters after insertion to prevent movement and urethral traction.
Unless otherwise clinically indicated, consider using the smallest bore catheter possible, consistent with good
drainage, to minimize bladder neck and urethral trauma.
If intermittent catheterization is used, perform it at regular intervals to prevent bladder overdistension
Following aseptic insertion of the urinary catheter, maintain a closed drainage system.
- If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system
using aseptic technique and sterile equipment
- Consider using urinary catheter systems with pre-connected, sealed catheter-tubing junctions
Maintain unobstructed urine flow:
- Keep the catheter and collecting tube free from kinking
- Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.
- Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid
splashing, and prevent contact of the drainage spigot with the nonsterile collecting container
Use standard precautions, including use of gloves and gown as appropriate, during any manipulation of the
catheter or collecting system
Complex urinary drainage systems are not necessary for routine use
Changing in-dwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather it is
suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or
when the closed system is compromised.
Unless clinical indications exist, do not use systemic antimicrobials routinely
Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine
hygiene is appropriate
Unless obstruction is anticipated, bladder irrigation is not recommended
- If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction
- Routine irrigation of the bladder with antimicrobials is not recommended
Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended
Clamping indwelling catheters prior to removal is not necessary

Background
Introduction
Urinary tract infections (UTIs) are the most common bacterial infections encountered in older
adults23 and are the second most common cause of infectious disease hospitalizations in adults
65 years and older. UTIs are also the most common reason for the use of antibiotics in LTC
settings.
UTIs account for approximately 25% of all community acquired bacterial infections, and at
least 30% of all bacterial infections in residents in LTC.24 The prevalence of UTIs increases
in both sexes with age. In the elderly, the incidence of UTI is nearly twice as high in women
as in men. Regular emptying of the bladder and a brisk urinary flow are mechanical defenses
against infection. In the aging bladder, the volume of urine in the bladder required to sense the
need to void increases by about 100 mL. Rate of urinary flow with each void is also decreased.25
Recent studies do not report any association between residual urine volume and bacteriuria
or symptomatic infection in LTC facility residents.26 Chronic indwelling catheters are more
commonly used in this population, resulting in catheter associated UTIs.
Risk Factors
LTC residents are prone to the development of UTIs because of the presence of comorbid conditions. The major risk factor for UTI is the presence of an indwelling catheter. Residents with
long-term indwelling catheters have almost a 100% prevalence of bacteriuria. Other common
risk factors for UTI include neurogenic bladder caused by conditions such as stroke, Alzheimers
disease, or Parkinsons disease, and dehydration. Risk factors differ for males and females,
see Table 7.
Table 7: Female versus Male Risk Factors3

Age Group
50 - 70
Female
Prior history of urinary infection at a
younger age
Diabetes
Male
Prostatic obstruction
Urological/surgical procedures
Gynecological diseases: cystocele &

related surgical procedures
>70
Gynecological diseases: cystocele and

related surgical procedures
Prostatic obstruction
Reduced mental status
Immunological changes
Urological/surgical procedures
Urological diseases (incontinence, residual Urinary catheter
urine, cystopathy) and related surgical
Reduced mental status
procedures
Co-morbid diseases
Urinary catheter
Co-morbid diseases
Immunological changes

Etiology
More types of pathogens are isolated from the urine of elderly residents with UTIs compared to
younger patients. Escherichia coli accounts for about 40% of pathogens of UTI in older residents
with indwelling catheters.27 Klebsiella pneumoniae is the second most commonly isolated
pathogen. Pathogens that are more common in men than in women include: Proteus mirabilis,
P. vulgaris, and Morganella morganii, while Proteus species are commonly isolated from
residents who are chronically catheterized.
In residents with recurrent infections, Gram negative organisms other than E. coli are isolated
more frequently. These tend to be more resistant. In addition, Gram positive organisms including
Enterococci, coagulase negative Staphylococci, and group B Streptococci, are frequently isolated.
Diagnosis
The quantitative definition of bacteriuria according to the Infectious Diseases Society of America
2005 guidelines28 is: for women, isolation of the same bacterial species with a count of 108
cfu/L in two consecutive voided urine specimens; and for men, isolation of one bacterial species
with a count of 108 cfu/L in one voided urine specimen; or isolation of one bacterial species
isolated with a count of 108 cfu/L in a single catheterized urine specimen for men or women.
The prevalence of asymptomatic bacteriuria in LTC facilities, is between 25-50% in women
and 15-40% in men.27 The fact that both asymptomatic bacteriuria and pyuria are so prevalent
among older adults is problematic for the clinician. The absence of bacteriuria excludes symptomatic UTI. However, a positive urine culture by itself does not confirm UTI and localizing
genitourinary symptoms are necessary for a diagnosis of UTI. Classic symptoms and signs
for UTI include dysuria, incontinence, increased urinary frequency or urgency, hematuria, and
suprapubic pain.
When pyelonephritis is present, costo-vertebral angle (CVA) pain or flank tenderness and fever
are usually encountered.29 The majority of individuals with delirium and a positive urine culture
do not have UTI as an explanation for the clinical deterioration. Urinary tract infection should
not be diagnosed in non-catheterized patients in the absence of localizing symptoms.10 These
points are summarized in Table 1.
Some practitioners use the McGeer definitions for LTC health care acquired infections to diagnose
symptomatic UTI.30 While there is no clear consensus related to diagnostic criteria, there is
agreement on management indicators which are divided into two categories: with or without
indwelling catheters.
Typical Symptoms with no indwelling catheter
A suspected UTI, without an indwelling catheter, is indicated by the following criteria:9,10
- Acute dysuria
OR
- Fever (> 38C), or an increase of 1.1C above baseline on 2 consecutive occasions or
chills PLUS any of the following:
New or increased urinary frequency, urinary urgency, incontinence
New flank/CVA or suprapubic pain or tenderness
Hematuria
10

Typical Symptoms with indwelling catheter
A suspected UTI, with an indwelling catheter, is indicated by any one of the following
criteria:
- Fever (> 38C) , or an increase of 1.1C above baseline on 2 consecutive occasions
- New flank/CVA or suprapubic pain or tenderness
- Rigors
- New onset delirium
The diversity of potential pathogens makes it necessary to obtain urine cultures in elderly
persons with suspected UTI. When or if to send a urine culture is another controversial issue.
In general, cultures should not be sent in the absence of symptoms. Surveillance cultures for
residents with indwelling catheters are not useful and are not recommended. Asymptomatic
bacteriuria can be identified in 95 to 100% of LTC residents who had indwelling catheters for
over 30 days.31
A positive dipstick test for leukocyte esterase or nitrite is not sufficient for the diagnosis of UTI.
A culture is essential. However, a negative dipstick for leukocyte esterase effectively excludes
a UTI.
Treatment
Recommendations are clear concerning asymptomatic bacteriuria in the older adult.11,28 Routine
screening and treatment are not recommended. There have been several studies showing no
benefits associated with the treatment of asymptomatic infections as measured by the rate of
subsequent symptomatic infections, improvement of chronic urinary symptoms or survival.
Pyuria is common among people with asymptomatic bacteriuria. Among residents of LTC
facilities, 90% of those with bacteriuria, 30% of those without bacteriuria, and 50-100% of
those with indwelling catheters have pyuria.11,32,33 The presence of pyuria is not an indication
for treatment.3
Antibiotic Agents
Until recently, amoxicillin was the standard treatment for UTIs, but up to 25% of E. coli are
now resistant to amoxicillin. A combination of amoxicillin-clavulanate is now sometimes given
for drug-resistant infections. Amoxicillin-clavulanate may also be useful for UTIs caused by
Gram positive organisms, including Enterococcus species.
Selection of an antimicrobial for treatment of a UTI is based on the known or anticipated culture
result, local resistance patterns, and resident tolerance. Narrow spectrum, first-line agents are
preferred. Ciprofloxacin is reserved for organisms resistant to first-line agents and should not
be used as first-line empiric treatment except in the following circumstances:
Lack of response to, or allergy to TMP-SMX
High rates of resistance to TMP-SMX in the community
Parenteral (usually given intramuscularly in LTC facilities) antibiotics may be given if the
resident is not able to take antibiotics orally (e.g., because of vomiting).
11

Duration
Takahashi et al examined the medical records of 196 elderly women (22% LTC residents and
78% community dwelling) in Olmsted County Minnesota and found that LTC residents were
more likely to be treated for a longer duration than community dwelling elderly.34 Nearly all
LTC residents were treated for more than 7 days and overall were 5.1 times more likely than
community subjects to be treated for 10 days or longer. The frequency of adverse drug events
increased with duration of treatment. The study also found that LTC residents were more likely
to receive re-treatment for persistent or recurrent symptoms. This suggests that care must be
taken not to over treat LTC residents but to review their clinical status after three to five days
of therapy. Failure to respond to a short course of antibiotics should prompt a search for underlying
problems such as diabetes mellitus, structural renal tract abnormality or antibiotic resistance.
The majority of individuals who have complicated UTI and present as cystitis can be treated
with 7 days of antibiotic therapy. Longer courses of therapy of 10-14 days may be needed
for individuals with presentations that include pyelonephritis, fever, and sepsis. In addition,
for residents with chronic indwelling catheters, if there is a prompt response to antimicrobial
therapy the duration of therapy should be no longer than seven days to limit the emergence of
resistant organisms.
Dose adjustment
Careful attention should be paid to appropriate antibiotic dosing in the elderly. Renal impairment
is common in this age group and often unrecognized, as a serum creatinine concentration within
the normal range may represent a significantly reduced glomerular filtration rate (GFR) in
elderly patients. LTC residents should all have their creatinine clearance calculated to assist
with medication dose adjustment.34
Consultation
Urologic consultation may be sought when obstructive uropathy, calculi, abscesses or GU tract
anatomic abnormalities are suspected. Imaging studies may occasionally be appropriate.
Recurrences
Recurrent UTI is common. When individuals have recurrent UTI, a careful microbiological
and urological evaluation is required to determine what interventions may be appropriate to
prevent recurrent infections. Use of low dose antibiotics to reduce recurrences is not recommended
and can promote the growth of resistant bacteria such that subsequent infections are difficult
to treat.
Catheter Associated UTIs
In LTC facilities, approximately 5% of residents have a chronic urinary catheter in place.
Catheters are commonly used for urinary retention, incontinence control, wound management
and resident comfort. Transurethral catheters are more common than suprapubic or condom-type
devices, but no method has been proven superior for use in LTC. The incidence of symptomatic
UTIs in chronically catheterized residents has been estimated at 21%.27 When compared with
urethral catheterization, most evidence suggests that the suprapubic route is not associated
with a reduced risk of bacteriuria for chronic catheters, however, there is some evidence that
this may be more comfortable, although catheter change may be more difficult.
12

Intermittent catheterization may be an alternative to indwelling catheter use. This technique is
commonly used in the spinal cord injury population who perform self-catheterization at home.
In LTC facilities, most residents are unable to perform this task independently and would rely
on nurses to perform the procedure. The burden on nursing time would prohibit general use of
this technique in many facilities and the cost of disposable catheters is also not insignificant.
Residents with long-term urinary catheters should have the need for their catheter reassessed.
If the indication is unclear, it could be removed and not replaced and the resident monitored for
urinary retention or problematic incontinence. This would provide the opportunity to consider
other potential solutions to avoid further catheter-related problems.
When an individual with long-term catheterization has a symptomatic UTI, replacement of the
catheter allows collection of a urine specimen which samples only bladder urine and is more
relevant for treatment, as well as improved clinical outcomes including earlier defervescence
and less likelihood of recurrent infection. The urine specimen for culture must be collected
through the new catheter before antimicrobials are initiated.
Catheter-related bacteriuria in the elderly is a frequent complication. Indwelling urinary catheterization causes bacteriuria to occur at a rate of 3 to 7% of residents per day of catheterization;
a single in and out catheterization may cause bacteriuria in as many as 3-5% of residents. By
about 30 days (the conventional cut off between short and long term catheterization), most
residents are bacteriuric. Bacteriuria associated with short-term catheterization usually involves
a single pathogen, most commonly E. coli; bacteriuria associated with long-term catheterization
is often polymicrobial.
Catheter associated UTIs are common and carry increased risks of complications and morbidity.
The CDC has published guidelines for prevention of catheter associated urinary tract infections.
These are listed in Table 6.
Antibiotics for Catheter Associated UTIs35
Residents using catheters who develop symptomatic UTIs should be treated for each episode
with antibiotics and the catheter should be removed, if possible. In order to ascertain the infecting
organism and prescribe the appropriate antimicrobial therapy, a urine culture is necessary.
Because there are likely to be multiple species of bacteria, it is generally recommended that an
antibiotic that is effective against a wide variety of microorganisms be used empirically. These
medications include ciprofloxacin and drug combinations such as ampicillin plus gentamicin.
Antibiotic Prophylaxis
Antibiotics should be given prior to any invasive genitourinary procedure which may be associated with bleeding. Otherwise the use of antibiotics to prevent urinary infection is not indicated
because this strategy does not decrease the frequency of symptomatic episodes, but does lead
to emergence of resistant organisms.
13
Urinary Tract Infection in Long Term Care Clinical Pathway
Typical Symptoms (1)
Typical Symptoms (1)
(No Indwelling Catheter)
(1) Practice Point
(Indwelling Catheter)
Indications (check all that apply):
Indications (check all that apply):
Acute Dysuria
OR
Temp >38o C or 1.1o above baseline on
2 consecutive occasions
PLUS one or more of the following:
New or increased urinary

frequency, urgency, incontinence
New flank or suprapubic pain or
tenderness
Hematuria
Temp >38o C or 1.1o above baseline

on 2 consecutive occasions
New flank or suprapubic pain or
tenderness
Rigors
New onset delirium
Date/Time ___________ Initials ____
Unless medical status is declining rapidly, PUSH

FLUIDS FOR 24 HRS and then REASSESS:
If typical symptoms develop, treat as for UTI
If non-specific symptoms continue without
development of typical symptoms, consider
an alternate diagnosis
If symptoms resolve, no further intervention is
required
PUSH FLUIDS (2)
Discuss with physician or nurse practitioner

Date/Time __________ Initials ____
Orders obtained (3)
Urine C&S (3)
Antibiotic therapy
Date/Time ________ Initials ____
(3) Practice Point

Urine C&S Results (4)

Significant
Not significant
C&S Results not significant

STOP or do not intitiate antibiotics
C&S Results are significant
Antibiotic is consistent with recommendations in guideline or Bugs &
Drugs.
Organism is susceptible to the prescribed antibiotic.
CrCl values reviewed. Therapy appropriate for renal function.
Pharmacist consulted (If N/A check here _____).
Findings discussed with physician or nurse practitioner.
Unless on fluid restriction
Continue to monitor resident status
Urine specimen collected
(2) Practice Point
Alternate diagnosis
Urine C&S (3)

Non-specific symptoms. Residents who are

cognitively impaired may not be able to verbalize
symptoms of a UTI. Non-specific symptoms which
may indicate a UTI include:
Worsening functional status
Worsening mental status, increased
confusion, delirium or agitation
Falls (new or more often)
Antibiotic therapy may or may not be ordered

depending on medical status
Urine specimens should be collected
BEFORE antibiotic therapy is initiated
Urine specimens should be refrigerated until
pick-up by lab
Urine dipslides should be kept at room
temperature until pick-up
(4) Practice Point

Bacterial count 108 cfu/L is significant
More than 3 organisms usually indicates
contamination
Clinical correlation is necessary for a
diagnosis of UTI
NOTE: Repeat C&S after antibiotic therapy is NOT
necessary unless typical UTI signs and symptoms
persist.
For complete guideline refer to the

TOP Website:
www.topalbertadoctors.org
Adapted from Alberta Health
Services (Edmonton) Seniors Health
Reference List
1. Swart W, Soler C, Holman J. Uncomplicated UTIs in elderly patients: How best to treat.
Consultant 2004;44(14):1805-9.
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costs. Dis Mon 2003;49(2):53-70.
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2004.
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initiation of antibiotics in residents of long-term facilities: Results of a consensus
conference. Infect Control Hosp Epidemiol 200;22(2):120-124.
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6. Windsor A. Bacteraemia in a geriatric unit. Gerontology. 1983;29(2):125-30.
7. Berman P, Hogan DB, Fox RA. The atypical presentation of infection in old age. Age
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(1993): 8992.
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Opinion in Urology 2002;12:51-5.
11. Wageniehner, Naber, Weidner. Asymptomatic bacteriuria in elderly patients : Significance
and implications for treatment. Drugs & Aging, 2005; 22(10): 801-807.
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Am J Med 2002;113 (suppl 1A): 555-665 .
13. Raz R. Asymptomatic bacteriuria. Clinical significance and management. Int J
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no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med
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New Engl J Med 1983;309:1420-5.
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2000;31:757-761
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Infections. Division of Healthcare Quality Promotion (DHQP), National Center for
Preparedness, Detection, and Control of Infectious Diseases. Date last modified: April 1
2005.
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23. Nicole N . Epidemiology of urinary tract infection. Infect Med 2001;18:153-62

24. Richards CL. Urinary tract infections in the frail elderly: issues for diagnosis, treatment
and prevention. Int Urol Nephrol 2004;33(11):753-8.
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function: a study in women. J Am Geriatr Soc 2006;54(3):405-12.
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bacteriuria in residents of nursing homes. Scand J Prim Health Care, 2005; 23: 52-56.
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Realities. The Internet Journal of Geriatrics and Gerontology, 2004; 1(2).
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for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis
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Toward Optimized Practice (TOP) Program
Arising out of the 2003 Master Agreement, TOP succeeds the former Alberta Clinical Practice
Guidelines program, and maintains and distributes Alberta CPGs. TOP is a health quality improvement initiative that fits within the broader health system focus on quality and complements
other strategies such as Primary Care Initiative and the Physician Office System Program.
The TOP program supports physician practices, and the teams they work with, by fostering
the use of evidence-based best practices and quality initiatives in medical care in Alberta. The
program offers a variety of tools and out-reach services to help physicians and their colleagues
meet the challenge of keeping practices current in an environment of continually emerging
evidence.
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Toward Optimized Practice Program
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T 780.482.0319
TF 1.866.505.3302
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Email: cpg@topalbertadoctors.org

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Urinary Tract Infection Guideline

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Guideline for the Diagnosis and Management of

Urinary Tract Infections in Long Term Care

Community acquired UTIs

To increase the accuracy of clinical diagnosis of UTIs for residents in LTC

Limit use of catheters