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 patients with cognitive impairment (Alzheimers, PD), prostate disease, kidney stones, urinary/ faecal incontinence, diabetics with poor glycaemic control, catheters, self-catheterisation structural abnormalities

Symptoms Symptomatic bacteruria (UTI) requires new symptoms 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 ) 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 ? 

References Primary Care Guidance: Diagnosing and managing infections https://www.gov.uk/government/collections/primary-care-guidance-diagnosing-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_tract_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