1. Managing Urinary Tract Infections in the Care Home
Jean Matthews
Primary Care Pharmacist
Aneurin Bevan University Health Board
February 2015

4. 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%)

5. When would you expect that your patient has a UTI?

6. 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

7. 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

8. 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?

9. 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?

10. 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

11. 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

12. 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

13. 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

14. Thank you for listening Any questions? Any answers ? 

15. References
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
Beveridge, Davey, Phillips and McMurdo (2011) Optimal management of urinary tract infections in older people, Clin Interven Aging , June 22nd, 6,