Attacking Inappropriate Antibiotic Use for Asymptomatic Bacteriuria in LTC through a Comprehensive UTI Prevention Protocol: A 2-Year Report

JoAnn Ermer-Seltun RN, MS, ARNP, CWOCNBladder Control Solutions, LLC; Mercy Medical Center, Mason City, IA; Associate Director for webWOC Nursing Education Program, Mpls., MN,

Metropolitan State University College of Nursing and Health Sciences, St. Paul, Minnesota USA

Data:Data tracking was done monthly and included: -# of urine cultures, # of patients on antibiotics for UTI treatment, # of patients on ASB/UTI Prevention protocol. Data was not tracked for: Residents who opted out of the protocol by Primary Care Provider Treatment, Hospice Coverage, or Family wishes. However, these “opt-out” residents with their urinary diagnostics and UTI antibiotics treatment were still included in the monthly totals.

Data Analysis:Statistical macro was used to: Assess normality of distribution, Graph box plot, Ob-tain simple descriptive statistics; Employ independent t-test to compare the mean between the 2 groups on: Urine cultures performed and Number of residents on antibiotics for UTI treatment. Due to the QI project assumptions: Level of signifi cance was set at p ≤ 0.01 . A cautious approach was taken to establish a more conservative level of signifi cance (2 variables: 2 * 0.05 = 0.01)

Objective:❏ Reduce the number of ASB (asymptomatic bacteriuria) conditions treated with

antibiotics by assisting LTC staff in distinguishing between symptomatic UTI and ASB through implementation of a Comprehensive UTI Prevention Protocol.

❏ This project examined the impact of the UTI education and prevention program on (1) antibiotic use for possible UTIs and (2) the number of urine cultures performed.

Background: In long term care (LTC), UTI’s are considered one of the most common infections treated. Also highly prevalent in LTC is asymptomatic bacteriuria (ASB), which mirrors a UTI with a positive culture, but lacks specifi c symptoms arising from the urinary tract (dysuria, frequency, fl ank pain etc.). ASB does NOT benefi t from antibiotic (ABX) treatment thus distinguishing between a symptomatic UTI from ASB is imperative to reduce inappropriate ABX use which can lead to increased ABX resistance and transmission of resistant bacteria to other LTC residents (1,2,4,5).

Review of Literature: The prevalence of ASB:25-50% among women and 15-40% among men in LTC, much higher than the prevalence in community-dwelling elders. Although ASB and symptomatic UTI look alike on paper, treatment is not warranted for ASB (1-5)!

Method: The quality improvement project took place in a 200-bed LTC facility. Residents were place on a 3-day UTI prevention protocol if 1-2 vague UTI symptoms were noted. The protocol consisted of monitoring the symptom(s) every shift for 3 days as well as instituting specifi c nursing interventions. If 3 symptoms occurred at any time during the protocol, the PCP was notifi ed and a catheterized UA and culture were sent.

UTI Prevention Protocol: House-wide implementation in LTC facility in Iowa: * Nursing education for Prevention of UTIs, and * Implementation of UTI Prevention Protocol for Residents with < 3 generalized

sign/symptoms of a UTI Observational Length: 51 months total * 20 – pre-intervention * 31 – post-intervention

Results: Both group data showed normal distribution, Independent t-test for assessing the difference between group means for: • The # of urine cultures obtained per month: t = 2.46, df = 29.37, p ≤ 0.01 • The # Residents on antibiotics for UTI treatment per month: t = 6.54, df = 25.48, p < 0.000005

Study Weakness:• Group size unequal• Data by month vs patient level• Duplicate patient inclusion possible for a given month• # Urine cultures ≠ # Residents on antibiotics• All “opt-out” patients included – infl ating monthly frequencies

Study Strengths:• Bonferroni correction increased signifi cance level to be met• Used one-tailed hypothetical distribution (vs. 2)• Patient safety paramount throughout protocol

Conclusion:• A decrease in the number of urine cultures drawn per month, p ≤ 0.01• A decrease in the number of residents on antibiotics for UTI treatment, p < 1 x 10-6

This type of intervention provides an opportunity for WOC Nurses to offer services that prevent UTI’s while developing a plan of care to attack inappropriate antibiotic use for ASB.

Many thanks to Cathryn Reimanis, RN, ND, CNS, CWOCN, ANP(c) for assisting with the statistical analysis on this project.

References:1. Benton TJ, Young RB & Leeper SC (2006). Asymptomatic bacteriuria in the nursing home. Annals of Long-Term Car;14(7):17-22. 2. Benton TJ & Nexon-Lewis, B (2007). The aging urinary tract and asymptomatic bacteriuria. 3. McGeer a et al (1991). Defi nitions of infection for surveillance in long-term care facilities. American Journal of Infection Control; 19(1):1-7. Available at: http://www.apic.org/AM/Template.cfm?Section=Defi nitions_And_Surveillance Clinical Geriatrics;15(2):17-22. 4. Nicole LE. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of ASB in Adults. Clinical Infectious Diseases; 40:643-54. 5. Nicolle LE, Bradley S, Colgan R, et al. (2005). Infectious Diseases Society of America, American Society of Nephrology, American Geriatrics Society. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clinical Infectious Disease; 40:643-644.

Nursing Shift Assessment of Resident

UTI Signs/Symptoms• New Flank Pain or Suprapubic Tenderness• Change in Urine Character: - Hematuria - Foul Smell - Sediment• Catheter Leakage, Possible Obstruction• Pyuria or Microscopic Hernaturia via Lab

Generalized Sign/Symptoms• Fever or Chills• Malaise• Decreased Appetite• Mental or Functional Status Change

= 3 Signs/Symptoms

1 or 2 Signs/Symptoms

No Signs/Symptoms

PCP Notifi ed or PCP Offi ce Visit or

Hospice Nurse Notifi ed

Urine Results ReviewedAntibiotic Regiman Started

3 Day UTI Prevention Protocol Initiated(Nursing Interventions, each shift)

• Temperature • Perineal and Foley Care • Increase Fluids (goal - 1500 cc) • Record Urine Color and Odor • Record Dysuria

No Need for Intervention

Resolution of UTISigns or Symptoms

(if previously present)

Day 4 Reassessment by RN Charge or Supervisor

Catheterized Urine SpecimenObtained

Sent to Lab for Culture and Sensitivity

As presented at the Wound, Ostomy and Continence Nurses Society Annual Conference • Phoenix, Az 2010

UTI Prevention Protocol 5/15/2010