AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
The frequently asked questions (FAQs) that are intended to support long-term care (LTC) facilities in the implementation of efforts to reduce the overuse of antibiotics. The answers to these commonly asked questions are based on evidence-based practices (when available) and consensus of experts from this program's national project team of clinical faculty; others are based on practical hygiene issues of daily living.
- Does prescribing prophylactic antibiotics help prevent urinary tract infections (UTIs)?
There are no benefits of antibiotic prophylaxis in patients who have short-and long-term urinary catheterization.1,2
Moreover, residents with or without urinary catheters, with asymptomatic bacteriuria, should not be treated with antimicrobial therapy.3 Overuse of antibiotics can lead to antimicrobial resistance, medication adverse events, and potential Clostridium difficile (C. diff) infection.
- Are there certain species found in the urine culture that should be considered red flags and that will always require antibiotics?
No. The catheter increases the ability of bacteria and yeast (Candida) to enter the bladder, but whether or not a symptomatic infection with tissue damage occurs depends on multiple factors.
- Would it be useful for LTC facilities to assess local antibiotic resistance patterns in their facility?
Yes. The best source for determining local antibiotic resistance patterns in your LTC facility is the laboratory that serves you. Laboratories often produce an “antibiogram” that details what percentage of each type of bacteria are resistant to a given antibiotic. For example, an antibiogram can tell you that 30 percent of E. coli detected at the laboratory are resistant to ciprofloxacin. A good source for the local antibiogram also might be an infection control practitioner. If the antibiogram for urinary tract pathogens is not available or identified, you may be able to get this information from other LTC facilities in your community. Another alternative is to request the antibiograms for urinary tract pathogens from the local hospital if you don't have antibiograms of cultures from residents in your facility.
- Would you recommend reviewing the serum white blood cell count to diagnose a CAUTI?
An increase in the total number of white blood cells, also known as leukocytosis, is only helpful in diagnosis of CAUTI if it is accompanied by either an acute change in mental status or functional decline. Otherwise, leukocytosis is nonspecific and can result from several noninfectious conditions, including stress, medications, etc. Therefore, the diagnosis of UTI should always be a diagnosis of exclusion if the resident has a positive urine culture diagnosis but does not have any UTI symptoms.4
- How do you recommend we engage physicians in antimicrobial stewardship based on the treatment guidelines?
It is important to build trust and be diplomatic when approaching another clinician. Start by sharing factual observations and information. Describe your observations and things you’ve considered, including the treatment guidelines. Then ask more questions to understand the provider's observations. You can use communication strategies and tools from TeamSTEPPS, an evidence-based teamwork system designed to enhance performance and patient safety. Another approach could be on a systems level to enlist the support of the director of nursing or an infection preventionist to address policy level changes.
- How does one have an appropriate conversation with the medical staff about placing residents on antibiotics for asymptomatic bacteriuria, especially in those residents who always have a resistant organism each time a urine culture is sent?
Emphasize your shared goals—you both want to deliver the best medical care to the resident based on evidence-based practices. Consider what factors or pressures may be driving the physician’s repeated rounds of cultures and antibiotics for this resident. Is the physician acting out of habit, because of concern about making a choice that differs from the norm or out of fear of missing urosepsis? Your conversation may differ to address these different pressures. For example, if you think the antibiotic use is just a reflex or habit, you might bring up the concept that overuse of antibiotics can cause harm to the resident, leading to C. diff infections. If the concern is of missing urosepsis, consider pointing out that you will help assess for any deterioration, and treating the urine in a resident without UTI might lead to missing the real problem. Final advice—have courage to bring up your concerns. These aren’t easy conversations to initiate.
- How can I explain to a resident why we decided to not conduct a urinalysis or urine culture?
It's important to remain sensitive to their concerns and assure them that you are closely observing the resident for signs and symptoms of a CAUTI. For example, you could say, “We’re not going to culture for a catheter-associated urinary tract infection today. We’re going to look at other causes. If anything changes, we haven’t lost any ground. We can start treatment whenever is necessary. Overuse of antibiotics can be harmful to you and makes them less effective later when antibiotics really are needed.” Provide them with additional resources and materials, such as the “When Do You Need an Antibiotic?” brochure.
- How do you start to change resident safety culture when the family asks for the patient to be sent to the hospital for a urinalysis when you determine it's not appropriate to conduct this test?
Bridge the gap between the LTC facility and hospital emergency department staff through diplomacy and information sharing based on the resources available in the Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities, as well as through resources such as the Toolkit for Reducing CAUTI in Hospitals.
1Meddings K, Rogers MA, Krein SL, et al. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf. 2014 Apr;23(4):277-89. PMID: 24077850.
2Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010 Apr;31(4):319-26. PMID: 20156062.
3Nicolle LE, SHEA Long-Term-Care Committee. Urinary tract infections in Long-term-care facilities. Infect Control Hosp Epidemiol. 2001 Mar;22(3):167-75. PMID: 11310697.
4Stone N, Muhammad S, Calder J, et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol. 2012 Oct;33(10):965–977. PMCID: PMC3538836.