Urinary Tract Infections (UTI) in Residential Care Facilities/Nursing Homes

Diagnosis of UTI

✔ For information on diagnosis of UTI in patients ≥65 years in residential care facilities please see the Decision Aid for management of suspected UTI in community settings: for adults aged 65 years and over or adults with a urinary catheter

✔ Diagnois for UTI should be based on a full clinical assessment.

✔ Dysuria, frequency, urgency, new onset incontinence, fever, suprapubic/ flank pain and haematuria are significant indicators of Urinary Tract Infection.

✔ Residents may have non-specific signs including confusion, lethargy, decreased oral intake and/or agitation and other causes for these signs should be also be considered.

✔ Consider other causes of urinary signs and symptoms such as Genitourinary Syndrome of Menopause (vulvovaginal atrophy), urethritis and sexually transmitted infections.

✔ Consider acute prostatitis in males >50 years with lower urinary tract symptoms, and referral for specialist opinion is advisable for recurrent UTI in males.

✘ The use of dipstick urinalysis in assessing for evidence of a UTI in all persons aged 65 years or over OR in those with a catheter is not recommended. For full guidance on dipstick urinalysis see Position Statements Dipstick Urinalysis for UTIs in Adults. Information on the SKIP THE DIP for UTI in over 65s quality improvement initiative is also available.

✘ Cloudy or foul-smelling urine are NOT indicators of UTI in the absence of signs and symptoms. In the absence of signs and symptoms of a UTI this may be suggestive of dehydration rather than of infection.

Empirical Treatment of UTI in Residents

1. Only consider empiric antibiotic therapy in SYMPTOMATIC residents.
2. Antibiotics (particularly ciprofloxacin and cephalosporins) are associated with C. difficile infection in elderly patients. Give antibiotics only if clinically indicated and avoid these agents where there is an alternative.
3. Choice of empirical therapy should be guided by local resistance rates where available.
4. Check the resident’s previous culture results and do not use an antibiotic empirically if an organism resistant to that antibiotic has recently been cultured (within 3 months).
5. Modify treatment according to culture results when available.

Treatment

Treatment guidelines for those in Residential Care Facilities/ Nursing Homes do not vary compared to those in the rest of Primary Care. For guidelines please see the following:

• Uncomplicated UTI in Adult Non-Pregnant Females
• Uncomplicated UTI in Adult Male i.e. no fever or flank pain
• Catheter Associated-UTI (CA-UTI)
• Acute Pyelonephritis
• View all UTI guidelines

Other considerations in management of Urinary Tract Infections

When should I send a urine to the lab for culture?

✔ Send urine to the lab in residents with signs and symptoms of a UTI

✘**DO NOT SEND URINE FOR CULTURE IF THERE ARE NO SIGNS AND SYMPTOMS OF UTI**

✔ Positive culture with no symptoms = asymptomatic bacteriuria ( ASB), not infection, and does not generally require antibiotic treatment in this patient group.

Should I consider antimicrobial prophylaxis?

✘ **DO NOT ROUTINELY USE ANTIBIOTIC PROPHYLAXIS TO PREVENT URINARY TRACT INFECTION**

• Antimicrobial prophylaxis may be considered in patients for whom the number of urinary infections are of such frequency or severity that they chronically impinge on function and well-being.
• For guidance on antimicrobial prophylaxis see Recurrent UTI in Adult Non-Pregnant Females guideline.
• For guidance on de-prescribing antibiotic prophylaxis see Deprescribing UTI Prophylaxis. Patients on antibiotic prophylaxis for UTI with breakthrough infections with urine cultures confirming resistance to prophylactic agent should have their prophylaxis stopped (exposure to antibiotic without benefit) and a clinical review to discuss ongoing management and /or need for referral. 

Recent Point Prevalence Surveys (PPS) of Antimicrobial use in HSE Residential Care Facilities (RCFs)

One of the key findings from HSE Older Persons RCFs Antimicrobial PPS 2020/21 was that there was a higher prevalence of overall antibitoic use  and prophylactic antibitoic use in HSE OPS RCFs in Ireland compared to European mean. UTIs accounted for 50% of infections treated with antibiotics. A key reommendation is to review ongoing need for UTI prophylaxis in excess of 6 months.

Patient Information

• HSE A-Z Urinary Tract Infections
• Older persons information leaflet on UTI

Safe Prescribing

• Doses are oral and for adults unless otherwise stated
• Fluoroquinolone warning
• Penicillin allergy – tips on prescribing in penicillin allergy
• Renal impairment dosing table
• Drug interactions table.
• Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed July 2023