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Welcome to the Infection Control and Long-Term Care Settings Podcast, brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare-associated infections and antibiotic resistance, and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
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Shay is excited to launch the first episode of this podcast, Antibiotic Stewardship: Management of Asymptomatic Bacteriuria in Long-Term Care.
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In this episode, our speakers will discuss the case of ASB in a long-term care setting and how to navigate the care of that patient.
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I'm Dr.
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Tidney Prince, Clinical Associate Professor of Epidemiology at the University of Florida.
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And I'm pleased to introduce our two panelists, Dr.
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Manita Gutani and Dr.
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Christopher Fernitz.
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Dr.
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Dutani is an associate professor of medicine and epidemiology, an ID Fellowship Program Director at Yale School of Medicine and Yale School of Public Health.
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Her research focuses on the diagnosis, management, and prevention of infections in older adults, specifically UTI and pneumonia.
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She has a specific interest in merging best practices of infectious diseases and palliative medicine in the management of infections at the end of life.
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Dr.
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Christopher Turniff is a chief of medicine and hospital epidemiologist at the William S.
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Middleton VA Hospital and an associate professor of medicine in the Division of Infectious Disease at the University of Wisconsin School of Medicine and Public Health.
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He has a general research interest in healthcare-associated infections among vulnerable elderly patients with a specific focus on antibiotic use and antibiotic resistance in long-term care facilities.
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I'll now turn the podcast over to our speakers.
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Well, Manisha, it's great to be on this podcast with you today.
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I think as we discussed this topic in advance, we thought that the best way to introduce the topic was through an illustrative case, which I'll jump into.
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So we've just been called by nursing staff from a local nursing home about Mrs.
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S, an 86-year-old female you care for, to report that she is a bit more confused and seemingly more uncomfortable.
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Mrs.
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S.
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past medical history is notable for hypertension, hyperlipidemia, corneal artery disease, diabetes mellitus, mild to moderate cognitive impairment felt to be secondary to Alzheimer's dementia, and osteoporosis complicated by multiple spinal compression fractures.
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She has recently been started on GABAPentin to better control her chronic back pain.
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The nurse calling you reports that Mrs.
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Est is apebrile and otherwise hemodynamically stable.
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Her blood sugars are within normal range, and her exam is negative for any lung abnormalities or any localizing findings that point to a source for her generalized discomfort.
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These symptoms were first recognized late yesterday by the on-call provider who was called and ordered a urinalysis.
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The urinalysis shows positive nitrates and leukocyte esterase.
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The nurse on the call with you is asking if he should send a urine culture and whether an antibiotic should be started.
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So, Manisha, I think this is a pretty common scenario that we encounter in long-term care.
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Can you speak to the commonality or the routine aspects of this case and how it might lead to overdiagnosis of urinary tract infection in long-term care facilities?
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Thanks, Chris.
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Absolutely.
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I completely agree with you that some of these very nonspecific signs and symptoms are often what triggers suspicion of UTI in this type of patient.
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So as we know, patients with dementia have difficulty communicating signs and symptoms, and so this remains a persistent challenge.
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But I think that confusion, change in behavior, change in mental status, generalized discomfort, these are all very, very common symptoms that through research have been shown not to be associated with urinary tract infection per se.
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But we also know that the exact kind of patient you described can have up to a 90% prevalence of asymptomatic bacteria at any given time.
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So in studies that have been done, if you do a urine culture on any kind of patient like this, even with generalized symptoms like the patient you presented, or more nonspecific symptoms even than this, maybe just at their baseline, they can have bacteria and pyuria 90% of the time.
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So I think this really raises a clinical conundrum for many patients.
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I'm sure you agree and have had similar experience.
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Yeah, I think what you're hitting on is a key point.
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I think when you talk to clinicians, most of them will agree that treating asymptomatic bacteria is something that we shouldn't be doing on a routine basis except in very specific situations.
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But I think that most of the clinicians feel that they're treating symptomatic urinary tract infection when we kind of talk about these non-specific geriatric presentations, such as behavior change, falls, confusion, et cetera.
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Can you speak to your experience on the IDSA guidelines, kind of looking at the quality of evidence supporting this idea that nonspecific geriatric symptoms can be associated or triggered by urinary tract infection?
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Absolutely.
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So this was a several-year process with many experts in the field in terms of the most recent IDSA guidelines that were published on asymptomatic bacteria.
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And I participated in the subgroup that really focused on the older adults living in long-term care facilities, assisted living facilities, and we did a thorough literature review and had many experts at the table who've done work in this field, and we tried to address several specific questions because, as you said, Chris, it's been well known that we should not treat asymptomatic bacteria.
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The problem is what is a symptom in this population, and that is where the real dilemma lies.
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So the guidelines reiterate that we shouldn't treat asymptomatic bacteria, we shouldn't screen it for inpatients that are older adults living in long-term care facilities without symptoms.
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But then we specifically addressed two specific populations.
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So the first was in a patient who has an altered mental status without fever and without hemodynamic instability, and definitely without any localizing genito-urinary symptoms, that that should not be a criteria for screening for UTI to send a urine culture in the UA.
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Secondly, a patient that experiences a fall alone.
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So again, no fever, no hemodynamic instability, no genito-urinary tract-specific symptoms or signs.
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That again, that patient should not have a urine scent to assess for UTI.
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So I think when we think about what symptoms are in this specific group, a fall and a change in mental status, which are often triggering symptoms, we're trying to give clear guidance that the data really supports that we should not be suspecting UTI in those specific patients.
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And I think that guideline is there to be able to help practitioners who are trying to sort out what is asymptomatic UTI in this population, that this is a cohort that we can continue to watch and monitor and not necessarily go right away to sending a urinalysis.
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And I think that really brings up the role of what urine testing would be.
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So, Chris, what are your thoughts on the UA as a screening test for UTI in this population?
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Yeah, I think that that's a really important point.
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So there's really two things that I get surprising looks from clinicians.
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The first we've kind of already touched on is this idea that the evidence supporting a causal association between UTI and non-specific geriatric symptoms is pretty weak or non-existent.
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The second is this idea that the tests that we have available to us to try and distinguish between asymptomatic bacteria and symptomatic UTI really are quite poor.
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This has been studied for quite some time, and I'm always a little bit surprised that clinicians don't appreciate how bad these tests are.
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So urinalysis in a number of studies has been shown to have a positive predictive value as low as 25% when you look at studies conducted in emergency room departments.
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And that is pretty amazing that we put so much reliance on a test that has a positive predictive value that low.
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And this is often used as an arbiter to decide whether one should get a urine culture or initiate antibiotic therapy.
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I will say that the urinalysis has reasonably good negative predictive values.
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So getting a urinalysis back that is negative for nitrites or leukocyte esterase really largely excludes the presence of bacteria, not 100% of the time, but 80 to 90% of the time.
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So I think it's one of those tests that, when used appropriately for its negative predictive value, it can be useful.
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But if you're using this test for its positive predictive value from the perspective that if this test comes back with either nitrates or leukocyte esterase, then it's okay for me to send a urine culture and or initiate antibiotics.
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I think that's kind of the wrong way of looking at this test.
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What do you think?
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I completely agree.
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So we had actually looked at this some years ago at 101 patients, and this was published in Itchy actually, and it was all long-term care patients, and we had the exact same experience that you're describing.
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So it had low positive predictive value, but it had 100% negative predictive value in that cohort of 101 patients that we looked at.
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Now that only represented 12 patients, so that's the problem is that if you test 100 patients, if 12 of them are negative, but all 12 of them were negative for a urine culture that was done at the same time.
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So it it basically negative nitrite and negative leukocyte est raise was 100% had 100% negative predictive value for a negative urine culture.
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So I think that the stepwise process in terms of urine testing is helpful from that perspective.
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But I think the problem is there's a very small subset of the population.
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And so really trying to limit who you even send these urine tests in in the first place is probably the biggest first challenge.
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And I think your case very clearly highlights one of the challenges in long-term care facilities and in nursing home care, which is that there may be different providers, there are different people who are caring for the patient.
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Much of the care is happening over the phone.
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So one provider one day sends the UA, and another provider the next day has to decide what to do with either the result or whether to send a urine culture, whether to prescribe an antibiotic.
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And I think that's where some of the challenges lie.
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But I completely agree that the UA does have a role and can be helpful, but it's just only helpful some of the time.
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Well, why don't we go ahead and continue with our case?
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Sounds good.
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While against your better judgment, you agree to send a urine culture in the patient that we discussed.
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You decide not to start an antibiotic, but you do recommend stopping the gabapentin.
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Two days later, the same nurse calls you to inform you that Mrs.
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S is actually looking better and seems to be back to her baseline, but her urine culture is growing greater than 100,000 E.
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coli.
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The nurse has already notified Mrs.
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S's daughter about the urine culture results.
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The daughter, quote, knew her mom had a UTI, unquote, and is asking what antibiotic you are planning to start her on.
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So I think this is raising one of the real additional challenges that come up in the care of this type of patient.
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Number one is the role that families play in the decision making, especially in a patient population that often can't advocate for themselves or communicate their own symptoms.
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And the second is the role of antibiotic treatment, and where I think it's very important to really be thinking about treating the patient, not a piece of paper or a culture result.
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So in the anecdote that we've shared, this patient actually is clinically improved.
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But I think it's very, very difficult for practitioners to see a result and decide not to treat.
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What some of the studies I've done have shown is that once that urine culture result is there, and if it's a positive result, about 95% of the time practitioners end up prescribing an antibiotic.
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So again, that raises the point about not sending urine specimens in the first place.
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But I think this challenge with how to manage both the patient and families, that results is a real one.
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So, Chris, do you have some thoughts then on how to deal with that with both antibiotic use and managing family pressure?
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Yeah, I think we've already touched on this idea of the cascade that testing sets off.
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And I've often said that once you've sent the urine culture, the horse is kind of out of the barn.
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And you've already alluded to this in the sense that 95% of the time an antibiotic will be started once you have a positive culture result.
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And there are a number of studies showing that 80% of the antibiotics initiated for treatment of suspected UTI get initiated after the urine culture results come back, which really kind of speaks to the profound influence that the positive culture has on provider decision making.
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And I think as you point out, the other kind of important influence on antibiotic decision making are provider perceptions, whether they're explicit or implied from family members for starting an antibiotic in these situations.
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And this has been shown, I think, very well in research in the pediatric population where provider perceptions about desires for antibiotics drive a lot of unnecessary antibiotic prescribing in the ambulatory setting.
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And this is a scenario that I think people in this space readily acknowledge exists, but hasn't been studied as well.
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We've done a number of studies where we've interviewed both nursing staff and providers.
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And while we were not explicitly looking for family pressure or desires, this was a pressure or factor influencing decision making both at the nursing staff and the provider level that came out unsolicited in a number of our interviews.
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And you don't have to look too hard in the literature to find a number of other papers showing that this is a prevalent influence on prescriber practice.
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And so I think this is something that we need to focus more on from a research perspective, but also need to acknowledge when we're discussing strategies and approaches to improving testing and treatment decision making in long-term care.
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And so this is something that I think segues nicely into talking about how do we start to design work systems or workflows that kind of address some of the major factors that are influencing what I think we would both agree is suboptimal prescribing decision making.
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One of the things that we've developed, not unique to our state, but certainly one that we've kind of moved into an implementation phase is this idea of standardizing the assessment of resident changing condition.
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So we're being explicit about what signs and symptoms are present.
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I think this case that we're discussing here illustrates nicely the frequency with which nonspecific geriatric symptoms are often the only trigger for suspecting urinary tract infection.
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It's important for nursing staff to be very explicit when they're doing an assessment of a resident change in condition about looking for other signs and symptoms that have greater accuracy or reliability for determining urinary tract infection.
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What I mean by that is the exam of the resident should really focus on whether there are symptoms that suggest urethral irritation, whether that be increased urinary frequencies, new onset urinary incontinence, whether the resident has fever or other vital sign of abnormalities that might suggest a systemic inflammatory response syndrome.
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And those things should be looked at or looked for explicitly.
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And if they're not present, they should be noted as a pertinent negative when relaying information to providers who are often making these decisions over the phone.
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And if you're in one of those situations where all you have is an isolated, non-specific geriatric syndrome like behavior change confusion, then it probably is very safe in those situations to delay sending a urinalysis to urine culture or starting antibiotics and observing these individuals very closely with vital sign checks and history and exams every shift to ascertain whether the resident is developing additional signs and symptoms that might support a diagnosis of UTI.
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But as we've already kind of discussed, these residents often have other reasons for why they've had a nonspecific geriatric manifestation like confusion.
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And in this case, clearly, I suspect in an overhanded way, we alluded to the fact that we started a new medication here that very frequently has cognitive impacts, in this case, GABAPent.
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Obviously, the resident's cognitive abnormalities that triggered a suspicion for UTI resolved with removal of the GABA pen.
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So this illustrates this idea that looking for other causes for the change and observing them without testing and treating can avoid unnecessary antibiotic use in this population.
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Can you speak to other factors that we commonly encounter in this population that might trigger these non-specific geriatric manifestations, Manisha?
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One of the ones I think is the most common is dehydration.
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And I think that many of these patients have a decreased thirst drive.
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For many of them, it may be difficult to ascertain whether they're dehydrated or not, but I think it's a very simple intervention in terms of rehydration, whether oral or even gentle IV hydration, which some facilities are able to do.
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I think that many times things like concentrated urine, change in character of the urine, smelly urine, the change in odor or color of the urine, these are things that nurses may relay to a covering provider, but in general have not been shown to be associated with true symptomatic UTI.
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Now, having said that, it could be there when you have a UTI, but I think that by process of elimination, you need to rehydrate a person to be able to confirm that that change is persisting or that there is some evidence of that that is still there.
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And this goes into the sort of stepwise protocol that you're talking about.
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I think one of the major advantages of long-term care is that there is active monitoring and the ability to see how a patient is doing over time.
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Things like constipation can result in symptoms, non-specific signs and symptoms.
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Depression is very common in this population.
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So there are many of these other things.
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And the unfortunate reality is that sometimes it's a lot harder to address some of these more either existential or more long-term problems than it is to just send a urine and start an antibiotic.
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And I think that is one of the major challenges in caring for these patients.
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But I think that something along the lines of rehydration, consoling families that we are actively watching and monitoring their family member.
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It's not that we're doing nothing, and that in the process of that, if these symptoms persist over two days, and if certainly fever or hypothermia, and sometimes people have used the 100-100-100 rule, so a temperature greater than 100, heart rate greater than 100, systolic blood pressure less than 100, or things like systolic blood pressure less than 90 or heart rate greater than 90, basically signs of hemodynamic instability.
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If you see evidence of that, you can always move forward with more aggressive testing.
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But I think that it's not that we're doing nothing in these other circumstances.
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And I think that's something that we have to reassure families with.
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Yeah, I think that's such an important point.
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At the end of the day, family members want to know that we're taking care of their loved one and that their loved one isn't suffering.
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And I think we need to do a much better job in educating family members as well as residents about the potential harms of antibiotic therapy.
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And as you allude to, this idea of active monitoring as demonstrating that these are the active things that we're going to be doing to monitor your mother, your father very carefully.
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And if anything changes or worsens in their clinical status, of course, we're going to move expeditiously and diagnose and treat a UTI if that's where the evidence is leading us.
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But by using this active monitoring approach, we're really kind of balancing the risks and the benefits of antibiotics much better.
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And by indiscriminately using antibiotics, we may actually be causing more harm.
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I think when we talk with family members, they're often surprised that antibiotics have harms, even in those situations where it's pretty clear that a resident has suffered a harm of an antibiotic, those effects can often be delayed by weeks or sometimes even months.
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And so we have to understand that sometimes.
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Sometimes non-medical people have a hard time drawing a line between an antibiotic and their side effects or their adverse effects.
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I've had a number of conversations with family members where they express surprise that that episodic C difficile that their mother had was triggered by an unnecessary ciprofloxicin prescription that was administered a month earlier for a little bit of confusion.
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And that often can help a provider convince family members that what we're really doing is in the best interest of their loved one.
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And they often become very big proponents in those situations.
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Now I think one of the things we have to be very cognizant of is that these are difficult conversations to have, particularly in the moment of a resident experiencing an acute change in condition.
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And so I think the other thing that nursing facilities and staff who are trying to make improvements in antibiotic prescribing and nursing facilities need to understand is that this is messaging that needs to be done upstream of the acute change in condition, or sometime after maybe suboptimal prescribing has occurred, kind of circling back in that situation with the family members and kind of talking about, you know, why this was probably not the best thing to do.
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And in the future, if this happens, this is what we would recommend.
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Family members have a great deal of anxiety when their loved ones are experiencing a change in condition.
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And if we go in and push hard at that time about not prescribing an antibiotic, we can often meet a lot of resistance that may be hard to overcome.
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So I think it's really important we be cognizant of the timing of those interventions and doing it up front when residents get admitted to the facility, doing it at some regular intervals, particularly with residents that have a lot of cognitive impairment and have received a lot of courses of antibiotic therapy, and doing some detailing of family members in those situations can be very beneficial.
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I completely agree, Chris.
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And I would just reiterate that I think the first time somebody's being treated for a UTI, this conversation may not make as much sense to a family member.
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But again, if this is somebody, as you said, who's had advanced dementia and maybe has had two or three episodes of quote suspected UTI over a period of time, and the family member can really now understand and see what antibiotics may or may not be doing for their loved one.
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I think this is a really appropriate time to have conversations upstream, as you said, for what the goals of care are and what the goals of infection management should be in this patient and for their loved one.
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So reassuring them that we can treat pain in other ways, that we can treat discomfort in other ways, that the goal of antibiotic therapy is really curative for infection, but that we can really align best practices of infection management with palliative care in some of these patients, and that, you know, reducing harm is just as important as treating symptoms.
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And I think that families who've gone through an episode of suspected UTI can really understand that.
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And it just goes back to your point of circling back to what are important ways to connect with the family and make them understand that we are truly caring for their loved one, that they're not being abandoned, because I think ultimately that's what they fear the most.
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Well, I think that that's a really good spot to conclude this discussion.
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I think to summarize here, I think we're both in agreement that nonspecific signs and symptoms, as well as injudicious use of urine testing and family pressures, are common triggers for overuse of antibiotics in nursing homes.
00:25:46.640 --> 00:26:32.960
I think we also agree that putting a focus on developing and implementing protocols that limit testing and treatment to those situations where residents have specific localizing symptoms as well as fever or other vital sign abnormalities can be an effective strategy for improving antibiotics in nursing homes, and that we really need to put some focus on educating families about the potential harms of antibiotic therapy and how using active monitoring protocols to quickly identify progression of symptoms that would lead us to a more firm diagnosis of UTI is an appropriate and effective strategy that can demonstrate that we're not doing nothing.
00:26:33.119 --> 00:26:40.799
We're actually providing the best care to the family member in an effort to balance the risks and benefits of antibiotic therapy.
00:26:40.960 --> 00:26:54.319
And then I think what you hit on there at the end about the value of having discussions of the role and purpose of antibiotics near the end of life is something that we need to be putting more focus on in nursing homes.
00:26:55.279 --> 00:26:58.160
Is there anything else that you'd like to add, Manisha?
00:26:58.640 --> 00:27:13.200
No, I think that we've had a great discussion, Chris, and I hope that people get something out of this that we really understand the challenge that patients and families and providers are faced with in distinguishing asymptomatic bacteria from symptomatic UTI.
00:27:13.279 --> 00:27:14.400
There's no clear answer.
00:27:14.559 --> 00:27:25.119
But I think what we've tried to do today is help provide a pathway of how to navigate that challenge and how to try to best care for the patients, which is ultimately our goal.
00:27:26.000 --> 00:27:27.279
Thank you to our speakers, Dr.
00:27:27.359 --> 00:27:29.039
Manita Kutani and Dr.
00:27:29.119 --> 00:27:32.640
Christopher Sernik for sharing your perspectives and experiences.
00:27:33.200 --> 00:27:35.680
Looking to expand your knowledge and infection control?
00:27:36.240 --> 00:27:42.880
Then join us at the Sixth International Conference on Healthcare Associated Infections at Decennial 2020.
00:27:43.119 --> 00:27:50.640
This conference will be held in Atlanta, Georgia, from March 26th to the 30th, and is co-hosted by FA and the CDC.
00:27:51.039 --> 00:27:56.400
Find out more and register at www.decennial2020.org.
00:27:56.640 --> 00:28:01.200
This concludes the first episode of the Infection Control in Long Term Care podcast.
00:28:01.440 --> 00:28:07.519
Stay tuned for our next episode Managing Multidrug Resistant Organisms in the Long Term Care Setting.
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Welcome to the Infection Control and Long-Term Care Settings Podcast, brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare-associated infections and antibiotic resistance, and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
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Shay is excited to launch the first episode of this podcast, Antibiotic Stewardship: Management of Asymptomatic Bacteriuria in Long-Term Care.
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In this episode, our speakers will discuss the case of ASB in a long-term care setting and how to navigate the care of that patient.
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I'm Dr.
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Tidney Prince, Clinical Associate Professor of Epidemiology at the University of Florida.
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And I'm pleased to introduce our two panelists, Dr.
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Manita Gutani and Dr.
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Christopher Fernitz.
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Dr.
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Dutani is an associate professor of medicine and epidemiology, an ID Fellowship Program Director at Yale School of Medicine and Yale School of Public Health.
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Her research focuses on the diagnosis, management, and prevention of infections in older adults, specifically UTI and pneumonia.
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She has a specific interest in merging best practices of infectious diseases and palliative medicine in the management of infections at the end of life.
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Dr.
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Christopher Turniff is a chief of medicine and hospital epidemiologist at the William S.
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Middleton VA Hospital and an associate professor of medicine in the Division of Infectious Disease at the University of Wisconsin School of Medicine and Public Health.
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He has a general research interest in healthcare-associated infections among vulnerable elderly patients with a specific focus on antibiotic use and antibiotic resistance in long-term care facilities.
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I'll now turn the podcast over to our speakers.
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Well, Manisha, it's great to be on this podcast with you today.
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I think as we discussed this topic in advance, we thought that the best way to introduce the topic was through an illustrative case, which I'll jump into.
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So we've just been called by nursing staff from a local nursing home about Mrs.
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S, an 86-year-old female you care for, to report that she is a bit more confused and seemingly more uncomfortable.
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Mrs.
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S.
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past medical history is notable for hypertension, hyperlipidemia, corneal artery disease, diabetes mellitus, mild to moderate cognitive impairment felt to be secondary to Alzheimer's dementia, and osteoporosis complicated by multiple spinal compression fractures.
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She has recently been started on GABAPentin to better control her chronic back pain.
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The nurse calling you reports that Mrs.
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Est is apebrile and otherwise hemodynamically stable.
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Her blood sugars are within normal range, and her exam is negative for any lung abnormalities or any localizing findings that point to a source for her generalized discomfort.
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These symptoms were first recognized late yesterday by the on-call provider who was called and ordered a urinalysis.
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The urinalysis shows positive nitrates and leukocyte esterase.
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The nurse on the call with you is asking if he should send a urine culture and whether an antibiotic should be started.
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So, Manisha, I think this is a pretty common scenario that we encounter in long-term care.
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Can you speak to the commonality or the routine aspects of this case and how it might lead to overdiagnosis of urinary tract infection in long-term care facilities?
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Thanks, Chris.
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Absolutely.
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I completely agree with you that some of these very nonspecific signs and symptoms are often what triggers suspicion of UTI in this type of patient.
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So as we know, patients with dementia have difficulty communicating signs and symptoms, and so this remains a persistent challenge.
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But I think that confusion, change in behavior, change in mental status, generalized discomfort, these are all very, very common symptoms that through research have been shown not to be associated with urinary tract infection per se.
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But we also know that the exact kind of patient you described can have up to a 90% prevalence of asymptomatic bacteria at any given time.
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So in studies that have been done, if you do a urine culture on any kind of patient like this, even with generalized symptoms like the patient you presented, or more nonspecific symptoms even than this, maybe just at their baseline, they can have bacteria and pyuria 90% of the time.
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So I think this really raises a clinical conundrum for many patients.
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I'm sure you agree and have had similar experience.
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Yeah, I think what you're hitting on is a key point.
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I think when you talk to clinicians, most of them will agree that treating asymptomatic bacteria is something that we shouldn't be doing on a routine basis except in very specific situations.
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But I think that most of the clinicians feel that they're treating symptomatic urinary tract infection when we kind of talk about these non-specific geriatric presentations, such as behavior change, falls, confusion, et cetera.
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Can you speak to your experience on the IDSA guidelines, kind of looking at the quality of evidence supporting this idea that nonspecific geriatric symptoms can be associated or triggered by urinary tract infection?
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Absolutely.
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So this was a several-year process with many experts in the field in terms of the most recent IDSA guidelines that were published on asymptomatic bacteria.
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And I participated in the subgroup that really focused on the older adults living in long-term care facilities, assisted living facilities, and we did a thorough literature review and had many experts at the table who've done work in this field, and we tried to address several specific questions because, as you said, Chris, it's been well known that we should not treat asymptomatic bacteria.
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The problem is what is a symptom in this population, and that is where the real dilemma lies.
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So the guidelines reiterate that we shouldn't treat asymptomatic bacteria, we shouldn't screen it for inpatients that are older adults living in long-term care facilities without symptoms.
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But then we specifically addressed two specific populations.
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So the first was in a patient who has an altered mental status without fever and without hemodynamic instability, and definitely without any localizing genito-urinary symptoms, that that should not be a criteria for screening for UTI to send a urine culture in the UA.
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Secondly, a patient that experiences a fall alone.
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So again, no fever, no hemodynamic instability, no genito-urinary tract-specific symptoms or signs.
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That again, that patient should not have a urine scent to assess for UTI.
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So I think when we think about what symptoms are in this specific group, a fall and a change in mental status, which are often triggering symptoms, we're trying to give clear guidance that the data really supports that we should not be suspecting UTI in those specific patients.
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And I think that guideline is there to be able to help practitioners who are trying to sort out what is asymptomatic UTI in this population, that this is a cohort that we can continue to watch and monitor and not necessarily go right away to sending a urinalysis.
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And I think that really brings up the role of what urine testing would be.
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So, Chris, what are your thoughts on the UA as a screening test for UTI in this population?
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Yeah, I think that that's a really important point.
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So there's really two things that I get surprising looks from clinicians.
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The first we've kind of already touched on is this idea that the evidence supporting a causal association between UTI and non-specific geriatric symptoms is pretty weak or non-existent.
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The second is this idea that the tests that we have available to us to try and distinguish between asymptomatic bacteria and symptomatic UTI really are quite poor.
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This has been studied for quite some time, and I'm always a little bit surprised that clinicians don't appreciate how bad these tests are.
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So urinalysis in a number of studies has been shown to have a positive predictive value as low as 25% when you look at studies conducted in emergency room departments.
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And that is pretty amazing that we put so much reliance on a test that has a positive predictive value that low.
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And this is often used as an arbiter to decide whether one should get a urine culture or initiate antibiotic therapy.
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I will say that the urinalysis has reasonably good negative predictive values.
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So getting a urinalysis back that is negative for nitrites or leukocyte esterase really largely excludes the presence of bacteria, not 100% of the time, but 80 to 90% of the time.
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So I think it's one of those tests that, when used appropriately for its negative predictive value, it can be useful.
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But if you're using this test for its positive predictive value from the perspective that if this test comes back with either nitrates or leukocyte esterase, then it's okay for me to send a urine culture and or initiate antibiotics.
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I think that's kind of the wrong way of looking at this test.
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What do you think?
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I completely agree.
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So we had actually looked at this some years ago at 101 patients, and this was published in Itchy actually, and it was all long-term care patients, and we had the exact same experience that you're describing.
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So it had low positive predictive value, but it had 100% negative predictive value in that cohort of 101 patients that we looked at.
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Now that only represented 12 patients, so that's the problem is that if you test 100 patients, if 12 of them are negative, but all 12 of them were negative for a urine culture that was done at the same time.
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So it it basically negative nitrite and negative leukocyte est raise was 100% had 100% negative predictive value for a negative urine culture.
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So I think that the stepwise process in terms of urine testing is helpful from that perspective.
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But I think the problem is there's a very small subset of the population.
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And so really trying to limit who you even send these urine tests in in the first place is probably the biggest first challenge.
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And I think your case very clearly highlights one of the challenges in long-term care facilities and in nursing home care, which is that there may be different providers, there are different people who are caring for the patient.
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Much of the care is happening over the phone.
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So one provider one day sends the UA, and another provider the next day has to decide what to do with either the result or whether to send a urine culture, whether to prescribe an antibiotic.
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And I think that's where some of the challenges lie.
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But I completely agree that the UA does have a role and can be helpful, but it's just only helpful some of the time.
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Well, why don't we go ahead and continue with our case?
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Sounds good.
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While against your better judgment, you agree to send a urine culture in the patient that we discussed.
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You decide not to start an antibiotic, but you do recommend stopping the gabapentin.
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Two days later, the same nurse calls you to inform you that Mrs.
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S is actually looking better and seems to be back to her baseline, but her urine culture is growing greater than 100,000 E.
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coli.
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The nurse has already notified Mrs.
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S's daughter about the urine culture results.
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The daughter, quote, knew her mom had a UTI, unquote, and is asking what antibiotic you are planning to start her on.
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So I think this is raising one of the real additional challenges that come up in the care of this type of patient.
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Number one is the role that families play in the decision making, especially in a patient population that often can't advocate for themselves or communicate their own symptoms.
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And the second is the role of antibiotic treatment, and where I think it's very important to really be thinking about treating the patient, not a piece of paper or a culture result.
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So in the anecdote that we've shared, this patient actually is clinically improved.
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But I think it's very, very difficult for practitioners to see a result and decide not to treat.
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What some of the studies I've done have shown is that once that urine culture result is there, and if it's a positive result, about 95% of the time practitioners end up prescribing an antibiotic.
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So again, that raises the point about not sending urine specimens in the first place.
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But I think this challenge with how to manage both the patient and families, that results is a real one.
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So, Chris, do you have some thoughts then on how to deal with that with both antibiotic use and managing family pressure?
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Yeah, I think we've already touched on this idea of the cascade that testing sets off.
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And I've often said that once you've sent the urine culture, the horse is kind of out of the barn.
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And you've already alluded to this in the sense that 95% of the time an antibiotic will be started once you have a positive culture result.
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And there are a number of studies showing that 80% of the antibiotics initiated for treatment of suspected UTI get initiated after the urine culture results come back, which really kind of speaks to the profound influence that the positive culture has on provider decision making.
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And I think as you point out, the other kind of important influence on antibiotic decision making are provider perceptions, whether they're explicit or implied from family members for starting an antibiotic in these situations.
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And this has been shown, I think, very well in research in the pediatric population where provider perceptions about desires for antibiotics drive a lot of unnecessary antibiotic prescribing in the ambulatory setting.
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And this is a scenario that I think people in this space readily acknowledge exists, but hasn't been studied as well.
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We've done a number of studies where we've interviewed both nursing staff and providers.
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And while we were not explicitly looking for family pressure or desires, this was a pressure or factor influencing decision making both at the nursing staff and the provider level that came out unsolicited in a number of our interviews.
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And you don't have to look too hard in the literature to find a number of other papers showing that this is a prevalent influence on prescriber practice.
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And so I think this is something that we need to focus more on from a research perspective, but also need to acknowledge when we're discussing strategies and approaches to improving testing and treatment decision making in long-term care.
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And so this is something that I think segues nicely into talking about how do we start to design work systems or workflows that kind of address some of the major factors that are influencing what I think we would both agree is suboptimal prescribing decision making.
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One of the things that we've developed, not unique to our state, but certainly one that we've kind of moved into an implementation phase is this idea of standardizing the assessment of resident changing condition.
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So we're being explicit about what signs and symptoms are present.
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I think this case that we're discussing here illustrates nicely the frequency with which nonspecific geriatric symptoms are often the only trigger for suspecting urinary tract infection.
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It's important for nursing staff to be very explicit when they're doing an assessment of a resident change in condition about looking for other signs and symptoms that have greater accuracy or reliability for determining urinary tract infection.
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What I mean by that is the exam of the resident should really focus on whether there are symptoms that suggest urethral irritation, whether that be increased urinary frequencies, new onset urinary incontinence, whether the resident has fever or other vital sign of abnormalities that might suggest a systemic inflammatory response syndrome.
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And those things should be looked at or looked for explicitly.
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And if they're not present, they should be noted as a pertinent negative when relaying information to providers who are often making these decisions over the phone.
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And if you're in one of those situations where all you have is an isolated, non-specific geriatric syndrome like behavior change confusion, then it probably is very safe in those situations to delay sending a urinalysis to urine culture or starting antibiotics and observing these individuals very closely with vital sign checks and history and exams every shift to ascertain whether the resident is developing additional signs and symptoms that might support a diagnosis of UTI.
00:17:22.480 --> 00:17:32.559
But as we've already kind of discussed, these residents often have other reasons for why they've had a nonspecific geriatric manifestation like confusion.
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And in this case, clearly, I suspect in an overhanded way, we alluded to the fact that we started a new medication here that very frequently has cognitive impacts, in this case, GABAPent.
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Obviously, the resident's cognitive abnormalities that triggered a suspicion for UTI resolved with removal of the GABA pen.
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So this illustrates this idea that looking for other causes for the change and observing them without testing and treating can avoid unnecessary antibiotic use in this population.
00:18:04.400 --> 00:18:12.720
Can you speak to other factors that we commonly encounter in this population that might trigger these non-specific geriatric manifestations, Manisha?
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One of the ones I think is the most common is dehydration.
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And I think that many of these patients have a decreased thirst drive.
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For many of them, it may be difficult to ascertain whether they're dehydrated or not, but I think it's a very simple intervention in terms of rehydration, whether oral or even gentle IV hydration, which some facilities are able to do.
00:18:39.119 --> 00:18:57.680
I think that many times things like concentrated urine, change in character of the urine, smelly urine, the change in odor or color of the urine, these are things that nurses may relay to a covering provider, but in general have not been shown to be associated with true symptomatic UTI.
00:18:57.759 --> 00:19:14.400
Now, having said that, it could be there when you have a UTI, but I think that by process of elimination, you need to rehydrate a person to be able to confirm that that change is persisting or that there is some evidence of that that is still there.
00:19:14.640 --> 00:19:18.160
And this goes into the sort of stepwise protocol that you're talking about.
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I think one of the major advantages of long-term care is that there is active monitoring and the ability to see how a patient is doing over time.
00:19:26.960 --> 00:19:32.480
Things like constipation can result in symptoms, non-specific signs and symptoms.
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Depression is very common in this population.
00:19:35.359 --> 00:19:36.960
So there are many of these other things.
00:19:37.039 --> 00:19:49.119
And the unfortunate reality is that sometimes it's a lot harder to address some of these more either existential or more long-term problems than it is to just send a urine and start an antibiotic.
00:19:49.359 --> 00:19:54.319
And I think that is one of the major challenges in caring for these patients.
00:19:54.559 --> 00:20:04.240
But I think that something along the lines of rehydration, consoling families that we are actively watching and monitoring their family member.
00:20:04.400 --> 00:20:30.880
It's not that we're doing nothing, and that in the process of that, if these symptoms persist over two days, and if certainly fever or hypothermia, and sometimes people have used the 100-100-100 rule, so a temperature greater than 100, heart rate greater than 100, systolic blood pressure less than 100, or things like systolic blood pressure less than 90 or heart rate greater than 90, basically signs of hemodynamic instability.
00:20:31.039 --> 00:20:35.680
If you see evidence of that, you can always move forward with more aggressive testing.
00:20:35.839 --> 00:20:39.680
But I think that it's not that we're doing nothing in these other circumstances.
00:20:39.759 --> 00:20:42.240
And I think that's something that we have to reassure families with.
00:20:42.559 --> 00:20:44.720
Yeah, I think that's such an important point.
00:20:44.960 --> 00:20:52.160
At the end of the day, family members want to know that we're taking care of their loved one and that their loved one isn't suffering.
00:20:52.400 --> 00:21:01.759
And I think we need to do a much better job in educating family members as well as residents about the potential harms of antibiotic therapy.
00:21:01.839 --> 00:21:14.799
And as you allude to, this idea of active monitoring as demonstrating that these are the active things that we're going to be doing to monitor your mother, your father very carefully.
00:21:14.880 --> 00:21:25.440
And if anything changes or worsens in their clinical status, of course, we're going to move expeditiously and diagnose and treat a UTI if that's where the evidence is leading us.
00:21:25.680 --> 00:21:33.200
But by using this active monitoring approach, we're really kind of balancing the risks and the benefits of antibiotics much better.
00:21:33.359 --> 00:21:38.400
And by indiscriminately using antibiotics, we may actually be causing more harm.
00:21:38.640 --> 00:21:57.440
I think when we talk with family members, they're often surprised that antibiotics have harms, even in those situations where it's pretty clear that a resident has suffered a harm of an antibiotic, those effects can often be delayed by weeks or sometimes even months.
00:21:57.519 --> 00:21:59.759
And so we have to understand that sometimes.
00:22:00.079 --> 00:22:08.319
Sometimes non-medical people have a hard time drawing a line between an antibiotic and their side effects or their adverse effects.
00:22:08.480 --> 00:22:26.160
I've had a number of conversations with family members where they express surprise that that episodic C difficile that their mother had was triggered by an unnecessary ciprofloxicin prescription that was administered a month earlier for a little bit of confusion.
00:22:26.319 --> 00:22:34.079
And that often can help a provider convince family members that what we're really doing is in the best interest of their loved one.
00:22:34.160 --> 00:22:38.000
And they often become very big proponents in those situations.
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Now I think one of the things we have to be very cognizant of is that these are difficult conversations to have, particularly in the moment of a resident experiencing an acute change in condition.
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And so I think the other thing that nursing facilities and staff who are trying to make improvements in antibiotic prescribing and nursing facilities need to understand is that this is messaging that needs to be done upstream of the acute change in condition, or sometime after maybe suboptimal prescribing has occurred, kind of circling back in that situation with the family members and kind of talking about, you know, why this was probably not the best thing to do.
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And in the future, if this happens, this is what we would recommend.
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Family members have a great deal of anxiety when their loved ones are experiencing a change in condition.
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And if we go in and push hard at that time about not prescribing an antibiotic, we can often meet a lot of resistance that may be hard to overcome.
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So I think it's really important we be cognizant of the timing of those interventions and doing it up front when residents get admitted to the facility, doing it at some regular intervals, particularly with residents that have a lot of cognitive impairment and have received a lot of courses of antibiotic therapy, and doing some detailing of family members in those situations can be very beneficial.
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I completely agree, Chris.
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And I would just reiterate that I think the first time somebody's being treated for a UTI, this conversation may not make as much sense to a family member.
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But again, if this is somebody, as you said, who's had advanced dementia and maybe has had two or three episodes of quote suspected UTI over a period of time, and the family member can really now understand and see what antibiotics may or may not be doing for their loved one.
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I think this is a really appropriate time to have conversations upstream, as you said, for what the goals of care are and what the goals of infection management should be in this patient and for their loved one.
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So reassuring them that we can treat pain in other ways, that we can treat discomfort in other ways, that the goal of antibiotic therapy is really curative for infection, but that we can really align best practices of infection management with palliative care in some of these patients, and that, you know, reducing harm is just as important as treating symptoms.
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And I think that families who've gone through an episode of suspected UTI can really understand that.
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And it just goes back to your point of circling back to what are important ways to connect with the family and make them understand that we are truly caring for their loved one, that they're not being abandoned, because I think ultimately that's what they fear the most.
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Well, I think that that's a really good spot to conclude this discussion.
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I think to summarize here, I think we're both in agreement that nonspecific signs and symptoms, as well as injudicious use of urine testing and family pressures, are common triggers for overuse of antibiotics in nursing homes.
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I think we also agree that putting a focus on developing and implementing protocols that limit testing and treatment to those situations where residents have specific localizing symptoms as well as fever or other vital sign abnormalities can be an effective strategy for improving antibiotics in nursing homes, and that we really need to put some focus on educating families about the potential harms of antibiotic therapy and how using active monitoring protocols to quickly identify progression of symptoms that would lead us to a more firm diagnosis of UTI is an appropriate and effective strategy that can demonstrate that we're not doing nothing.
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We're actually providing the best care to the family member in an effort to balance the risks and benefits of antibiotic therapy.
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And then I think what you hit on there at the end about the value of having discussions of the role and purpose of antibiotics near the end of life is something that we need to be putting more focus on in nursing homes.
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Is there anything else that you'd like to add, Manisha?
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No, I think that we've had a great discussion, Chris, and I hope that people get something out of this that we really understand the challenge that patients and families and providers are faced with in distinguishing asymptomatic bacteria from symptomatic UTI.
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There's no clear answer.
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But I think what we've tried to do today is help provide a pathway of how to navigate that challenge and how to try to best care for the patients, which is ultimately our goal.
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Thank you to our speakers, Dr.
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Manita Kutani and Dr.
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Christopher Sernik for sharing your perspectives and experiences.
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Looking to expand your knowledge and infection control?
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Then join us at the Sixth International Conference on Healthcare Associated Infections at Decennial 2020.
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This conference will be held in Atlanta, Georgia, from March 26th to the 30th, and is co-hosted by FA and the CDC.
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Find out more and register at www.decennial2020.org.
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This concludes the first episode of the Infection Control in Long Term Care podcast.
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Stay tuned for our next episode Managing Multidrug Resistant Organisms in the Long Term Care Setting.
