What if changes to policies, procedures and culture in long-term aged care could reduce unnecessary antibiotics and improve consumer care and antimicrobial stewardship in the future?
Many consumers of long-term care are prescribed antimicrobials that are for unconfirmed infections. Urinary tract infection is one of the most frequent reasons for receiving antibiotics. Yet bacteria can and do live in the bladder of many women without causing symptoms (asymptomatic bacteriuria occurs in up to 50 per cent of older women) and these women do not benefit from receiving antibiotics.
An older woman admitted to an aged care home with impaired mobility, increased short term memory loss, incontinence (urinary and faecal) and past history of urinary tract infection had her urine tested and antibiotics given on a number of occasions. Contributors to this included:
- Care plan – her admission care plan stated “test urine if unwell or complaining of discomfort when voiding or if urine is offensive”.
- Care day procedure – in addition to this, each month staff undertook routine observations including testing her urine, blood pressure and weight.
- Staff culture – her family reported that she was grieving and “teary and snappy” soon after admission and staff suggested she may have a UTI and tested her urine with a comment “that is the first thing we generally test when residents are increasingly angry and teary”.
- Family prompting – family learn from past behaviour of staff. Progress notes indicate that there were several requests from various family members to test her urine for infection when she seemed confused.
- Falls – following a fall staff would attempt to obtain a urine specimen.
- Dehydration and confusion – many of her ward urinalysis’ specific gravity results were elevated suggesting she may have been dehydrated. Dehydration may have been the cause of the confusion or a result of the confusion.
- Disagreements/agitation – ward urinalysis was attempted when agitation seemed worse. On one occasion staff continued to attempt to obtain a specimen over a week even though her agitation had abated.
- “Test for cure” following antibiotic treatment for suspected UTI, dipstick urinalysis was undertaken on several occasions when she no longer had symptoms.
On only one occasion did she have symptoms of dysuria. Most testing occurred when she was confused without other specific signs and symptoms of a urinary tract infection.
When there was a positive result from a ward urinalysis the next step was to collect a clean catch urine specimen and urine cultures showed growth of organisms several times during her admission and she was treated with antibiotics.
Over time the frequency of urine testing became less frequent due to:
- Hydration/staff assistance – as her health and abilities deteriorated, staff were requested to assist, supervise and encourage her to complete all her meals and drinks. This enhanced support led to less confusion and less signs and symptoms of a urinary tract infection. It is hypothesised that she was less prone to dehydration when she was fully supported with her food and fluid intake.
- Plan of care changes – over time her plan of care changed to “cognitive issues to be managed with a gentle approach, reassurance etc.” with no direction to test urine when unwell as previously directed.
- Organisational policy changes – the policy to routinely test urine was reviewed and removed.
Frequent testing and administration of antibiotics for asymptomatic bacteriuria can cause side effects for the consumer being treated. The use of antibiotics also increases the risk of antibiotic resistance, with resistant bacteria able to be transmitted to other consumers and staff.
Some other implications identified in this case history include:
- Potential for missed diagnoses – dehydration and other causes for confusion could be missed.
- Resident, family distress – sometimes an in/out urinary catheter was inserted to obtain the urine sample. For this consumer, who had a very private nature and strong catholic faith, the loss of dignity and modesty during an in-out catheter procedure is likely to have been distressing for her. Furthermore there is the potential for the introduction of infection during this procedure.
- Increased workload for the staff – staff were required to undertake/assist not only the urine specimen but also extra documentation, liaise with the general practitioner and pharmacy (when antibiotics were prescribed) with extra visitation time and workload required from the GP.
- Cost to service and health system – the cost to the health care system includes the cost of extra care provision, the cost of equipment required for the collection (dipsticks, specimen containers, bed pan, and in-out catheters) plus pathology costs and costs of the antibiotics.
Diagnosis of a UTI in older women with dementia and non-specific symptoms can be demanding and a challenge. When chronic urinary incontinence, nocturia, increased frailty or a general sense of lack of wellbeing is present, routine urine studies are not recommended. A persistent change in behaviour and a change in the characteristics of their urine which is not responsive to other interventions (e.g. rehydration) suggests the need for further investigation.
For this consumer antibiotics did not improve her incontinence or other symptoms which is suggestive that she had asymptomatic bacteriuria rather than a UTI.
Changes to policies, procedures and culture in long term aged care may reduce testing for UTI, resulting in reduced unnecessary antibiotics and improved consumer care and antimicrobial stewardship in the future.
It is important to assess consumers using validated criteria and treating a validated infection using Australian therapeutic guidelines.
Barry Lowe is the lead nurse – antimicrobial stewardship at Southern Cross Care (SA & NT) who has been seconded to the Drug and Therapeutics Information Service (SAHLN).
Sue Edwards, BPharm, is a Clinical pharmacist at Drug and Therapeutics Information Service (DATIS).Do you have an idea for a story?
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