Supported by AMDA — The Society for Post-Acute and Long-Term Care Medicine, an effort to improve the diagnosis and treatment of uncomplicated bladder infections in noncatheterized long-term care facility residents is progressing. The results of the 12-month intervention trial are nearing publication, and a tool kit is available on the Society’s website (https://paltc.org/content/iou-toolkit
) to cover both diagnosis and empirical therapy for uncomplicated urinary tract infection (UTI).
The consensus recommendations for empirical therapy of uncomplicated cystitis — part of the Improving Outcomes of UTI Management in Long-Term Care (IOU) project/study — were published in JAGS in March (J Am Geriatric Soc 2019;67:539–545), just as urinary tract infections were again a topic of discussion at the Society’s annual conference.
“There are a lot of guidelines out there for diagnosis of UTI overall,” David Nace, MD, MPH, CMD, director of long-term care and flu programs at the University of Pittsburgh School of Medicine and a leader of the IOU project, said in an interview. “But there haven’t been any guidelines specific to simple bladder infections in nursing home patients.”
The expert panel of clinical pharmacists agreed that the preferred drugs for empirical treatment of uncomplicated cystitis are nitrofurantoin and trimethoprim/sulfamethoxazole (TMP/SMZ). Both drugs are effective against most cases of Escherichia coli and Klebsiella spp, which together account for over 80% of urinary tract infections in nursing homes. TMP/SMZ is more active against Proteus, and nitrofurantoin is preferred when treating Enterococcus infections, the guidelines note.
Nitrofurantoin (with a maximum recommended dosing of 100 mg twice a day) used to be discouraged in older adults, but it is no longer on the American Geriatric Society’s Beers Criteria and can be used safely in those with a creatinine clearance of 30 mL/min or higher.
“You wouldn’t use it for complicated infections, but for simple infections it’s a go-to drug,” said Dr. Nace, who also is chief of medical affairs at UPMC Senior Communities. “As of recently, [we know] it can be used with relatively little development of resistance. And it’s much safer in terms of adverse drug events than ciprofloxacin.”
For those with a creatinine clearance lower than 15 mL/min — less than 15% to 17% of the typical nursing home population, Dr. Nace said — ciprofloxacin (250 mg twice a day) or fosfomycin (3 g once) are the recommended drugs of choice.
The IOU project’s guidelines for empirical therapy were developed — as was the project’s diagnostic algorithm — through a literature review and a Delphi process for consensus building. Although the 19-member panel of clinical pharmacists reached a consensus on treatment choice, dosing, and drug–drug interactions to avoid, it failed to reach consensus on one area: the optimal duration of treatment, especially for men.
“The panel felt really strongly that you don’t need 10 days [of treatment] in men, but they didn’t feel comfortable with three to five days,” said Dr. Nace. “So we [operationalized] the definition to fall in the middle, at seven days for men.”
For women, the recommended duration of anti-infective treatment is three days. And in either men or women, consideration of a five-day course of nitrofurantoin is “reasonable,” the recommendations note, given that there are fewer data available than with the other drugs. “It looks, at this point, like [effectiveness] may be more dose related — a matter of getting an adequate dose — than related to duration,” Dr. Nace told Caring.
The guidelines are meant for empirical treatment pending culture results. Clinicians should reassess a patient’s progress along with antibiotic appropriateness once the culture results and sensitivities are known. And in choosing an initial empirical antibiotic therapy, clinicians should be attentive to resistance patterns in the facility as well as to disease severity, recent antibiotic use, and/or prior history of antimicrobial resistance in an individual patient, the guidelines say.
In a session on UTIs at the Society’s conference, Muhammad Salman Ashraf, MBBS, of the University of Nebraska Medical Center, shared similar advice. He urged clinicians to consider the results of cultures performed in the past six months to two years — and to look at a facility-specific antibiogram when culture results aren’t available — when choosing an empirical treatment.
In general, he told Caring later, the IOU project’s recommended durations for antibiotic treatment of uncomplicated cystitis will be adequate. However, reevaluation at 48 to 72 hours (an “antibiotic time-out”) is still important. “If on the third day of a recommended course of antibiotic the resident is not getting better and still has symptoms, we will have to reconsider the diagnosis or the antibiotic choice,” Dr. Ashraf said.
The IOU project’s diagnostic guidelines were published in JAMDA last year (J Am Med Dir Assoc 2018;19:765–769) and focus on whether residents have simple cystitis or not. “This is where most of the mistakes are being made — in distinguishing asymptomatic bacteria from a potential uncomplicated infection,” Dr. Nace said.
The IOU project has been supported by a grant from the Agency for Healthcare Research and Quality (AHRQ) and has been a collaborative effort between the University of Pittsburgh, the University of Wisconsin, and the Society. Its tools — the diagnostic and treatment guidelines as well as an order set for suspected UTI, case vignettes, and other elements — have been tested in a 12-month soon-to-be-published controlled intervention study.
Christine Kilgore is a freelance writer in Falls Church, VA.