clinical focus
Antimicrobial stewardship
Over-testing for UTIs does
not benefit consumers.
By Barry Lowe
W
hat 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
36 agedcareinsite.com.au
and antibiotics given on a number of
occasions. Contributors to this included:
• C
are plan – her admission care plan
stated “test urine if unwell or complaining
of discomfort when voiding or if urine is
offensive”.
• C
are day procedure – in addition to
this, each month staff undertook routine
observations including testing her urine,
blood pressure and weight.
• S
taff 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”.
• F
amily 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.
• F
alls – following a fall, staff would
attempt to obtain a urine specimen.
• D
ehydration 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.
• D
isagreements/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:
• H
ydration/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.