U

rinary tract infection (UTI) is the most common infection found in extended care facilities. Prevention of UTIs in the incontinent resident can be difficult due to predisposing factors, such as neurogenic bladder, fecal incontinence, inadequate fluid intake, suppressed immune system, or advanced age to name a few (see Table 1). Because of these conditions, a facility-wide commitment must be made to follow the A-B-Cs of UTI prevention: Assemble policies and procedures in accordance with standards of care; Build staff competencies; and Collect and analyze data.

Assemble Policies and Procedures
       The first step in effective UTI prevention is to assemble policies and procedures in accordance with standards of care. The interdisciplinary team (i.e., nursing, dietary, environmental services, etc.) should have written infection control policies and procedures. Major areas of concern should be policies and procedures for perineal care of incontinent residents including residents with indwelling urinary catheters. Appropriate indwelling catheter utilization, hand hygiene, disinfection of patient care items, strategies for UTI prevention, early detection and management of UTI, and monitoring and tracking of UTIs through an infection control program are also areas that require effective policies and procedures.

Build Staff Competencies
       Prevention plays a key role in the limitation of UTIs in extended care facilities. Many preventive strategies are suggested in Table 2, but the most effective approach is thorough handwashing. Facility-wide campaigns to encourage hand hygiene can improve poor adherence. Although disconcerting to many facilities, these campaigns should be repeated regularly. Ring wearing can reduce the effectiveness of hand hygiene and should be discouraged.Hand disinfection with the use of antiseptic, alcohol-based hand-rub solutions is more effective in reducing hand contamination and encouraging compliance than handwashing with soap and water. The Centers for Disease Control and Prevention (CDC) published hand hygiene guidelines, which are available at http://www.cdc.gov/handhygiene/.
       When instructing staff on issues related to UTIs, an understanding of some general principles and definitions is essential.
       Older adults often do not present with the classic symptoms of UTI—dysuria (painful voiding), urgency, and frequency. Staff must be attuned to subtle variations in a resident’s condition indicative of UTI, such as changes in mental status, decline in physical function, new onset of incontinence, decreased appetite, somnolence, and mild fever.[5,6] Although fever in a younger adult is defined as greater than 101°F, this is not true for the elderly. Studies of fever in the elderly advise that an elevation of the resident’s temperature over baseline of 2°F (-16.6°C) or an oral temperature of greater than 100°F (37.8°C) should be evaluated for infection.[7] Adding to the difficulty of identifying a UTI in the elderly is that fever, the cardinal sign of infection, may be absent 20 to 30 percent of the time.[3]
       The complexity of identifying a UTI in the elderly is further aggravated by the phenomena of asymptomatic bacteriuria, or colonization, characterized by greater than 105 colony-forming units (CFU)/mL without dysuria, urinary frequency, incontinence of recent onset, flank pain, fever, or other signs of infection during the week preceding the time the urine sample was obtained. About half of women and one third of men in nursing homes have bacterial colonization of the urinary tract. Treating asymptomatic bacteriuria does not affect morbidity or mortality; it only increases the likelihood of organisms resistant to antibiotic therapy. Asymptomatic bacteriuria does not require antibiotics.[5,6]
       Bacteria in urine with associated symptoms is considered symptomatic bacteriuria or symptomatic UTI. UTIs are often classified as upper and lower tract infections. Cystitis, infection of the bladder, is an example of a common lower tract infection. Pyelonephritis is the chief upper tract infection and involves infection of the kidney structures.[5,6]
       In order for a resident to be diagnosed with symptomatic bacteriuria, one of the following criteria must be met:
1. The resident does not have an indwelling urinary catheter and has at least three of the following signs and symptoms: fever (>38°C) or chills; new or increased burning pain on urination, frequency, or urgency; new flank or suprapubic pain or tenderness; change in character of urine (e.g., new bloody urine, foul smell, or amount of sediment); worsening of mental or functional status (may be new or increased incontinence)
2. The resident has an indwelling catheter and has at least two of the following signs or symptoms: fever (>38° C) or chills; new flank or suprapubic pain or tenderness; change in character of urine (e.g., new bloody urine, foul smell, or amount of sediment); worsening of mental or functional status.[8]
       Persistence of bacteria implies the continued presence of the same infecting microorganisms isolated at the start of treatment. This can be caused by several factors, including an underlying structural or functional abnormality, bacterial resistance, inadequate drug dosage, or poor patient compliance.[5]
       Recurrent infections are classified as either relapse or reinfection UTI. Relapse refers to consecutive urinary tract infections caused by the same bacterial strain in urine that was rendered as partially or temporarily sterile by antibiotic therapy, which generally occurs within two weeks of completion of therapy. Reinfection UTI is defined as an infection that arises four weeks after the previous infection has been cured. The bacterial strain is often different from the strain that caused the successfully treated prior infection. Prophylactic antimicrobial therapy is the use of antimicrobial drugs for the prevention of reinfection of the urinary tract. It assumes that bacteria have been completely eliminated before the initiation of prophylaxis.[5]

Collect and Analyze Data
       The facility should track and monitor residents with infections and those with early signs and symptoms of infection. In 1997, the Society of Healthcare Epidemiologists of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC) published a position paper on infection control in long-term care facilities. This paper recommends components of an infection control program in long-term care and can be accessed at http://www.shea-online.org/pdfs/IC-LTCF97.PDF.
       The infection control program may be incorporated into the facility’s quality assurance program. In addition to components outlined by SHEA and APIC, facilities should conduct ongoing monitoring activities to assure compliance to policies and resident’s plan of care. Examples of quality assurance studies include but are not limited to bedside observation of all direct care staff responsible for providing catheter care to assure skills are current and competent; walking rounds to assure fluids are available, accessible, and offered routinely; observation of the frequency and quality of hand hygiene; and examination of resident care to verify interventions are provided as outlined by the interdisciplinary care plan.

Conclusions
       Urinary tract infection is the most common nosocomial infection in extended care facilities. Because of the impact on the resident’s morbidity, mortality, and quality of life, all members of the healthcare team should collaborate to implement preventative strategies into routine, daily care. These strategies will reduce the incidence of infection, improve the quality of care within the facility, and enrich the quality of life for the resident.