Reference Article

UTIs What are the signs / symptoms of a Urinary Tract Infection?

Criteria for a UTI C/W CDC & adapted from McGeer criteria At least 1 of the following signs/ symptoms: Acute dysuria or pain, swelling or tenderness of testes, epididymis or prostate Fever or leukocytosis + at least 1 of these localizing criteria: Acute CVA Pain or Tenderness Suprapubic Pain Gross Hematuria New or marked increase in incontinence New or marked increase in urgency New or marked increase in frequency If no fever or leucocytosis, 2 or more from items ii – vi, above, are documented Note: Does not include change in behavior, urine odor or color, or appearance of sediment in urine

UTI Cheat Sheet

Asymptomatic Bacteriuria Isolation of >100,000 bacteria in an appropriately collected urine specimen from an individual without symptoms or signs of a UTI

Asymptomatic Bacteriuria In nursing homes at any given time, 50+% of women and 15-40% of men have asymptomatic bacteriuria1 Antimicrobial treatment has not been shown to be of benefit. 191 nursing home residents with incontinence and bacteriuria were randomly assigned to immediate or delayed treatment. Eradicating bacteriuria had no short-term effects on severity of chronic urinary incontinence and bacteriuria tends to recur after therapy with emergence of antibiotic resistance2 1 Nicolle, LE. Asymptomatic bacteriuria in the elderly. Infect Dis Clin North Am 1997; 11:647 2 Ouslander, JG, et al. Does eradicating bacteriuria affect severity of chronic urinary incontinence in nursing home residents? Ann Intern Med 1995; 122:749

Asymptomatic Bacteriuria 50 elderly, LTC women with asymptomatic bacteriuria randomly assigned to receive antibiotics for all episodes of bacteriuria or no therapy unless symptoms developed for 1 year3 Only 5 of 50 went >6 months with no bacteriuria Of those on no therapy, 71% had persistent invasion with the same organism Antimicrobial therapy was associated with approximately: Twice the number of reinfections 10 X the number of adverse antimicrobial drug effects Isolation of increasingly resistant organisms No differences in cause-related morbidity or mortality were observed between the groups… thus the Recommendation is for: No therapy for asymptomatic bacteriuria 3. Nicolle, L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med 1987; 83:27

UTI Studies in Denver LTC 2013-14: Retrospective cohort chart review study Setting: 6 Denver nursing homes* *All are facilities where Dr. Gahm is medical director and had done a UTI Inservice since 2011 NH # Beds Of 5-Star Rating A 110 3 stars B 95 2 stars C 120 4 stars D 60 5 stars E 155 F 75 -looked at differences between facilities, if they look any worse -full analysis*

Results 115 Charts Identified with Treated UTIs Only 30 of 115 met McGeer Criteria (26%) Average Treatment Duration 7.3 Days (3-17 days)

CAUTI Cheat Sheet

Clinical Characteristics, Diagnostic Evaluation, and Antibiotic Prescribing Patterns for Skin Infections in Nursing Homes Norihiro Yogo, Gregory Gahm, Bryan C Knepper, William J Burman, Philip C Mehler, Timothy C Jenkins

Methods Retrospective cohort study 2013 -2014 12 NHs in Denver metro area New start of antibiotics for skin infections 135 cases reviewed – 100 included, 35 excluded

Results Anti-MRSA Rx in 28 though purulent infections were uncommon Antibiotics started by call from nurse: 52 Patient not evaluated by a provider within 48 hours: 41 Did not meet minimum criteria for start of antibiotics*: 24 44% had no documentation of an infection; 56% had no documented physical examination Total duration of therapy, median days: 7 (7-10) Anti-MRSA Rx in 28 though purulent infections were uncommon 43 received treatment of ≥ 10 days (14’ skin infection guidelines recommend 5 days for most) *New or increasing purulent drainage; or at least 2 of the clinical features of fever, redness, tenderness, warmth, or new or increased swelling of the affected site [Loeb et al, ICHE. 2001]

SSTI Cheat Sheet

URIs Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected. If you suspect Strep, do a rapid strep before starting antibiotics!

Eye & GI Cheat Sheet

Pneumonia Cheat Sheet

LRTI Cheat Sheet

Gregory Gahm, MD ggahmmd@gmail.com