Educational Module for Nursing

Assistants in Long-term Care Facilities:

Urinary Tract Infections and
Asymptomatic Bacteriuria

Minnesota Department of Health

Infectious Disease Epidemiology, Prevention, and Control Division
PO Box 64975, Saint Paul, MN 55164-0975 12/2014
651-201-5414 or 1-877-676-5414 www.health.state.mn.us
 Urinary Tract Infections and Asymptomatic Bacteriuria in LTCF Residents:
Pre-test
1. Is the following statement true or false?
Asymptomatic bacteriuria is defined as bacteria in the
urine without symptoms of UTI.
True False

2. Which of the following are risk factors for the development

of asymptomatic bacteriuria in long-term care (LTC)
residents?
a. Increased age
b. Increased number of diagnoses
c. Decreased ability to perform activities of daily living
d. Indwelling urinary catheter
e. All of the above
 UTI and Asymptomatic Bacteriuria in LTCF Residents:
Pre-test
3. Recognizing changes in resident condition is an essential
component of care for a resident with a possible urinary
tract infection. Which of the following symptoms or
conditions is not important to recognize in a resident who
may have a UTI?
a. Pain with urination or urinary urgency/frequency
b. New onset or worsening of:
• Sudden, severe confusion
• Shaking chills
• Urinary incontinence
c. Tenderness in the lower abdominal and flank areas
d. Blood in the urine
e. None of the above (all symptoms and conditions listed are
important to recognize)
 Learning Objectives
• Define these terms:
– Urinary tract infection (UTI)
– Asymptomatic bacteriuria

• Describe risk factors for UTI and asymptomatic

bacteriuria among LTCF residents
• Describe the physical and non-physical resident changes that
should be recognized and communicated
 Urinary Tract Infection (UTI)
Definition:
• A UTI is an infection in the bladder, kidney, or ureters (tubes
that connect the kidneys to the bladder) that is characterized
by bacteria in the urine (bacteriuria) and clinical symptoms
(such as painful urination, fever, etc.).
• The presence of bacteria in the urine is determined by a urine
culture.
LTCF Resident Risk Factors for Developing a UTI

• A number of factors place LTCF residents at greater risk for

infection, including individual and facility characteristics

While many risk factors cannot be changed, you can still take several actions to
reduce residents’ risk of developing a UTI
 UTI Risk Factors
Risk Factor Description Action Steps for Nursing
Increased Age Older people have weaker immune systems Increased responsibility for staff to
and are less able to fight infections adhere to Standard Precautions,
especially hand hygiene

Chronic Diabetes, heart disease, and kidney disease Increased responsibility for staff to
Disease lower a person’s ability to fight infections adhere to Standard Precautions,
especially hand hygiene
People with Alzheimer’s, Parkinson’s, or Avoid unnecessary catheterization;
cerebrovascular diseases may have a when catheters are needed, follow
complication called neurogenic bladder protocols for appropriate catheter
(nerves and muscles controlling the bladder care
are affected)
Functional Incomplete bladder emptying caused by Provide regular opportunities for
Impairment decreased mobility or other functional resident to empty bladder, assist as
impairment needed
 UTI Risk Factors, cont.
Risk Factor Description Action Steps for Nursing
Invasive Invasive devices such as urinary catheters Avoid unnecessary catheterization
devices allow bacteria and viruses to enter the body

Twisted urinary catheter tubing prevents Ensure tubing is secured properly,

urine flow into collection bag without kinks or twists, with
collection bag below bladder.
Notify nurse of tubing problems.

Follow protocols for appropriate

catheter care
Other factors Dehydration and poor fluid intake Offer fluids frequently (unless on
that promote fluid restriction)
bacterial
Prostatic hypertrophy (enlarged prostate) in Care givers should be aware of
growth in
men (sometimes referred to as “BPH”) these increased risks among elderly
urine residents
Decreased estrogen in women
Recognition of a Resident’s Change in Condition:
Physical and Non-Physical Changes

Physical Changes Non-Physical Changes

Walking Demeanor
Urination and bowel patterns Appetite
Skin Sleeping
Level of weakness Speech
Falls Confusion or agitation
Vital signs Resident complaints of pain

Communicate resident changes to the

resident’s nurse as soon as possible.
 Figure 1. Clinical Symptoms of UTI
For residents WITH For residents WITHOUT
indwelling urinary catheters: indwelling urinary catheters:
• Fever >100°F (>37.9°C) or 2.4°F
(1.5°C) increase above baseline • Acute dysuria (painful urination)
• New costovertebral angle (CVA) or
tenderness (flank pain)
• Rigors (shaking chills) with or without • Fever >100°F (>37.9°C) or 2.4°F
identified cause (1.5°C) increase above baseline
• Delirium (new onset) and at least one of the following:
• Altered mental status
New or worsening:
• Malaise
• Suprapubic pain (pain over the
• Lethargy with no other identified
bladder)
cause
• Urinary frequency or urgency
• Acute hematuria
• Urinary incontinence
• Pelvic discomfort
• Gross hematuria (blood in the
urine)
If recent catheter removal:
• Costovertebral angle (CVA)
• Dysuria
tenderness (flank pain)
• Urgent or frequent urination
• Suprapubic pain or tenderness
 Laboratory Testing for UTI
Most UTIs result from bacteria present close to the urinary
opening, where they can gain entry to the bladder. The
most common organisms found in urine are:
• Escherichia coli (E. coli) • Klebsiella pneumoniae • Proteus mirabilis
• Enterococci • Streptococci (Group B) • Candida

When should a urinalysis (UA) or urine culture (UC) be

performed?
• Symptoms of UTI should be present before nurses request a urinalysis
or culture

Bacteria in the urine without signs and symptoms of infection is not a

UTI and does not require an antibiotic prescription
 Laboratory Testing for UTI, cont.

Accurate lab results are only possible if the urine specimen

is collected using appropriate techniques that prevent
contamination of the specimen. These include:
– Clean catch collection , based on facility protocol (assist resident
as needed)
• Wipe from the urinary opening toward the anus with towelettes
• Mid-stream urine

– Bladder catheterization (from sterile port of indwelling catheter)

• If catheter has been in place for more than 14 days, specimen will
likely show the presence of bacteria growing inside the catheter;
results will be more meaningful if specimen is collected from
newly placed catheter, if catheter is still needed
• Discuss with resident’s nurse
 Laboratory Testing for UTI, cont.

• Collect a urine specimen before giving antibiotics. A urine

culture may be falsely negative if the specimen is collected
after antibiotics have been started.
– Talk to the nurse to make sure steps are completed in the right
order

• UA or UC should only be performed on residents with signs or

symptoms of a UTI in order to:
– Confirm the presence and type of bacteria
– Determine which antibiotics will kill the bacteria
 Treating UTI

The Society for

Healthcare Epidemiology
in America (SHEA) has
guidelines to help
providers decide when
antibiotics should be
started to treat UTI in
residents of LTCF
 Preventing UTI in LTCF Residents
• Use Standard Precautions when caring for all residents
– Wear gloves when there is potential for having contact with blood, body
fluids, secretions or excretions (including contact with urine, feces and
genital mucous membranes)

– Wear gowns when there is potential for clothing to become

contaminated by splashing or contact with blood, body fluids,
secretions or excretions, regardless of the resident’s multidrug resistant
organism (MDRO) status.

– Always clean your hands

• Before touching a resident; putting on gloves; performing a
clean/aseptic procedure; and
• After blood, body fluid exposure; removing gloves; touching a
resident or his or her surroundings
 Preventing UTI in LTCF Residents
• Increase hydration in residents at high risk for UTI
– Check with the resident’s nurse to make sure he or she is not on a
fluid restriction
• Prevent fecal soiling
– Offer regular opportunities for toileting
– Regularly check for soiling in incontinent residents
• Encourage frequent bladder emptying by offering assistance
with/providing toileting opportunities
• Ensure proper perineal and catheter care is provided
– Wipe front to back to prevent contamination of urethra with fecal
bacteria
 Asymptomatic Bacteriuria

• Asymptomatic bacteriuria (ASB) means there are bacteria in

the urine without symptoms of UTI.

• ASB is very common and considered a harmless condition

among LTCF residents.

• Routine testing for bacteriuria among LTCF residents is not

recommended
 Prevalence of Asymptomatic Bacteriuria
• Many LTCF residents without indwelling urinary catheters
have bacteria in their urine (bacteriuria)

• Nearly 100% of LTCF residents with an indwelling urinary

catheter have bacteria in their urine

• 98% of LTCF residents with bacteriuria do not have clinical

symptoms
Prevalence of Asymptomatic Bacteriuria, cont.

Table 2. Prevalence of Asymptomatic Bacteriuria

Group Prevalence
Pre-menopausal women 1 – 5%
Post-menopausal women 2.8 – 8.6%
Pregnant women 1.9 – 9.5%
Elderly females in LTCF 25 – 50%
Elderly males in LTCF 15 – 40%
Short-term catheter 9 – 23%
Chronic indwelling catheter 100%
 Risk Factors for Asymptomatic Bacteriuria
among LTCF Residents

• Indwelling catheter

• Increased:
– Age
– Number of diagnoses
– Number of medications

• Decreased:
– Ability to perform independent activities of daily living (ADLs)
– Mental status
– Independent mobility
– Overall health status (self-rated)
 UTI and Asymptomatic Bacteriuria FAQs
Do nonspecific behavioral and mental status changes mean
a resident has a UTI?

• There are many myths about what symptoms indicate a UTI

• The following symptoms should be evaluated but current
guidelines do not link these symptoms to a UTI that needs
antibiotic treatment:
– Chronic incontinence (during sleep or when awake, when coughing or
sneezing)
– Anorexia (loss of appetite)
– Difficulty falling asleep or staying asleep
– Fatigue
– Malaise (a generalized feeling of discomfort, illness, or lack of well-
being)
– Weakness
– Mental status change
– Fall
UTI and Asymptomatic Bacteriuria FAQs, cont.

Does the presence of pyuria (pus in the urine) mean a

resident has a symptomatic UTI?

• No, the presence of pyuria alone does not mean that the
person has a symptomatic UTI.

• Pyuria is considered an immune response to the presence of

bacteria in the urine.

• Pyuria without symptoms should not be treated with

antibiotics.
– Treatment decisions must be made by a provider
UTI and Asymptomatic Bacteriuria FAQs, cont.

Does foul-smelling urine mean a resident has a UTI?

• A resident’s urine can smell foul for several reasons, including

dehydration, diet, medication, or the presence of specific
bacteria.

• Foul-smelling urine without clinical symptoms of a UTI does

not indicate the presence of a UTI and does not require
antibiotics.
– Treatment decisions must be made by a provider
UTI and Asymptomatic Bacteriuria FAQs, cont.
Are antibiotics needed to treat a UTI?

• Symptomatic UTI should be treated with antibiotics.

• Residents with asymptomatic bacteriuria generally should not

be treated with antibiotics.
– Treatment decisions must be made by a provider
UTI and Asymptomatic Bacteriuria FAQs, cont.
Does it matter if asymptomatic bacteriuria is treated
with antibiotics?
• Yes! Antibiotics should only be given for bacterial infections
– Treatment decisions must be made by a provider

• Inappropriate antibiotic use can lead to antibiotic resistance

• Infections caused by antibiotic-resistant bacteria can be:

– More severe
– Require more powerful and toxic antibiotics
– Can lead to secondary infections, longer hospital stays, and
increased healthcare costs
 UTI and Asymptomatic Bacteriuria FAQs, cont.
Does it matter if asymptomatic bacteriuria is treated with
antibiotics?
• Antibiotics can cause bad reactions and side effects, including:
– Allergic reactions, rashes, harmful drug interactions
– Disruption of normal flora
• Clostridium difficile diarrhea
• Yeast infections
– Increased future infections with resistant bacteria
• Due to the potential of adverse drug reactions or development
of antibiotic-resistant super-infections, inappropriate antibiotic
prescribing can result in increased mortality

Not only do residents not benefit from having asymptomatic bacteriuria

treated with antibiotics, doing so may actually cause harm.
 UTI and Asymptomatic Bacteriuria FAQs, cont.
Should prophylactic antibiotics be given to prevent a UTI
in residents with asymptomatic bacteriuria?
• Antibiotics should not be given to prevent a UTI in LTCF
residents, unless it’s prior to a surgical urinary tract procedure
or if the resident is pregnant.
– Treatment decisions must be made by a provider
Do cranberry juice and other cranberry products prevent
UTI?
• There are no clear data to indicate that cranberry juice
prevents UTI, but if not otherwise restricted, there is no
reason not to give cranberry juice to residents. Check with the
resident’s nurse to make sure it’s ok to provide cranberry juice
to a resident.
 Glossary, part 1
Antibiotic resistance - The ability of bacteria to change so that they
develop the ability to survive when exposed to antibiotics that are
intended to kill them.

Asymptomatic bacteriuria - Presence of bacteria in urine without signs

or symptoms of UTI

Bacteremia - Bacteria in the blood

Bacteria - Bacteria are single-celled life forms. Bacteria are present in

soil, water, and all living organisms. Many disease-causing organisms are
bacteria; however, not all bacteria cause disease. Some bacteria are
necessary for essential functions like digestion.

Colonization - Bacteria are present without causing disease

 Glossary, part 2

Costovertebral angle (CVA) tenderness - Pain near the ribs and

thoracic vertebrae (sometimes called ‘flank pain’)

Cystitis – Infection of the urinary tract that is limited to the bladder,

usually involving only the mucosal surface. This is the infection that
most people think of when they say “UTI.” A more common term
would be “bladder infection”.

Delirium – Sudden, severe confusion. An altered state of

consciousness, consisting of confusion, distractibility, and
disorientation.

Dysuria – Difficulty or pain with urination

Hematuria - Blood in the urine

 Glossary, part 3
Infection - The presence and multiplication of microorganisms (germs)
that are causing symptoms (fever, redness, wound drainage). Infection
generally implies that the person has signs or symptoms of a disease.

Pyelonephritis - Infection of the kidney usually resulting from travel of

the infection from the bladder to the ureter (the tube connecting the
bladder and kidney) and then to the kidney. This infection is commonly
referred to as a kidney infection.

Pyuria - Presence of white blood cells or pus in the urine

Rigors - Shaking chills

Suprapubic pain – Pain in the lower abdominal region

 Glossary, part 4
Urinary incontinence - Involuntary excretion of urine from one's body. It
is often temporary, and almost always results from an underlying
medical condition.

Urinary tract infection (UTI) - An infection of the urinary tract (bladder,

kidney, ureters, urethra (the tube that releases urine from the body))
that is characterized by bacteriuria and symptoms.

Urosepsis - Sepsis occurs when bacteria enter the blood stream and lead
to a widespread infection – urosepsis means the infection has stemmed
from an infection of the urinary tract.

Virus - A submicroscopic (very small) particle that can reproduce only if

it’s inside the cell of a living organism. Viruses cannot be killed by
antibiotics.
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 References, part 2
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 References, part 3
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 References, part 4

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