NR 669 Week 6 Evidence and Application Example

Evidence and Application Write-Up: How Urine Cultures and Antibiotics Are Started for Suspected Urinary Infections in a Skilled Nursing Facility, Compared With the Evidence

Student Name

College of Nursing, Chamberlain University

NR 669: Advanced Nursing Role Immersion Part 3

Instructor Name

Month Day, Year

Evidence and Application Write-Up: How Urine Cultures and Antibiotics Are Started for Suspected Urinary Infections in a Skilled Nursing Facility, Compared With the Evidence

The Practice, in Operational Detail

The description below comes from six weeks of reviewing calls and orders and from watching four calls being made. When a resident's condition changes, such as new confusion, a fall, reduced eating or foul-smelling urine, the certified nursing assistant tells the floor nurse. The floor nurse assesses the resident, often checks a urine dipstick, and calls the on-call prescriber, usually by phone and often on an evening or weekend. The nurse describes the change and the dipstick result. The prescriber orders a urine culture and, in most cases, starts an antibiotic the same day. Results return in two to three days; the antibiotic is reviewed, if at all, at the prescriber's next visit.

Frequency, from the September and early October review: 17 antibiotic starts for suspected infections in six weeks, of which 11 were for suspected urinary infections. In 10 of the 11, a urine culture was sent. The most common reasons recorded for the call were confusion (6), foul or cloudy urine (4) and a fall (2).

The Question the Practice Raises

Are urine cultures and antibiotics being started for residents without urinary symptoms, in whom a positive culture is likely to be asymptomatic bacteriuria rather than infection?

Sources, With Their Settings Named

Minimum criteria for starting antibiotics in long-term care residents, from a consensus conference of long-term care infectious disease experts in North America (Loeb et al., 2001). For residents without a catheter, the criteria for a suspected urinary infection include acute dysuria alone, or fever with at least one new urinary symptom such as urgency, frequency, suprapubic pain, gross hematuria, costovertebral angle tenderness or urinary incontinence.

Surveillance definitions for long-term care, revised by a national working group (Stone et al., 2012), which are stricter and used for counting infections, not for treatment decisions.

The 2019 IDSA guidance on bacteria in the urine without symptoms, which advises against testing for it or treating it among long-term care residents, and, for residents with delirium but without local urinary symptoms or signs of systemic infection, recommends assessing for other causes and careful observation rather than antibiotics (Nicolle et al., 2019).

Distance, Measured Both Ways

Where the site departs from the evidence: of the 11 urinary antibiotic starts, 3 met the minimum criteria for initiation; 8 did not. Of the 8, 6 were started for confusion or a fall without urinary symptoms or fever, and 2 for foul or cloudy urine alone. Ten urine cultures were sent; most grew bacteria, as expected in older residents, which prescribers then took as confirmation.

Local reasons for the departure: calls happen by phone, often at night, from nurses who are worried about a resident they know well; prescribers cannot examine the resident; families often ask for a test; and there is no shared form that structures what the nurse reports.

Where the site matches or exceeds the evidence: nurses notice changes quickly, which is the point of surveillance; residents with catheters had cultures sent only with fever, consistent with the guidance; and two starts were stopped by prescribers when cultures were negative, which is good stewardship.

A Change Sized to This Place

A one-page decision aid that a nurse fills in before phoning about a possible urinary infection, structured as situation, background, assessment and request. It prompts the nurse to record whether the resident has dysuria, fever, new urgency, frequency, suprapubic pain, flank pain or new incontinence; to note whether the change could have another cause; and to ask, when no urinary symptoms are present, for observation with fluids and a recheck in 24 hours rather than a culture. It fits the existing phone call, needs no new staff and can be used on the next shift, which matters in a building where any change requiring training time competes with mandatory competencies.

The change is sized to the facility: it does not require prescribers to visit more often, does not change the laboratory process and does not ask nurses to refuse an order. It changes what the prescriber hears. A prescriber who hears that a resident has new confusion, no fever, normal fluid intake and no urinary symptoms is in a very different position from one who hears only that the urine is cloudy and the dipstick positive.

Why Not Other Changes

Requiring prescriber examination before any antibiotic: not feasible with twice-weekly visits. Stopping urine dipsticks: considered, since dipsticks are often positive in older residents without infection, but nurses rely on them and removing them without a replacement would be resisted. Educating prescribers alone: the prescribers are from an outside group and attend no facility meetings. The decision aid works at the point where nurse and prescriber already meet, the phone call.

How the Change Would Be Tested

On one long-term unit for four weeks, counting calls about suspected urinary infection, cultures sent and antibiotics started, compared with the previous four weeks. The IP would track the counts on the existing line list, so no new form is needed for measurement.

Who Would Need to Agree

Three people, each for a different part of the change, and none of them can make it work alone. The director of nursing, for nursing use and for adding the aid to the unit's call procedure; the medical director, for the prescriber group; the IP, as the person who would track antibiotic starts afterward.

What the IP and Director of Nursing Said

The IP agreed with the pattern and said it had been a concern for two years, but that raising it with an outside prescriber group had never risen to the top of a half-time list. The director of nursing worried that nurses might feel blamed. The decision aid is framed to avoid that: it gives nurses a structure for the call rather than telling them they have been calling wrongly.

What the Comparison Cannot Show

Whether any resident was harmed or helped by the antibiotics given. Eleven starts over six weeks is a snapshot, not a trend. It also cannot show what prescribers knew from the call that the record did not capture; a nurse may have described symptoms that were never written down, which the decision aid would also fix.

References

Loeb, M., Bentley, D. W., Bradley, S., Crossley, K., Garibaldi, R., Gantz, N., McGeer, A., Muder, R. R., Mylotte, J., Nicolle, L. E., Nurse, B., Paton, S., Simor, A. E., Smith, P., & Strausbaugh, L. (2001). Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: Results of a consensus conference. Infection Control & Hospital Epidemiology, 22(2), 120-124. https://doi.org/10.1086/501875

Nicolle, L. E., Gupta, K., Bradley, S. F., Colgan, R., DeMuri, G. P., Drekonja, D., Eckert, L. O., Geerlings, S. E., Köves, B., Hooton, T. M., Juthani-Mehta, M., Knight, S. L., Saint, S., Schaeffer, A. J., Trautner, B., Wullt, B., & Siemieniuk, R. (2019). Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 68(10), e83-e110. https://doi.org/10.1093/cid/ciy1121

Stone, N. D., Ashraf, M. S., Calder, J., Crnich, C. J., Crossley, K., Drinka, P. J., Gould, C. V., Juthani-Mehta, M., Lautenbach, E., Loeb, M., MacCannell, T., Malani, P. N., Mody, L., Mylotte, J. M., Nicolle, L. E., Roghmann, M.-C., Schweon, S. J., Simor, A. E., Smith, P. W., . . . Bradley, S. F. (2012). Surveillance definitions of infections in long-term care facilities: Revisiting the McGeer criteria. Infection Control & Hospital Epidemiology, 33(10), 965-977. https://doi.org/10.1086/667743