Proper Treatment of UTIs Often Eludes Nursing Homes, Hospitals

April 21, 2021
Frank Diamond

Investigators University of Michigan-Flint, School of Nursing noted that the Cooper Tool and the Stone criteria are similar but use different methods to arrive at a UTI diagnosis.

When nursing home (NH) residents are hospitalized, they are often treated for urinary tract infections (UTIs) at the hospital before they’re sent back to the NH. That can cause a disconnect when it comes to treatment, according to a retrospective cohort study in the American Journal of Infection Control (AJIC).

“A variety of guidelines are used with NH residents and hospitalized patients for many common diagnoses and treatments,” conclude investigators with the University of Michigan-Flint, School of Nursing. “However, data on hospital use of guidelines specifically designed for NH residents is lacking.”

The COVID-19 pandemic highlighted serious problems at NHs and other long-term care facilities (LTCFs). The disease took advantage of systemic problems at LTCFs. For their part, NH officials early on in the pandemic agreed with that assessment, saying that lack of funding compared to hospitals and other health care facilities prevented them from beating back the disease. That lack of funding prevents many LTCFs from keeping a fulltime infection preventionist (IP) on staff, something that the Association for Professionals in Infection Control and Epidemiology (APIC)lobbies for. (Until the cavalry and money arrives, however, there are cost-effective and innovative ways LTCFs can battle COVID-19 and other infections, as Infection Control Today® reported.)

Investigators in the AJIC study compared two techniques for diagnosing UTIs: the Cooper tool, and the Stone criteria. They wanted to “retrospectively determine whether hospitalized NH residents were appropriately diagnosed and treated for UTIs when comparing the Cooper Tool and Stone criteria. By comparing the Cooper Tool with the older, more recognized, Stone criteria, we hoped to gain a clear understanding of diagnostic agreement with NH residents transferred to the hospital.”

Investigators noted that the Cooper Tool and the Stone criteria are similar, but use different methods to arrive at a UTI diagnosis. “Cooper requires two or three signs and symptoms and an algorithm to guide the user toward or against urine testing,” the study states. “The Stone criteria requires a variable level of signs and symptoms depending on which symptoms the resident presents with, making it more intricate and less intuitive for the user.”

The data were collected from 3 nursing homes in southeast Michigan that had a total of 427 beds from June 2016 to June 2019. The persons in the study resided in the nursing home for 30 days or more. During that period, 621 NH residents were sent to hospitals and then transferred back to the nursing homes, with 79 having been diagnosed and treated for UTIs at the hospital. Nine of the 79 residents (11.4%) were appropriately treated using the Stone criteria, while 11 of the 79 residents were appropriately treated using the Cooper Tool.

The study states that “there was not a statistically significant difference in the proportion of those who were or were not treated appropriately when analyzed using the Cooper tool and Stone criteria.”

Less than one third of the charts for the 79 residents contained urinalysis results. No urinalysis was ordered for a UTI diagnosis in some cases. “With both Cooper and Stone, the results indicated that a high percentage of UTIs were not appropriately diagnosed or treated,” the study states. “Statistically, both Cooper and Stone showed a moderate level of agreement and no statistical difference in the assessment of appropriateness of treatment.”

For non-catheterized patients, the 2 methods agreed 100% of the time. The Cooper Tool is easier for health care professionals to understand and use than the Stone criteria, and that suggests that it would be used more often.

“Appropriate treatments were seen more frequently with catheterized residents with both Cooper and Stone, a finding that could be related to the fact that such residents require fewer signs and symptoms to meet the diagnostic criteria,” the study states. “For example, of those with a catheter, only mental status change, functional status change or fever are required by Stone to meet sign and symptom criteria. These three signs and symptoms were the most documented in this study.”

UTIs continue to be one of the biggest problems in nursing homes, with UTIs accounting for about 20% of infections at LTCFs, according to the Centers for Disease Control and Prevention (CDC). One of the problems associated with UTIs is that nursing home care often centers on using antibiotics, often inappropriately. (It should be noted that hospitals often inappropriately prescribe antibiotics for UTIs, so much so that the CDC recently launched an effort to cut down on such overprescribing by 90% by 2025.)