Urinary Tract Infections in Pennsylvania Long-Term Care Facilities: An Epidemiological Study From 2016 Through 2020
Keywords:healthcare-associated infection, HAI, long-term care, urinary tract infection, SUTI, CAUTI, Proteus, fluoroquinolone, antibiotic stewardship
Urinary tract infections (UTIs) are common healthcare-associated infections (HAIs) in older adults that live in long-term care (LTC) facilities. A query of the Pennsylvania Patient Safety Reporting System (PA-PSRS) found that symptomatic UTI (SUTI) and catheter-associated UTI (CAUTI) rates increased from 2016 and peaked in the second quarter of 2020. Although the number of urinary catheter days reported by LTC facilities has trended downward from 2016 to the beginning of 2020, the urinary catheter utilization rate increased slightly in the second quarter of 2020. We also examined various epidemiological factors. An average of 47.6% of SUTIs and 32.3% of CAUTIs were associated with E. coli from 2016 through 2020. However, the percentage of CAUTIs associated with E. coli decreased while the percentage of CAUTIs associated with organisms of the tribe Proteeae (Proteus, Providencia, and Morganella genera) increased from 2016 through 2020. Furthermore, the percentage of CAUTIs associated with carbapenem-resistant Enterobacterales (CRE) and organisms producing extended-spectrum beta-lactamases (ESBL) also increased, while the percentage of CAUTIs associated with vancomycin-resistant Enterococci (VRE) decreased from 2016 through 2020. An average of 38.5% of SUTIs and 41.5% of CAUTIs were reported to be treated with fluoroquinolones from 2016 through 2020. However, the percentage of both SUTIs and CAUTIs treated with fluoroquinolones decreased from 2016 through 2020, while an increasing percentage of both SUTIs and CAUTIs was reported to have been treated with cephalosporins and carbapenems from 2016 through 2020. Thus, to promote resident safety, we use these epidemiological trends to better understand current risks for residents and to further guide development of best practices for prevention, identification, and treatment of UTIs as well as to advance antibiotic stewardship practices.
Kistler CE, Zimmerman S, Scales K, Ward K, Weber D, Reed D, et al. The Antibiotic Prescribing Pathway for Presumed Urinary Tract Infections in Nursing Home Residents. J Am Geriatr Soc. 2017;65(8):1719-25. doi: 10.1111/jgs.14857.
Ryan S, Gillespie E, Stuart RL. Urinary Tract Infection Surveillance in Residential Aged Care. Am J Infect Control. 2018;46(1):67-72. doi: 10.1016/j.ajic.2017.07.002.
Tsan L, Davis C, Langberg R, Hojlo C, Pierce J, Miller M, et al. Prevalence of Nursing Home-Associated Infections in the Department of Veterans Affairs Nursing Home Care Units. Am J Infect Control. 2008;36(3):173-9. doi: 10.1016/j.ajic.2007.06.008.
Tsan L, Langberg R, Davis C, Phillips Y, Pierce J, Hojlo C, et al. Nursing Home-Associated Infections in Department of Veterans Affairs Community Living Centers. Am J Infect Control. 2010;38(6):461-6. doi: 10.1016/j.ajic.2009.12.009.
Rowe TA, Juthani-Mehta M. Urinary Tract Infection in Older Adults. Aging Health. 2013;9(5):519-28. doi: 10.2217/ahe.13.38.
Latour K, Lepeleire JD, Jans B, Buntinx F, Catry B. Diagnosis, Prevention and Control of Urinary Tract Infections: A Survey of Routine Practices in Belgian Nursing Homes. J Infect Prev. 2020;21(5):182-8. doi: 10.1177/1757177420921914.
Alpay Y, Aykin N, Korkmaz P, Gulduren HM, Caglan FC. Urinary Tract Infections in the Geriatric Patients. Pak J Med Sci. 2018;34(1):67-72. doi: 10.12669/pjms.341.14013. PubMed PMID: 29643881.
Stuart R, Lim CJ, Kong D. Reducing Inappropriate Antibiotic Prescribing in the Residential Care Setting: Current Perspectives. Clin Interv Aging. 2014:165. doi: 10.2147/cia.s46058.
Ben-David D, Masarwa S, Fallach N, Temkin E, Solter E, Carmeli Y, et al. Success of a National Intervention in Controlling Carbapenem-Resistant Enterobacteriaceae in Israel’s Long-Term Care Facilities. Clin Infect Dis. 2019;68(6):964-71. doi: 10.1093/cid/ciy572.
Bonkat G, Pilatz A, Wagenlehner F. Time to Adapt Our Practice? The European Commission has Restricted the Use of Fluoroquinolones Since March 2019. Eur Urol. 2019;76:273-5.
Concia E, Bragantini D, Mazzaferri F. Clinical Evaluation of Guidelines and Therapeutic Approaches in Multi Drug-Resistant Urinary Tract Infections. J Chemother. 2017;29(sup1):19-28. doi: 10.1080/1120009x.2017.1380397.
Richards GA, Brink AJ, Feldman C. Rational Use of the Fluoroquinolones. S Afr Med J. 2019;109(6):378. doi: 10.7196/samj.2019.v109i6.14002.
Rosello A, Hayward AC, Hopkins S, Horner C, Ironmonger D, Hawkey PM, et al. Impact of Long-Term Care Facility Residence on the Antibiotic Resistance of Urinary Tract Escherichia Coli and Klebsiella. J Antimicrob Chemother. 2017:dkw555. doi: 10.1093/jac/dkw555.
Suay G, Pérez G. Present and Future of Carbapenem-Resistant Enterobacteriaceae (CRE) Infections. Antibiotics. 2019;8(3):122. doi: 10.3390/antibiotics8030122.
CDC. Core Elements of Antibiotic Stewardship for Nursing Homes. U.S. Department of Health and Human Services, CDC; 2015 [cited 2021 June, 15]. Available at: http://www.cdc.gov/longtermcare/index.html.
Appaneal HJ, Caffrey AR, Lopes VV, Crnich CJ, Dosa DM, Laplante KL. National Trends in the Treatment of Urinary Tract Infections Among Veterans’ Affairs Community Living Center Residents. Infect Control Hosp Epidemiol. 2019;40(10):1087-93. doi: 10.1017/ice.2019.204.
Brown KA, Chambers A, Macfarlane S, Langford B, Leung V, Quirk J, et al. Reducing Unnecessary Urine Culturing and Antibiotic Overprescribing in Long-Term Care: A Before-and-After Analysis. CMAJ Open. 2019;7(1):E174-E81. doi: 10.9778/cmajo.20180064.
Zilberberg MD, Nathanson BH, Sulham K, Fan W, Shorr AF. Carbapenem Resistance, Inappropriate Empiric Treatment and Outcomes Among Patients Hospitalized With Enterobacteriaceae Urinary Tract Infection, Pneumonia and Sepsis. BMC Infect Dis. 2017;17(1). doi: 10.1186/s12879-017-2383-z.
Ezelarab HAA, Abbas SH, Hassan HA, Abuo-Rahma GE-DA. Recent Updates of Fluoroquinolones as Antibacterial Agents. Arch Pharm (Weinheim). 2018;351(9):1800141. doi: https://doi.org/10.1002/ardp.201800141.
Hecker MT, Son AH, Murphy NN, Sethi AK, Wilson BM, Watkins RR, et al. Impact of Syndrome-Specific Antimicrobial Stewardship Interventions on Use of and Resistance to Fluoroquinolones: An Interrupted Time Series Analysis. Am J Infect Control. 2019;47(8):869-75. doi: 10.1016/j.ajic.2019.01.026.
Frankel WC, Trautner BW, Spiegelman A, Grigoryan L, LeMaire SA. Patients at Risk for Aortic Rupture Often Exposed to Fluoroquinolones During Hospitalization. Antimicrob Agents Chemother. 2019;63(2):e01712-18. doi: 10.1128/AAC.01712-18. PubMed PMID: 30478167.
Redmond SN, Silva SY, Wilson BM, Cadnum JL, Donskey CJ. Impact of Reduced Fluoroquinolone Use on Clostridioides difficile Infections Resulting From the Fluoroquinolone-Resistant Ribotype 027 Strain in a Veterans Affairs Medical Center. Pathog Immun. 2019;4(2):251. doi: 10.20411/pai.v4i2.327.
Feneley RCL, Hopley IB, Wells PNT. Urinary Catheters: History, Current Status, Adverse Events and Research Agenda. J Med Eng Technol. 2015;39(8):459-70. doi: 10.3109/03091902.2015.1085600.
Cravens DD, Zweig S. Urinary Catheter Management. Am Fam Physician. 2000;61(2):369-76.
Parker V, Giles M, Graham L, Suthers B, Watts W, O’Brien T, et al. Avoiding Inappropriate Urinary Catheter Use and Catheter-Associated Urinary Tract Infection (CAUTI): A Pre-Post Control Intervention Study. BMC Health Serv Res. 2017;17(1). doi: 10.1186/s12913-017-2268-2.
Madigan E, Felber D. Care of Patients With Long-Term Indwelling Urinary Catheters. Online J Issues Nurs. 2003.
Meddings J, Rogers MAM, Krein SL, Fakih MG, Olmsted RN, Saint S. Reducing Unnecessary Urinary Catheter Use and Other Strategies to Prevent Catheter-Associated Urinary Tract Infection: An Integrative Review. BMJ Qual Saf. 2014;23(4):277-89. doi: 10.1136/bmjqs-2012-001774.
Montoya A, Mody L. Common Infections in Nursing Homes: A Review of Current Issues and Challenges. Aging Health. 2011;7(6):889-99. doi: 10.2217/ahe.11.80.
Melzer M, Welch C. Does the Presence of a Urinary Catheter Predict Severe Sepsis in a Bacteraemic Cohort? J Hosp Infect. 2017;95(4):376-82. doi: 10.1016/j.jhin.2017.01.003.
Barbadoro P, Labricciosa FM, Recanatini C, Gori G, Tirabassi F, Martini E, et al. Catheter-Associated Urinary Tract Infection: Role of the Setting of Catheter Insertion. Am J Infect Control. 2015;43(7):707-10. doi: 10.1016/j.ajic.2015.02.011.
Jacobsen SM, Shirtliff ME. Proteus Mirabilis Biofilms and Catheter-Associated Urinary Tract Infections. Virulence. 2011;2(5):460-5. doi: 10.4161/viru.2.5.17783.
Armbruster CE, Mobley HLT, Pearson MM. Pathogenesis of Proteus Mirabilis Infection. EcoSal Plus. 2018;8(1). doi: 10.1128/ecosalplus.esp-0009-2017.
Kepner S, Harper A, Jones R. 2020 Healthcare-Associated Infections in the Long-Term Care Setting: An Analysis of Reports From Pennsylvania. Patient Saf. 2021;3(2):22-33. doi: https://doi.org/10.33940/data/2021.6.2.
Medical Care Availability and Reduction of Error (MCARE) Act, Pub. L. No. 154 Stat. 13 (2002).
Stone ND, Ashraf MS, Calder J, Crnich CJ, Crossley K, Drinka PJ, et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol. 2012;33(10):965-77. doi: 10.1086/667743. PubMed PMID: 22961014.
Bradley S, Sheeran M. Optimal Use of Antibiotics for Urinary Tract Infections in Long-Term Care Facilities: Successful Strategies Prevent Resident Harm. Pa Patient Saf Advis. 2017;14(3).
Lean K, Nawaz RF, Jawad S, Vincent C. Reducing Urinary Tract Infections in Care Homes by Improving Hydration. BMJ Open Qual. 2019;8(3):e000563. doi: 10.1136/bmjoq-2018-000563.
Breitenbucher RB. UTI: Managing the Most Common Nursing Home Infection. Geriatr. 1990;45(5):68-75. PubMed PMID: 107519383.
Persad S, Watermeyer S, Griffiths A, Cherian B, Evans J. Association Between Urinary Tract Infection and Postmicturition Wiping Habit. Acta Obstet Gynecol Scand. 2006;85(11):1395-6. doi: 10.1080/00016340600936977.
Lara L, Troop P, Beadleson-Baird M. The Risk of Urinary Tract Infection in Bowel Incontinent Men. J Gerontol Nurs. 1990;16(5):24-6. PubMed PMID: 1021723405.
Pennsylvania Department of Health. COVID-19 Long-Term Care Facilities Data for Pennsylvania. https://www.health.pa.gov/topics/disease/coronavirus/Pages/LTCF-Data.aspx. Updated June 25, 2021. Accessed June 25, 2021.
Centers for Medicare & Medicaid Services. Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (REVISED) - QSO-20-14-NH. https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf. Published 2020. Updated March 13, 2020. Accessed October 13, 2021.
Assi MA, Doll M, Pryor R, Cooper K, Bearman G, Stevens MP. Impact of Coronavirus Disease 2019 (COVID-19) on Healthcare-Associated Infections: An Update and Perspective. Infect Cont Hosp Epidemiol. 2021:1-2. doi: 10.1017/ice.2021.92.
Fakih MG. Reducing Inappropriate Urinary Catheter Use. Arch Intern Med. 2012;172(3):255. doi: 10.1001/archinternmed.2011.627.
Taylor M, Reynolds C, Jones R. Challenges and Potential Solutions for Patient Safety in an Infectious-Agent-Isolation Environment: A Study of 484 COVID-19-Related Event Reports Across 94 Hospitals. Patient Saf. 2021;3(2):45-62. doi: https://doi.org/10.33940/infection/2021.6.4.
Diamond F. Study: CLABSI, CAUTI Rates Higher for COVID Patients. Infection Control Today. https://www.infectioncontroltoday.com/view/study-clabsi-cauti-rates-higher-for-covid-patients. Updated October 21, 2020. Accessed October 13, 2021.
Centers for Disease Control and Prevention (CDC): National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Symptoms of COVID-19. CDC website. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html#self-checker. Accessed June 25, 2021.
Armbruster CE, Smith SN, Johnson AO, DeOrnellas V, Eaton KA, Yep A, et al. The Pathogenic Potential of Proteus mirabilis Is Enhanced by Other Uropathogens during Polymicrobial Urinary Tract Infection. Infect Immun. 2017;85(2):e00808-16. doi: 10.1128/IAI.00808-16. PubMed PMID: 27895127.
Filipiak A, Chrapek M, Literacka E, Wawszczak M, Głuszek S, Majchrzak M, et al. Pathogenic Factors Correlate With Antimicrobial Resistance Among Clinical Proteus mirabilis Strains. Front Microbiol. 2020;11. doi: 10.3389/fmicb.2020.579389.
Milo S, Hathaway H, Nzakizwanayo J, Alves DR, Esteban PP, Jones BV, et al. Prevention of Encrustation and Blockage of Urinary Catheters by Proteus mirabilis via pH-Triggered Release of Bacteriophage. J Mater Chem B. 2017;5(27):5403-11. doi: 10.1039/c7tb01302g.
O’Hara CM, Brenner FW, Miller JM. Classification, Identification, and Clinical Significance of Proteus, Providencia, and Morganella. Clin Microbiol Rev. 2000;13(4):534-46. doi: 10.1128/CMR.13.4.534. PubMed PMID: 11023955.
Schaffer JN, Pearson MM. Proteus mirabilis and Urinary Tract Infections. Microbiol Spectr. 2015;3(5). doi: 10.1128/microbiolspec.uti-0017-2013.
Liu H, Zhu J, Hu Q, Rao X. Morganella morganii, A Non-Negligent Opportunistic Pathogen. Int J Infect Dis. 2016;50:10-7.
Mittal R, Aggarwal S, Sharma S, Chhibber S, Harjai K. Urinary Tract Infections Caused by Pseudomonas aeruginosa: A Minireview. J Infect Public Health. 2009;2(3):101-11. doi: 10.1016/j.jiph.2009.08.003.
U.S. Centers for Medicare & Medicaid Services. CMS Finalizes Improvements in Care, Safety, and Consumer Protections for Long-Term Care Facility Residents. Press release. https://www.cms.gov/newsroom/press-releases/cms-finalizes-improvements-care-safety-and-consumer-protections-long-term-care-facility-residents. Published September 28, 2016. Accessed June 25, 2021.
Adkins J. Participating in a National Project, Pennsylvania Nursing Homes Successfully Reduce CAUTIs. Pa Pat Saf Advis. 2016;13(4):149-53.
Agency for Healthcare Research and Quality. Technical Interventions to Prevent CAUTI. AHRQ website. https://www.ahrq.gov/hai/cauti-tools/guides/implguide-pt3.html#:~:text=%20Technical%20Interventions%20To%20Prevent%20CAUTI%20%201,aware%20of%20the%20indications%20for%20urinary...%20More%20. Updated October 2015. Accessed June 25, 2021.
Bradley SM, Schweon SJ, Mody L, Mahajan D, Olmsted RN. Identifying Safe Practices for Use of the Urinary Leg Bag Drainage System in the Postacute and Long-Term Care Setting: An Integrative Review. Am J Infect Control. 2018;46(9):973-9. doi: 10.1016/j.ajic.2018.03.029.
Agency for Healthcare Research and Quality. Collection of Microbiological Cultures. AHRQ website. https://www.ahrq. gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/ microbiological-cultures.pdf. Published June 2021. Accessed November 18, 2021.