Falls not associated with UTIs in elderly nursing home residents

Theresa Rowe, Virginia Towle, Peter H. Van Ness, Manisha Juthani-Mehta.   Lack of association between falls and bacteruria plus pyuria in older nursing home residents.  Journal of American Geriatrics Society 2013, 62(4); 653.

by Kirk Huslage, RN, BSN, MSPH, CIC

Falls are common occurrences among nursing home residents, with an estimated 36% of residents having at least 1 fall event in the past 6 months.  While falls are certainly caused by multiple factors, they are frequently attributed to the presence of a urinary tract infection (UTI), and often result in potentially inappropriate  treatment with antibiotics for a presumed UTI.  A group from the Department of Internal Medicine at Yale University School of Medicine recently undertook a prospective cohort study of 551 nursing home residents in the New Haven, CT community to determine if there is a correlation between falls and the presence of UTI [defined as bacteruria ( >100, 000 colony-forming units/ml bacteria) plus pyuria (>10 WBC/high-powered field in UA)].  The longitudinal association between falls and bacteruria plus pyuria was examined.

In the analysis, the researchers found that of the 45 fall episodes, nine (20%) were associated with bacteruria plus pyuria .  For comparison, of the 352 episodes without falls, 137 (38.9%) were also associated with bacteruria plus pyuria.  Using a multivariable regression model, the researchers did not find a statistically significant correlation between falls and bacteruria plus pyuria.  This suggests that UTI is unlikely to be associated with falls and a majority of individuals in this cohort for whom UTI was suspected due to falls would not have benefited from antibiotics.

Editors Comments:  This study is important because antibiotic resistance among nursing home residents is increasing and is heavily associated with antibiotic overuse and misuse.   Indeed, antibiotics are the most frequently prescribed medications in nursing homes, with approximately 70% of residents receiving at least one course of antibiotics annually.

Many long-term care residents are colonized with bacteria, and it is challenging to separate colonization from true infection in this population.   Several studies have shown that 30-50% of elderly long-term care residents can have positive urine culture even without any symptoms of a urinary tract infection, resulting in many of these patients being placed inappropriately on antibiotic therapy.

Please see the CDC FAQ on Antibiotic Use in Nursing Homes for more information on the problem and what can be done at your facility to improve antibiotic utilization and stewardship.

References:
1.  T Rowe, V Towle, et al. Lack of positive association between falls and bacteruria plus pyuria in older nursing home resdient. J Am Geriatr Soc 2013 2013;64(4):653.

2.  Loeb M et al. Antibiotic use in Ontario faciltiies that provide chronic care.  J Gen Intern Med 2001;16:376-383.

Hand Hygiene before non-sterile gloving: a waste of time?

Rock, C, Harris, AD, Reich, NG, Johnson, JK, Thom, KA.  Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time? - A randomized controlled trial.  Am J Infect Control 2013; 41(11); 994-996.  

by Kirk Huslage, RN, BSN, MSPH, CIC

Hand hygiene is recognized as a basic measure for the prevention of HAIs, but there have been limited studies about the importance of hand hygiene prior to donning non-sterile gloves.   A group of researchers from the University of Maryland School of Medicine conducted a prospective, randomized controlled trial of healthcare personnel entering Contact Isolation rooms in 7 ICUs in an academic medical center. 

Two hundred thrity Healthcare personnel were randomized into two groups, hand hygiene prior to donning gloves (n=115)  and direct gloving without hand hygiene(n=115).   Workers for whom hand hygiene was observed prior randomization or they had already participated.  For both groups, hand imprint cultures were taken prior to any intervention, and were  repeated following donning of non-sterile gloves for both groups.  Both groups were also timed to see how long it took to don gloves.

The researchers found no statistical difference in the average colony forming units (CFU) counts of gloved hands between the hand hygiene  prior to gloving and direct gloving groups (6.9 vs 8.1 CFU, p=0.52).  Pathogenic organisms were rarely identified (1 MRSA isolate in hand hygiene prior to gloving group and 2 MSSA isolates in the direct gloving group), with most other organisms constituting expected transient flora including CONS, micococcus, diphtheroids adn bacillus.    They also found that the average time needed per episode for the hand hygiene and direct gloving groups were 53.3 seconds and 21.8 seconds (p <0.01), respectively.