A Practical Guide to Better UTI Management in Long-Term Care
Urinary tract infections (UTIs) are among the most commonly reported infections in long-term care (LTC) residents. However, managing UTIs in this population is complex and often misunderstood.
In Ontario, Public Health Ontario (PHO), has developed a structured UTI Program to address one of the biggest challenges in LTC: the overuse of antibiotics and the misdiagnosis of UTIs.
The Problem: Overdiagnosis and Overtreatment
In LTC settings, many residents, especially older adults, may have bacteria in their urine without symptoms.
This is called asymptomatic bacteriuria. It is common and does not require treatment.
However, in practice:
- Up to 80% of LTC residents with asymptomatic bacteriuria are treated with antibiotics.
- About 50% of cases misinterpret bacteria in urine as an infection.
- Antibiotics are often prescribed for vague symptoms such as confusion or falls, which are not reliable indicators of a UTI on their own.
This can lead to antibiotic resistance, increased risk of C. difficile infection, medication side effects, and avoidable hospitalizations.
The Ontario UTI Program: A Shift Toward Evidence-Based Care
To address these issues, Public Health Ontario developed the UTI Program to support LTC homes in improving UTI management and reducing unnecessary antibiotic use.
The program focuses on:
- Antimicrobial stewardship
- Standardized clinical decision-making
- Education for staff, residents, and families
- System-wide practice changes in LTC homes
The program aligns closely with broader infection prevention and control strategies and supports safer, more consistent decision-making across long-term care teams.
The 5 Key Practice Changes
At the heart of the UTI Program are five evidence-based practice changes:
- Test Only When Symptoms Are Present Urine cultures should only be collected when residents show clear clinical signs of a UTI. They should not be collected for routine screening or vague symptoms alone.
- Proper Specimen Collection Correct specimen collection and storage help reduce contamination and improve diagnostic accuracy.
- Prescribe Antibiotics Appropriately Antibiotics should only be prescribed when clinical criteria are met and should be reassessed once laboratory results are available.
- Eliminate Dipstick Testing Dipsticks are not reliable for diagnosing UTIs in long-term care residents and should not be used as the basis for treatment decisions.
- Stop Routine Screening Routine urine testing at admission or annually is discouraged unless symptoms are present.
Rethinking “UTI Symptoms” in Long-Term Care
A major focus of the program is correcting common misconceptions about what does and does not indicate a UTI.
Cloudy or foul-smelling urine, confusion or delirium alone, falls, or general decline are not reliable indicators of a UTI on their own.
Instead, clinicians should look for clear symptoms such as:
- Acute dysuria
- Fever with urinary symptoms
- New or worsening urgency or frequency
This shift helps avoid unnecessary testing and treatment and supports more appropriate clinical decision-making.
Implementation in Long-Term Care Homes
The Ontario UTI Program follows a structured quality improvement approach.
- Assess
Evaluate current practices, antibiotic use, and staff knowledge. - Plan
Develop policies, assign champions, and identify gaps. - Implement
Introduce tools such as clinical assessment algorithms, decision-making checklists, and staff education resources.
These tools are designed to support consistent, evidence-based care across teams.
Benefits of the UTI Program
Long-term care homes that adopt the program may see:
- Reduced unnecessary antibiotic use
- Improved resident safety
- Better diagnostic accuracy
- Enhanced staff confidence in clinical decision-making
- Stronger antimicrobial stewardship practices
More broadly, the program contributes to province-wide efforts to reduce unnecessary antibiotic use in long-term care.
The Role of the Interdisciplinary Team
Effective UTI management in long-term care requires collaboration across the care team.
Nurses support frontline assessment and monitoring.
Physicians and nurse practitioners support diagnosis and prescribing decisions.
Pharmacists provide antibiotic stewardship support.
Personal support workers observe and report changes in the resident’s condition.
Families benefit from education, so they understand why antibiotics are not always needed.
Key Takeaways for Practice
Not all bacteria in urine means infection.
Asymptomatic bacteriuria should not be treated with antibiotics.
Standardized assessment tools support better decision-making.
Urine dipsticks should not be used to diagnose UTIs in long-term care residents.
Education and culture change are essential to improving practice.
Final Thoughts
UTI management in long-term care is no longer about treating positive urine tests. It is about treating the right resident, at the right time, with the right intervention.
Ontario’s UTI Program represents an important step forward in improving care quality, protecting residents, and reducing harm from unnecessary antibiotics. By embracing these practices, long-term care homes can move toward safer, smarter, and more sustainable care.
Free UTI Resource for LTC Teams
Ditch the guesswork with a practical guide to symptom-based UTI decision-making.
Clients that partnered with our consultants to develop a structured UTI reduction program have reported reductions in UTIs of up to 50%.
Contact us to get in touch with a certified IPAC Consultant.
