Implementing Ontario’s UTI Program in Long-Term Care: Where Practice Gets Complicated

The Ontario UTI Program has been a major step forward for antimicrobial stewardship in long-term care. The goals are clear: reduce unnecessary antibiotic use, improve resident safety, and support more consistent, evidence-based decision-making.

But in practice, UTI management in LTC is rarely simple.

One of the biggest challenges is that many residents have bacteria in their urine without having a true infection. This is called asymptomatic bacteriuria, and it does not require antibiotics. The problem is that once urine is tested and bacteria are found, the result can easily drive the decision-making process.

That is where many homes get stuck.

A positive urine culture does not automatically mean a resident has a UTI. A UTI diagnosis should be based on clinical symptoms first, with urine testing used to support the assessment, not replace it.

This is one of the most important mindset shifts in UTI management:

Assessment should drive testing. Testing should not drive treatment.

In long-term care, non-specific changes such as confusion, falls, cloudy urine, foul-smelling urine, or general decline can understandably raise concern. Staff know their residents well, and they often notice when something is not right.

However, these signs on their own are not enough to diagnose a UTI.

When these changes occur, the first step should be a broader assessment. Has the resident had a change in medications? Are they dehydrated? Are they constipated? Are they in pain? Is there a respiratory concern? Has there been a change in sleep, nutrition, or mobility?

Jumping straight to a urine test can create a narrow focus too early. Once a urine result comes back positive, the team may feel pressure to treat, even if the resident does not meet clinical criteria for a UTI.

This is how unnecessary antibiotics happen.

A better approach is to pause and ask:
What symptoms are present?
Do the symptoms meet UTI criteria?
Could there be another cause?
Is urine testing clinically indicated?
If antibiotics are started, when will they be reassessed?

This is where consistency matters. The Ontario UTI Program gives homes the framework, but the day-to-day application depends on how well the team understands the difference between observing a change, assessing the resident, testing appropriately, and treating only when criteria are met.

It also requires strong communication with families.

Families may ask for antibiotics because they are worried and want something done quickly. In those moments, staff need language that is clear and reassuring. For example:

“We are taking this change seriously, but antibiotics are only helpful when there is evidence of a true infection. Right now, we are completing a full assessment so we can understand what is causing the change and avoid treatment that may cause harm.”

That kind of explanation helps shift the conversation from “Why aren’t you treating?” to “How are we assessing safely?”

The goal is not to ignore symptoms or delay care. The goal is to make sure the right concern is being treated.

For LTC homes, the practical takeaway is this:

Do not let a urine result become the starting point.

Start with the resident. Start with symptoms. Start with assessment.

The Ontario UTI Program works best when teams are aligned on that approach. Nurses, physicians, nurse practitioners, pharmacists, PSWs, leadership, and families all play a role in reducing unnecessary antibiotic use and improving resident safety.

Guidelines alone do not change practice. Consistent interpretation, coaching, and real-world reinforcement do.

In long-term care, better UTI management is not about doing less. It is about doing the right things in the right order.