Antibiotics for (presumed) UTI
I noticed on mom's last pharmacy bill that she'd been prescribed an antibiotic in mid November. I had heard nothing about this so I contacted the NP who provides care at mom's MC. She replied that the med was prescribed "at request of staff due to some behaviors." I also heard nothing from MC last month about unusual behavior, nor did I witness any on my visits. I reminded the NP that I would like to be notified of changes in both behavior and medications.
Fast forward to yesterday. Got a voice mail message from the NP that she was again prescribing an antibiotic for mom, based on staff reports of low urine output and "agitation." She said that she did this since staff were having difficulty collecting a urine specimen from mom and "so that she won't be in the hospital over the holidays."
I've seen mom about twice a week, including today. I haven't seen any unusual behaviors or agitation. The only example that the staff on duty today could give me is that she said no to several attempts at bathing and hygiene. This is typical for her. They said first shift would take her to the restroom and she'd only pee a few drops and had dry diaper. Second shift reported some incontinence. She is still partially continent and goes to the restroom alone, without fanfare, so it's likely that she was doing that in the early morning without staff noticing. I took her to the restroom at 10 this morning and she urinated a good amount, considering that her fluid intake is low on a good day.
My question here is, have any of you seen antibiotics used in facilities on the basis of behavior? I'm well aware that a UTI can cause havoc in elderly persons' behavior. But this pattern at Mom's MC does not seem to follow good antibiotic stewardship nor logic. Open to suggestions, as I certainly don't want "behaviors" to escalate. They seem to.have a low threshold for shipping residents to the ER, something I'd also like to avoid.
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It does seem odd to me. I think there is something called a nuns cap that makes collecting urine pretty easy. Why would this not be used so they could do an actual test? It’s my understanding that they really don’t need much urine to do a test. I agree it seems irresponsible to prescribe antibiotics without a test. Repeatedly treating her for a uti she may not even have doesn’t make any sense. If behavior is the issue and there is no uti then it seems like an anxiety medication (or increase) may be more in order. But even then it should be run by you and you should be given some specific examples of problems they are having.
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Overuse of antibiotics can cause your mom to develop antibiotic resistant strains of bacteria. If a urinalysis, urine culture & sensitivity does not show an infection, neither is she having any classic signs of a uti, there is ZERO reason for them to be treating. Antibiotics do nothing to rectify "odd behaviors."
While you don't want mom going to the ER, I would rather my mom go and get an official diagnosis & treatment plan, rather than be treated by someone obviously unqualified...ijs
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Yes, they do use that specimen collection "hat" but they just set it in the toilet and leave it. Mom takes it out, then puts it in the trash. This summer I noticed that they just put the same container back in the toilet. No wonder they got a contaminated specimen. When she went to ER, they catheterized her and the culture grew NO bacteria. Same situation, twice in one month. Plus the ER doctor disagreed with the antibiotic that the MC provider prescribed, saying it was inappropriate for an elderly person with kidney dysfunction. Guess what, she got the same thing last month and is on it again now. Sigh. I will talk with the provider again on Friday when she will be at the facility. Also the health director (RN) to get a better understanding of policy regarding antibiotic usage.
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just my opinion….every time my dad had different behavior they wanted to blame a UTI. Sometimes he had one but many times he did not. I do believe a UTI can cause increased confusion but I also think some behaviors are the progression of the disease and “normal” and facilities don’t want to deal with it. My dad gave aides a hard time about changing clothes and showering too. There was a therapist though that could get him to do both. Why? Because she got to know him and he trusted her. If she said it was time for a shower he went. I am so grateful for everyone who helped with my dad they were all angels to me BUT I do think UTI’s and antibiotics are something they hide behind when things get more difficult.
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I agree with all of you. I went over to the MC today with the intention of bringing mom to my house for lunch. She came over for Thanksgiving and it went reasonably well. But today she was so confused that she couldn't figure out to get into the car. To shorten a long story, I had to walk her back into the facility and sit there with her for lunch. She truly could not use a spoon or fork and only got a few bites in before falling asleep.
So this could be effects of a true UTI or something else she's coming down with, or it could be the antibiotic she's been on for two days. She's very sensitive to meds of any kind. Or … could be progression of dementia. I had a frank talk with a med tech there who knows mom well and she said that is what she suspects from daily observation. I guess I'm glad that I didn't bring her home today because I may not have been able to get her in the car to take her back!
The NP is supposed to be in to see her tomorrow so I'll go over to talk about the policy on antibiotics. If she keeps fading like this, I won't be surprised if they find some reason to send her to ER (in the summer they sent her because she refused meds one morning while she was on this antibiotic for UTI). They don't typically call me till she's in the ambulance on the way 🙄. I have a short range of patience for this before I ask for hospice. Any thoughts?
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FIrst @psg712 happy holidays. You sound remarkably sane for someone dealing with such a frustrating situation! Thats first. I’m glad you’re just trying to sort it out.
LIke others have said (and you), I think MC’s do jump to UTIs but maybe because they are so common. I’ve never heard of prescribing antibiotics without a confirmed test. That said, maybe they were just trying to be on the safe side - however misinformed that is.
It also could just be the progression. What I’ve noticed is my mom has good days and bad days. Sometimes she’s completely gone - like scary out of it - and then there’s moments when she’s right with me in the conversation.
I would have a very honest conversation with the NP. What is their UTI protocol? PRotocol for ER visits? What is it that is so “difficult” or unusual about her “agitation”? It may also just be this disease. This happened every other month for my mom in her last MC. Her current MC is so much better, the care is so much better, and they do seem to have fewer ER trips. That said, the residents are pretty far along in their journey so they are used to it.
Lean on the staff. Press them for answers. The holidays are so hard because we don’t know what to expect. I hope you get some peace and rest this holiday.
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Update: I had a face to face conversation with the NP today. She agrees that waiting for culture results is best before starting an antibiotic for a resident, but in both recent cases, she waited a week for staff to collect a specimen. They kept saying that they couldn't get one (apparently you can lead someone to a toilet, but you cannot make her pee). So since mom was showing extra confusion and some unusual activity, and because the holidays were upon us and she didn't want potential infection to escalate to a need for hospitalization, the NP ordered the antibiotic without the culture. She commented today that "we don't usually worry too much about antibiotic resistance in someone her age." I guess I need to recognize that my perspective, working with patients in acute care situations, is different from the management of residents in long term care.
A couple of staff told me today that the unusual behavior included continual pacing the hallways without her walker for a couple of days, going in and out of her room, gathering up baby dolls and passing them to other residents, would not eat or drink, skipped her usual afternoon nap and early bedtime. Truly this is all odd for mom, who is quite sedentary and rarely interacts with other residents. She seems back to baseline today (3rd day on the 7-day antibiotic course). She interacted a little with me with few words then dozed off. Staff also notes general progression of confusion over the last few months. We'll probably have more conversations about all of this in the coming months, but for now I guess I'll let it be. I probably need to visit more often than twice a week to get a better feel for her patterns of behavior as things keep changing.
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It's kinda crazy, but so much of what you are saying about the situations with the UTI and the staff at the MC is so much like what I'm dealing with right now with my mom who is 82. I feel like the NP is just saying somewhere he thinks will and isn't truly taking the time of effort to effectively evaluate her. It's so frustrating to always have to question everything everyone is saying to you ! It makes you not trust anyone there..0
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I wholeheartedly disagree with your mom's NP.
"She commented today that "we don't usually worry too much about antibiotic resistance in someone her age." I guess I need to recognize that my perspective, working with patients in acute care situations, is different from the management of residents in long term care."
The fear of antibiotic resistance remains the same as in any other age group. The NP does not want to send your mom to the ER as much documentation is required. Your only question should be what is best for mom. Not only is resistance an extremely valid reason NOT to give unwarranted atb, but the frequent usage is reeking havoc on your gut ecosystem, killing off necessary microbe. Do not allow them to be willy nilly with your mom's health. If the cnas cannot get her to give a clean catch urine specimen, have the hospital do a straight cath to get an accurate diagnosis.
Yes, her behaviors maybe unusual for her but none that you've mentioned, falls in the category or level of altered mental state normally associated with an UTI.
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@psg712 thanks for the update. I’m glad she seems a bit more baseline. The truth is none of these places are perfect, and thank how we are there to advocate because sometimes (like in this case) things are not cut and dry: overall, even though the NPs decision seems odd/off, it seems like your mom has gotten good care there.
Ironically your mom’s erratic behavior sounds like my mom now on a normal day. This disease progresses. You and I have been on this journey a while now. 2 days a week should give you a sense - maybe check in a bit more for now - but also remember that during these stages we can’t always undertand what causes what.I wish I had more knowledge about antibiotic resistance but I know very little. I don’t see one or two extra courses as causing harm but I may be wrong. Let us know what happens and how she’s doing.
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Thank you all for your input and support. I plan to set up a meeting early in the new year with the health director at the facility to review mom's care plan, and we'll discuss the behavior and antibiotic situation then too. The NP is not employed by the facility. She is a part of a provider group that travels among facilities and provides medical care.
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