By Amar Mohan, MD, CMD | PALTmed Georgia | Georgia PALTC News
Every November, U.S. Antibiotic Awareness Week (November 18 to 24) spotlights the most common prescribing problem in long-term care: the "UTI" that was never a UTI. CDC estimates that up to 70 percent of nursing home residents receive an antibiotic in a given year, and up to 75 percent of those prescriptions are incorrect in drug, dose, duration, or indication. Asymptomatic bacteriuria is the major driver. Here are four pearls for your next medical director meeting, and the Georgia-specific reasons they matter.
Pearl 1: Bacteriuria is the baseline, not the diagnosis
Asymptomatic bacteriuria is present in roughly 25 to 50 percent of women and 15 to 40 percent of men living in long-term care, and in essentially 100 percent of residents with a chronic indwelling catheter. A positive culture here is the expected finding, not evidence of infection. The 2019 IDSA guideline is unambiguous: do not screen for or treat asymptomatic bacteriuria in long-term care residents (strong recommendation), citing moderate-quality evidence of no benefit and high-quality evidence of harm.
Pearl 2: Confusion or a fall is not a urinary symptom
The most common path to an unnecessary antibiotic starts with "resident more confused today, UA sent." IDSA addresses this scenario directly: for an older resident with functional or cognitive impairment who has bacteriuria plus new delirium or a fall, but no local genitourinary symptoms and no systemic signs such as fever or hemodynamic instability, assess for other causes and observe carefully rather than treat the bacteriuria. Dehydration, new medications, pain, and constipation deserve the first look.
Pearl 3: Use explicit minimum criteria before any urine test
PALTmed national's Choosing Wisely list makes the sequencing clear: don't obtain a urinalysis or culture until clinical criteria are met. The AHRQ Suspected UTI SBAR, which operationalizes published minimum criteria for starting antibiotics, is a ready-made protocol your nurses can use at the bedside. For a resident without a catheter, criteria are met with acute dysuria alone; or a temperature of 100°F (38°C) plus at least one new or worsening urinary symptom (urgency, frequency, suprapubic pain, gross hematuria, flank pain, or incontinence); or, without fever, two or more of those new urinary symptoms. For a resident with an indwelling catheter, any one of the following qualifies: fever, new back or flank pain, rigors or shaking chills, a new dramatic change in mental status, or hypotension. If criteria are not met, the SBAR directs hydration, scheduled vital signs, and a defined callback window instead of a culture.
Pearl 4: Be skeptical of molecular urine panels
PCR-based urine panels are marketed aggressively to nursing homes, and they detect organisms in asymptomatic residents even more readily than culture does. PALTmed's newest Choosing Wisely statement (April 2025) says not to use molecular testing in place of urine culture to diagnose or guide treatment of UTI. If your lab contract includes reflex PCR testing, the medical director should review it.
What this means for Georgia medical directors
It is a survey issue. 42 CFR 483.80(a)(3) requires an antibiotic stewardship program "that includes antibiotic use protocols and a system to monitor antibiotic use," surveyed at F881. A written suspected-UTI protocol plus a monthly antibiotic line list reviewed at QAA is the minimum defensible structure, and under the expanded F841 guidance surveyors expect to see the medical director's hand in it.
It is a payment issue. Georgia's Supplemental Quality Incentive Payment program rewards facilities that improve year over year on four CMS long-stay measures, and "percent of long-stay residents with a urinary tract infection" is one of them. For SFY 2027 payments, DCH compares calendar year 2026 against 2025, and for SFY 2028 it compares 2027 against 2026. Every asymptomatic resident coded and treated as a UTI inflates that measure. Diagnostic stewardship lowers it honestly.
Georgia DPH will help for free. The DPH Healthcare-Associated Infections program offers no-cost, non-regulatory 60-minute antibiotic stewardship consultations to long-term care facilities and runs an LTC Antibiotic Stewardship Honor Roll each fall. Both are easy wins to bring to your administrator.
Monday-morning checklist
- Adopt the AHRQ Suspected UTI SBAR (or an equivalent minimum-criteria protocol) as a standing nursing order set, and educate night and weekend staff first.
- Add a "no culture without criteria" step to your change-in-condition policy, including for new confusion and falls.
- Review your lab contract for reflex PCR urine panels and remove them from routine use.
- Track antibiotic starts for UTI per 1,000 resident-days, present them at QAA quarterly, and pull your long-stay UTI quality measure now so you know where 2026 stands against 2025.
Sources
- CDC: Core Elements of Antibiotic Stewardship for Nursing Homes
- CDC: Antibiotic Stewardship in Nursing Homes (infographic with prescribing statistics)
- CDC: U.S. Antibiotic Awareness Week (November 18-24)
- Nicolle LE, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the IDSA. Clin Infect Dis. 2019;68(10):e83-e110
- StatPearls: Bacteriuria (prevalence of asymptomatic bacteriuria in long-term care)
- AHRQ Nursing Home Antimicrobial Stewardship Guide: Suspected UTI SBAR
- PALTmed (AMDA) Choosing Wisely statements, including "Don't obtain urine tests until clinical criteria are met"
- PALTmed: Choosing Wisely recommendations for the interdisciplinary team (April 2025), including molecular urine testing
- 42 CFR 483.80 Infection control (eCFR)
- Georgia DCH: Supplemental Quality Incentive Payments
- Georgia DPH: Antibiotic Stewardship (consultations and LTC Honor Roll)
This article is for educational purposes only and is not legal, billing, or clinical practice advice. Clinical decisions should be individualized; verify current guidance with the cited primary sources and applicable CMS, Georgia DCH, and Georgia DPH requirements.
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