The prevalence of UTIs in Norwegian nursing homes was high compared to the prevalence in nursing homes elsewhere in Europe, where overall prevalence was 1.1 % (varying from 0 % to 3.7 % between countries) (7). Number of residents, their age, degree of incontinence and catheter use varied among the countries in the European survey, such that the prevalence was not necessarily comparable (7).
In accordance with previous findings (17) the point prevalence survey in the spring showed that UTI was the most frequently occurring type of healthcare-associated infection in Norwegian nursing homes. The prevalence was higher in residents with urinary catheters than in those without catheters. In order to prevent UTIs and thereby also reduce the use of antibiotics in nursing homes, the national guidelines for the prevention of catheter-associated UTIs should be adhered to (18).
The prevalence of antibiotic use in the survey in the spring was high compared to the prevalence in nursing homes elsewhere in Europe, where overall prevalence was 4.4 % (varying from 2 % to 11 % between countries) (7). The proportion of prophylactic prescriptions for UTIs was considerably higher in Norwegian nursing homes than in nursing homes in most other European countries (7). Methenamine was the drug most commonly prescribed as a prophylactic in Norwegian nursing homes. Although methenamine is not considered to be resistance-inducing and has few adverse effects, unnecessary use of drugs should be avoided due to patient-related and economic costs.
Antibiotics that were recommended as first-line drugs in the national guidelines represented approximately 60 % of the prescriptions for treatment of both lower and upper UTIs. For both indications, pivmecillinam constituted a significantly larger proportion of the prescriptions than the other first-line drugs, even though these are ranked equally in the guidelines. Trimethoprim and trimethoprim-sulfamethoxazole were prescribed with approximately the same frequency for lower and upper UTIs, although trimethoprim is a first-line drug for lower UTIs and trimethoprim-sulfamethoxazole is a first-line drug for upper UTIs.
The guidelines recommend the same antibiotics for women and men. However, trimethoprim-sulfamethoxazole, ciprofloxacin and amoxicillin were prescribed more frequently for men than for women with lower UTIs. In a study from Vestfold county, significant gender differences were found in nursing homes with regard to urinary tract pathogens and patterns of resistance (12), which raises questions as to whether the guidelines should be changed with respect to first-line drugs.
Dosages of amoxicillin and ciprofloxacin prescribed for treatment of lower UTIs conformed to a large extent with the guidelines regarding upper UTI. The higher dosage of amoxicillin, together with the fact that this was the most frequently prescribed drug for the treatment of lower respiratory tract infections, gives reason to believe that this drug was prescribed in cases where it was difficult to know whether the resident had a UTI, a lower respiratory tract infection or both.
Although ciprofloxacin is a first-line drug for treatment of upper UTIs, the guidelines specify that for treatment of lower UTI, ciprofloxacin and amoxicillin should only be used after the urine culture results are available. However, the proportion of prescriptions for lower UTIs where a microbiological sample was taken was no higher when prescribing these drugs than when prescribing first-line drugs. The survey only provides answers to whether a microbiological sample has been taken, not whether the treatment is based on test results. Nor does it provide answers to whether there was a clinical suspicion of infection when the sample was taken, as there should be according to the guidelines. Given that 15 – 50 % of nursing home residents have asymptomatic bacteriuria, a positive sample result is not necessarily tantamount to a UTI (19).
The fact that choice of drug, dosage and microbiological testing in the treatment of lower UTIs did not always conform to the guidelines, may indicate non-compliance, but may also be attributable to incorrect recording of the indication. We do not know the criteria on which the doctors have based their choice of indication and cannot therefore draw any conclusions on wrong diagnosis and overtreatment of UTIs in Norwegian nursing homes.
The low participation in the point prevalence survey in the spring may be due to the fact that the Norwegian Institute of Public Health’s reminders failed to reach all nursing homes, or that there is a relatively high turnover of personnel in many nursing homes. We do not know the degree to which the participating nursing homes constituted a representative sample.
Point prevalence surveys only provide a snapshot. Consequently, it is more probable that long-term rather than short-term infections and antibiotic use are included. Nevertheless, the findings in the spring survey are supported by findings in the previous point prevalence survey of healthcare-associated infections and antibiotic use in nursing homes (20).
Despite the widespread use of methenamine, UTIs are a relatively frequent occurrence in Norwegian nursing homes. Norwegian nursing home doctors should therefore consider whether their use of this drug is in accordance with national and international recommendations (4, 11). The survey indicates that compliance with the national guidelines for treatment of lower UTIs could be improved with regard to choice of drug, dosage and microbiological testing.