Prevention of urinary tract infections in nursing homes: lack of evidence-based prescription?
ABSTRACT Urinary tract infections (UTIs, including upper and lower symptomatic) are the most common infections in nursing homes and prevention may reduce patient suffering, antibiotic use and resistance. The spectre of agents used in preventing UTIs in nursing homes is scarcely documented and the aim of this study was to explore which agents are prescribed for this purpose.
We conducted a one-day, point-prevalence study in 44 Norwegian nursing homes during April-May 2006. Nursing home residents prescribed any agent for UTI prophylaxis were included. Information recorded was type of agent and dose, patient age and gender, together with nursing home characteristics. Appropriateness of prophylactic prescribing was evaluated with references to evidence in the literature and current national guidelines.
The study included 1473 residents. 18% (n = 269) of the residents had at least one agent recorded as prophylaxis of UTI, varying between 0-50% among the nursing homes. Methenamine was used by 48% of residents prescribed prophylaxis, vitamin C by 32%, and cranberry products by 10%. Estrogens were used by 30% but only one third was for vaginal administration. Trimethoprim and nitrofurantoin were used as prophylaxis by 5% and 4%, respectively.
The agents frequently prescribed to prevent UTIs in Norwegian nursing homes lack documented efficacy including methenamine and vitamin C. Recommended agents like trimethoprim, nitrofurantoin and vaginal estrogens are infrequently used. We conclude that prescribing of prophylactic agents for UTIs in nursing homes is not evidence-based.
- SourceAvailable from: Monique A.A. Caljouw[Show abstract] [Hide abstract]
ABSTRACT: Objectives: To determine whether cranberry capsules prevent urinary tract infection (UTI) in long-term care facility (LTCF) residents. Design: Double-blind randomized placebo-controlled multicenter trial. Setting: Long-term care facilities (LTCFs). Participants: LTCF residents (N = 928; 703 women, median age 84). Measurements: Cranberry and placebo capsules were taken twice daily for 12 months. Participants were stratified according to UTI risk (risk factors included long-term catheterization, diabetes mellitus, ≥1 UTI in preceding year). Main outcomes were incidence of UTI according to a clinical definition and a strict definition. Results: In participants with high UTI risk at baseline (n = 516), the incidence of clinically defined UTI was lower with cranberry capsules than with placebo (62.8 vs 84.8 per 100 person-years at risk, P = .04); the treatment effect was 0.74 (95% confidence interval (CI) = 0.57–0.97). For the strict definition, the treatment effect was 1.02 (95% CI = 0.68–1.55). No difference in UTI incidence between cranberry and placebo was found in participants with low UTI risk (n = 412). Conclusion: In LTCF residents with high UTI risk at baseline, taking cranberry capsules twice daily reduces the incidence of clinically defined UTI, although it does not reduce the incidence of strictly defined UTI. No difference in incidence of UTI was found in residents with low UTI risk.Journal of the American Geriatrics Society 01/2014; 62:103-110. · 4.22 Impact Factor
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ABSTRACT: Urinary tract infection is a common problem of elderly populations. Clinical trials addressing urinary infection in the elderly frequently use nonstandardized diagnostic criteria, which compromises the validity of conclusions. Studies of prevention of infection in postmenopausal women in the community consistently report outcomes similar to observations in premenopausal women. Antimicrobial prophylaxis or self-treatment is effective, and cranberry products or probiotics are not beneficial. Critical evaluation of nursing home populations reports no association between nonspecific, nonlocalizing symptoms of any duration and bacteriuria. Optimal antimicrobial use for urinary infection, particularly for residents of long term care facilities, remains challenging. A high proportion of residents in some facilities receive prophylactic therapy to prevent urinary tract infections without evidence to support this practice. Evaluations of multifaceted antimicrobial stewardship programs to improve antimicrobial use in nursing homes report modest benefits.Current Translational Geriatrics and Experimental Gerontology Reports. 09/2013; 2(3).
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ABSTRACT: OBJECTIVES: To determine whether cranberry capsules prevent urinary tract infection (UTI) in long-term care facility (LTCF) residents. DESIGN: Double-blind randomized placebo-controlled mul-ticenter trial. SETTING: Long-term care facilities (LTCFs). PARTICIPANTS: LTCF residents (N = 928; 703 women, median age 84). MEASUREMENTS: Cranberry and placebo capsules were taken twice daily for 12 months. Participants were strati-fied according to UTI risk (risk factors included long-term catheterization, diabetes mellitus, ≥1 UTI in preceding year). Main outcomes were incidence of UTI according to a clinical definition and a strict definition. RESULTS: In participants with high UTI risk at baseline (n = 516), the incidence of clinically defined UTI was lower with cranberry capsules than with placebo (62.8 vs 84.8 per 100 person-years at risk, P = .04); the treatment effect was 0.74 (95% confidence interval (CI) = 0.57– 0.97). For the strict definition, the treatment effect was 1.02 (95% CI = 0.68–1.55). No difference in UTI inci-dence between cranberry and placebo was found in partici-pants with low UTI risk (n = 412). CONCLUSION: In LTCF residents with high UTI risk at baseline, taking cranberry capsules twice daily reduces the incidence of clinically defined UTI, although it does not reduce the incidence of strictly defined UTI. No difference in incidence of UTI was found in residents with low UTI risk. J Am Geriatr Soc 62:103–110, 2014. U rinary tract infection (UTI) is a common bacterial infection in residents of long-term care facilities (LTCF), 1,2 accounting for nearly 25% of all infections. 3,4 UTI not only causes several days of illness, but may have more-severe consequences such as delirium, dehydration, urosepsis, hospitalization, or even death. 5,6 Interventions to prevent UTI could reduce these severe consequences, 7 but there are no evidence-based interven-tions that decrease UTI in institutionalized populations. 1 The use of prophylactic antibiotics is currently controversial because of side-effects and antibiotic resistance. 8,9 Prophy-laxis with cranberry is a potential prevention strategy. 10,11 Cranberries contain proanthocyanidins (PACs), which are stable phenolic compounds with anti-adhesion activity against Escherichia coli. 12–14 In vitro, antibacterial activity of concentrated cranberry juice against other pathogens such Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Proteus mirabilis has also been demon-strated. 15,16 There is aggregated evidence that cranberry juice may lead to a decrease in the incidence of symptomatic UTIs over a 12-month period, particularly in women with recurrent UTIs. 17,18 Another recent systematic review indi-cates that cranberry-containing products are associated with a protective effect against UTI in different sub-groups, albeit with heterogeneity across the included tri-als. 19 A recent study in children without urological abnormalities showed a 65% reduction of UTI with the use of cranberry. 20
RESEARCH ARTICLEOpen Access
Prevention of urinary tract infections in nursing
homes: lack of evidence-based prescription?
Jenny Bergman1*, Jan Schjøtt2,3and Hege S Blix4
Background: Urinary tract infections (UTIs, including upper and lower symptomatic) are the most common
infections in nursing homes and prevention may reduce patient suffering, antibiotic use and resistance. The spectre
of agents used in preventing UTIs in nursing homes is scarcely documented and the aim of this study was to
explore which agents are prescribed for this purpose.
Methods: We conducted a one-day, point-prevalence study in 44 Norwegian nursing homes during April-May
2006. Nursing home residents prescribed any agent for UTI prophylaxis were included. Information recorded was
type of agent and dose, patient age and gender, together with nursing home characteristics. Appropriateness of
prophylactic prescribing was evaluated with references to evidence in the literature and current national
Results: The study included 1473 residents. 18% (n = 269) of the residents had at least one agent recorded as
prophylaxis of UTI, varying between 0-50% among the nursing homes. Methenamine was used by 48% of residents
prescribed prophylaxis, vitamin C by 32%, and cranberry products by 10%. Estrogens were used by 30% but only
one third was for vaginal administration. Trimethoprim and nitrofurantoin were used as prophylaxis by 5% and 4%,
Conclusions: The agents frequently prescribed to prevent UTIs in Norwegian nursing homes lack documented
efficacy including methenamine and vitamin C. Recommended agents like trimethoprim, nitrofurantoin and vaginal
estrogens are infrequently used. We conclude that prescribing of prophylactic agents for UTIs in nursing homes is
Urinary tract infections (UTIs) in the elderly include
upper and lower symptomatic UTIs . Asymptomatic
bacteriuria is common and there is a wide consensus
that this should not be treated. Guidelines have been
developed for diagnostic criteria and treatment of UTIs
[1-3]. In spite of this, studies show that a large propor-
tion of antibacterial use in nursing homes may be inap-
Nursing home residents frequently have infections and
the prevalence is estimated to be 6-8%. UTIs accounts
for around half of these infections and the estimates are
similar irrespective of differences in study design [6-8].
uropathogens has been relatively stable in the last dec-
ade . Antimicrobial resistance pattern and health pol-
icy influences the national guidelines and pivmecillinam,
trimethoprim and nitrofurantoin are the drugs of choice
for treatment of acute symptomatic UTIs in Norway.
Quinolones are only recommended in case of resistance
or in upper UTI [3,10].
As a consequence of the high frequency of UTIs in
nursing homes, several prevention strategies for recur-
rent UTIs are suggested. In addition to infection control
programs and appropriate use of urinary catheters, use
of prophylactic agents has been regarded as important.
The use of prophylactic treatments for UTIs is com-
monly studied in subpopulations with risk factors like
catheter use or urine reflux. These risk factors are pre-
valent in nursing homes, but little is known about UTI
prophylaxis in these institutions. There is evidence that
prophylaxis with low-dose antibiotics [11,12] and vaginal
* Correspondence: firstname.lastname@example.org
1Regional medicines information and pharmacovigilance centre (RELIS Vest),
Haukeland University Hospital, Bergen, Norway
Full list of author information is available at the end of the article
Bergman et al. BMC Geriatrics 2011, 11:69
© 2011 Bergman et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
estrogens in postmenopausal women reduce the rate of
UTIs . In accordance with this, Norwegian guide-
lines recommend low dose of trimethoprim and nitro-
furantoin as UTI prophylaxis in nursing homes
residents. Vaginal administration of estrogens can also
be tried . Less proof is found for other prophylactic
agents like methenamine and cranberries [14-16]
although they are mentioned in the guidelines with a
lower grade of evidence .
We could not find any studies looking at the preva-
lence and pattern of UTI prevention in nursing homes.
The aim of this study was to explore which agents are
used and the prescribing pattern for this purpose in
During April and May 2006, a one-day point-prevalence
prescription study among all residents in 44 Norwegian
nursing homes was carried out. The nursing homes
were enrolled by members of the national network of
consultant pharmacists. Data were collected by the use
of two questionnaires and the consultant pharmacists
were responsible for the data quality with the aid of
nurses in the respective institutions. One questionnaire
concerned the nursing home characteristics and demo-
graphics and the second questionnaire concerned the
prescription of prophylactic agents for UTIs. Appropri-
ateness of the prophylactic prescribing was evaluated
with reference to evidence in the literature and current
national guidelines . The study was approved by the
ethical committee and the Norwegian Social Science
Nursing homes in Norway are community-based, not a
part of hospitals, and populate 14% of the elderly aged
80 years and older. In 2006 there were 1003 nursing
homes with 40 537 beds in Norway and 77% of the resi-
dents were ≥ 80 years of age (Statistics Norway http://
www.ssb.no). Nursing homes provide 24 hrs nursing
care and have own physicians employed, part or full
time. The physicians are normally general practitioners
(GPs) and specialisation in geriatrics is not compulsory.
The nursing home physician has the medical responsi-
bility for the patients in the nursing home and pre-
scribes all drugs and other agents used for medicinal
purposes in the medical record. Infection prevention
and control specialists are not employed at nursing
homes in Norway.
The data collected for each nursing home were num-
ber of residents, proportion of single rooms and level of
care for each institution. Level of care was categorised
as rehabilitation, long term somatic or dementia special
care units when at least 70% of the beds fell into one of
the categories. Otherwise it was called a mixed institu-
tion. Risk factors like catheter use and faecal inconti-
nence were not recorded. Demographics included
registration of gender and age.
Prophylactic agents and antibiotics for therapy
All possible agents used for prevention of UTIs noted in
the residents medical records were included, i.e. medic-
inal agents, vitamins and herbals, and they were recorded
by name, daily dose and route of administration. Agents
were classified according to The Anatomical Therapeutic
Chemical (ATC) system . Cranberry products repre-
sents a heterogeneous group of agents (including differ-
ent doses of extracts, juices and capsules) but were coded
together. The indication for UTI prophylaxis by the nur-
sing home physician was accepted without further details
of treatment criteria. Furthermore, length of treatment
(according to the physician) was recorded in days. Pro-
phylactic treatments are expected to be long-term and if
no date of evaluation or withdrawal was assigned by the
physician in the medical record, the treatments were
recorded as continuous in the study.
The data was analysed using SPSS 15.0 (SPSS Inc., Chi-
cago IL). Descriptive statistics are shown as means with
standard deviations (SD).
Nursing home and resident characteristics
Forty-four nursing homes with a total of 1473 residents
were included. The institutions were situated in central
and northern parts of Norway in five out of 19 Norwe-
gian counties. Data collection was performed by 11 con-
sultant pharmacists. The average nursing home had 33
residents (SD = 18.0, range 8-86). 19% of the residents
lived in dementia special care homes, 43% in long term
somatic homes and 38% in mixed institutions. In 26
nursing homes (59%) all residents had single rooms; one
nursing home had no single rooms while in the remain-
ing 17 nursing homes the majority of the residents lived
in single rooms. 81% of the residents prescribed prophy-
laxis were females and 61% were above 80 years of age.
Prophylactic agents for UTIs
269 residents (18%) used at least one agent for UTI pro-
phylaxis, Table 1. The proportion of residents with UTI
prophylaxis varied between 0-50% among the nursing
homes. Fifteen percent of the residents in homes for
demented patients used prophylaxis for UTI, while 19%
were prescribed UTI prophylaxis in long-term somatic
and mixed institutions. However the pattern of prophy-
lactic agents did not differ between the different types
Bergman et al. BMC Geriatrics 2011, 11:69
Page 2 of 6
of institutions. Among residents using prophylactic
agents, 74% had one agent prescribed, while 26% were
prescribed two, three or four concomitant prophylactic
agents, Table 1.
Methenamine was used by 48% of the residents pre-
scribed prophylaxis, vitamin C by 32%, estrogens by 30%
and cranberry products by 10%. In women receiving
estrogens as prophylactic treatment, 25 (31%) had vagi-
nal administered drugs and the others oral. Trimetho-
prim and nitrofurantoin were used as prophylaxis for
UTIs in 9% of the residents, Table 1.
Dosages of prophylactic agents are shown in Table 2 and
were within the recommended dosage range for preven-
tion of UTIs as stated in the summary of product charac-
teristics (SPC) for methenamine, estrogens, trimethoprim
and nitrofurantoin. The prescribing of cranberry products
appeared to follow suggested dosage by manufacturers in
general, though recommendation sheets were not available
for every commercial product used. The dosage of vitamin
C varied between 60-2000 mg per day.
The main finding of this study is that agents frequently
prescribed to prevent UTIs in Norwegian nursing
homes lack documented efficacy in the elderly. Recom-
mended agents like trimethoprim, nitrofurantoin and
vaginal estrogens are infrequently used. Instead we
observed a high prevalence of methenamine, vitamin C,
systemic estrogens and cranberry products. We con-
clude that prescribing of prophylactic agents for UTIs in
nursing homes is not evidence-based according to the
literature and current national guidelines.
Recurrent UTIs are common, especially in older
women. Thus, high frequency of residents using prophy-
laxis in our study could be expected. However, the high
variation in prevalence and the choices of prophylactic
agents were surprising. One or several concomitant pro-
phylactic agents were used by almost one fifth of the
residents. At present we do not know which factors
contribute to this high variation in prophylactic
Table 1 Prophylaxis regimes for urinary tract infections in 1473 nursing home residents, number and proportions (%)
of all residents and of residents with prophylaxis.
Number % of all residents % of residents with prophylaxis
Residents given prophylaxis for UTIs 269
3% Three or four agents
Agents used for prophylaxis
Table 2 Dosage of UTI prophylactic agents used in 1473 nursing home residents; Last columns: Norwegian guidelines
on recommended UTI prophylactic treatments in nursing homes.
Dosage of UTI prophylactic agents used in 1473 nursing
Norwegian guidelines: recommended UTI prophylaxis in nursing homes
Agents used Mean (SD)Dosage range Dosage Comments
1.87 g (0.47)
490 mg (370)
1 - 2 g daily
60 - 2000 mg daily
0.5 - 2 g daily*
0.5 - 1.5 mg weekly**
1 - 2 capsules daily***
100 - 160 mg daily
50 - 150 mg daily
1 g twice daily
Low grade documentation****
Vaginal estrogens can be tried in recurrent UTIs
--Low grade documentation****
Consider local resistance pattern
Less effective with low or intermediate eGFR*****, pulmonal
and kidney function must be assessed if long term treatment
110 mg (26)
70 mg (35)
100 mg daily
50 mg daily
* oral daily doses, ** vaginal weekly doses estriol (50 - 52 μg estradiol weekly), *** 2 residents received 4 ml mixture or 0.5 drinking glass of cranberry juice daily
**** Evidence grading system as commonly used in clinical practice Guidelines
***** Estimated glomerular filtration rate
Bergman et al. BMC Geriatrics 2011, 11:69
Page 3 of 6
This and former studies have shown that the urinary
antiseptic agent methenamine is frequently used in Nor-
way and in Norwegian nursing homes, in contrast to
most other countries in Europe [18,19]. In Norway, the
use has even been increasing, and in 2010 methenamine
represented 17% of antibacterials for systemic use, mea-
sured as share of DDDs among antiinfectives for sys-
temic use (ATC-group J01) . A Cochrane review of
methenamine for preventing UTIs, found the overall
quality of the studies to be poor. Few studies addressed
long term use or the use in postmenopausal women or
elderly in general. In the review it was concluded that
methenamine may be effective for preventing UTI in
patients without renal tract abnormalities, particularly
when used for short-term prophylaxis . In our study
we found methenamine to be used frequently. The use
appeared to be continuous which is in accordance with
the SPC that does not state any limitations to treatment
duration but in contrast with other documentation as
summarized in the Cochrane review [15,21]. Current
Norwegian guidelines include prophylactic use of
methenamine as in patients without catheter, but point
out the low grade of documentation for this agent .
Traditionally, cranberries have been used to prevent
UTIs, but studies of efficacy have shown conflicting
results. A recent Cochrane review concluded that cran-
berries could be effective, but that the evidence for the
elderly still was inconclusive . Another review did
not recommend cranberry products for the prophylaxis
of UTIs due to heterogeneity in study design and
results, and a lack of consensus regarding both dosage
regime and formulations. Interactions may be a problem
in patients with polypharmacy, especially for concen-
trated cranberry products . In addition, intolerance
to cranberries probably represents a problem in the
elderly and high withdrawal rates are reported in several
studies [16,22]. In contrast to this, the withdrawal rates
due to adverse reactions were the same comparing 500
mg cranberry extract with 100 mg trimethoprim in one
study and with trimethoprim-sulfamethoxazole in
another study. These studies included community dwell-
ing women, age 45-93 years and 18 years to menopause
respectively, and the relevance for nursing home resi-
dents is unclear [23,24].
Vaginal estrogens have been shown to decrease UTIs
while systemic estrogens do not appear to have the
same effect . In our study only 31% (25 of 81) of the
estrogens prescribed as UTI prophylaxis were for vaginal
administration. This is troublesome because systemic
estrogens have been associated with increased risk of
cardiovascular disease, venous thromboembolic events
and breast cancer . Current Norwegian guidelines
recommend vaginal estrogens to women with recurrent
Trimethoprim and nitrofurantoin were the two anti-
biotics prescribed for prevention and used only by few
of the nursing home patients. Long-term antibiotics are
well documented to reduce the rate of UTIs but may be
complicated by bacterial resistance and adverse drug
reactions (ADRs) [11,12]. The prevalence of trimetho-
prim resistance in Escherichia coli isolates in Norway
was 19% in 2007, being the drug with the highest preva-
lence of resistance in urinary tract isolates . Nitrofur-
antoin was only resistant in 2.3% of the isolates .
However, nitrofurantoin should be used with caution in
patients with renal impairment as reduced renal clear-
ance increase the risk of ADRs and sufficient concentra-
tion in the urine depends on renal function. In addition,
long term use of nitrofurantoin is associated with lung
fibrosis and peripheral neuropathy [3,26]. As glomerular
filtration rate decline by age, nursing home patients are
at risk of a negative risk/benefit balance for the use of
nitrofurantoin . Local resistance pattern and indivi-
dual renal function should therefore be considered
before prescribing trimethoprim or nitrofurantoin for
long-term use to nursing home residents.
Vitamin C has traditionally been regarded as effective
in preventing recurrent UTIs. However, we could not
find any studies showing that vitamin C is effective in
preventing UTIs in the elderly. Norwegian guidelines do
not recommend the use of vitamin C for UTI prophy-
laxis in nursing homes.
To summarize, our results show lack of evidence-
based prescribing of prophylactic agents for UTIs in
Norwegian nursing homes, according to evidence in the
literature and current national guidelines. Low dose
antibiotics and vaginal estrogens are at present recom-
mended agents. However, they were only used by 18%
of the residents prescribed prophylaxis in this study.
The use of methenamine and cranberries were common,
but the efficacy of these agents is not well documented.
Systemic estrogens and vitamin C have no place in pre-
venting UTIs and are to be considered as inappropriate
as alternative and more evidence-based therapy exists.
Prophylactic agents were prescribed continuously to
residents, suggesting that their use were not regularly
evaluated. The influence of catheter use and other risk
factors are not known in our study, but an European
surveillance study found the use of urinary catheter to
be low (4,8%) in Norwegian nursing homes .
Generalisations from prevalence studies must be made
carefully, but results can be useful to define quality
improvement projects in institutions with less developed
infection control systems than in hospitals. In previously
published data from this study we showed prescribing of
antibiotics for therapy to be in line with other studies
from nursing homes [6,7,18]. We found all prescribing
of UTI prophylaxis to be continuously which minimize
Bergman et al. BMC Geriatrics 2011, 11:69
Page 4 of 6
the variation in results of this prevalence study. Interest-
ingly, a recent Dutch study found a high occurrence of
non-catheter related UTIs in nursing homes, perhaps
due to frequent faecal incontinence among residents
. If this is true, prophylaxis should be focused on
improving hygiene and providing incontinence materials
rather than prescription of the agents found in our
study. Notably, our study included a large number of
nursing homes representing diversity in size and func-
tion. Thus, we believe the results from this study apply
to Norwegian nursing homes in general, and that they
also could be of international interest.
This study showed a high prevalence and large variation
in the use of UTI prophylactic agents in Norwegian nur-
sing homes. The prescribing of agents to prevent UTIs
was in most cases not in accordance with evidence in
the literature or current national guidelines. The wide
prescribing of agents that lack documentation of effec-
tiveness is troublesome, and could represent an interna-
tional problem as treatment of recurrent UTIs is a
common challenge in the elderly. Thus, further studies
are needed to clarify this prescribing behaviour and to
evaluate possible benefits and disadvantages of prophy-
lactic treatments in nursing home residents.
We thank the consultant pharmacists and data providers; Egil Fagerheim,
Kari Urnes Fagerheim, Trine Fevik, Hilde Flatås, Bodil Stien Haugene, Kirsti
Wang Jørgensen, Marja Kos, May Oddrun Sti, Elisabeth Grav Sørensen,
Margareth Wiik, Trine Aag, making it possible to perform this study.
1Regional medicines information and pharmacovigilance centre (RELIS Vest),
Haukeland University Hospital, Bergen, Norway.2Section of Clinical
Pharmacology, Laboratory of Clinical Biochemistry, Haukeland University
Hospital, Bergen, Norway.3Section of Pharmacology, Institute of Medicine,
University of Bergen, Bergen, Norway.4Department of
Pharmacoepidemiology, Norwegian Institute of Public Health, Oslo, Norway.
All authors (JB, JS, HSB) have participated in the design and coordination,
been involved in drafting the manuscript, critically reviewed the manuscript,
read and approved the final manuscript.
The authors (JB, JS, HSB) declare that they have no competing interests. The
authors are employed at their respective institutions. Otherwise, the study
was carried out without financial support.
Received: 7 July 2011 Accepted: 1 November 2011
Published: 1 November 2011
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The pre-publication history for this paper can be accessed here:
Cite this article as: Bergman et al.: Prevention of urinary tract infections
in nursing homes: lack of evidence-based prescription? BMC Geriatrics
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