1. Dr Rohan Wee Aged Care Physician Northern Health
UTIs in Older People
Dr Rohan Wee
Aged Care Physician
Northern Health

2. Are UTIs Important? Most frequent infection in residential care
Dementia, incontinence & decreased mobility are risk factors for developing UTIs
Asymptomatic bacteriuria is common
15-30% in men
25-50% in women
Long term IDCs are always colonised

3. How do we diagnose a UTI? Symptoms Probability of UTI in women 90%
Dysuria, frequency, lower abdominal pain, urgency, haematuria
Absence of vaginal discharge or irritation
Probability of UTI in women 90%
Urinalysis
Pyuria
MSU

4. The problem is…
Residential care residents often can’t give reliable histories
Urinalysis and culture are often done for atypical symptoms
Change in behaviour
Decrease in appetite etc
Asymptomatic bacteriuria is common

5. Asymptomatic bacteriuria (1)
Is more common in
Diabetics
The elderly
Long term IDCs
Pyuria is not a reliable predictor of bacteriuria
Urinalysis is not useful in predicting bacteriuria

6. Asymptomatic bacteriuria (2)
Why would we treat if asymptomatic?
Prevent later infections
Not evidence to suggest this works
Less asymptomatic bacteriuria in follow up but not UTIs
Survival benefit
Increased mortality in patients with bacteriuria
No improvement in mortality if treated
Probably reflects differences in patient groups
Improve continence
No benefit in a residential care population

7. What to do … When the urine smells or is cloudy
When the FWT is “positive”
With the MSU results

8. “Doctor - the urine smells”
No evidence that an offensive odour correlates with UTI
Prospective trial comparing diagnosis by smell to clean catch urine did not find that smell was reliable in identifying UTI
No evidence that cloudy urine correlates to UTI

9. Urinalysis in Residential Care
Does a “positive” FWT mean UTI?
High false positive rate
False negatives do occur
In an asymptomatic patient
Positive FWT is probably a false positive
Negative FWT means UTI unlikely

10. The MSU is Positive The asymptomatic patient The symptomatic patient
Long term IDC

11. The Asymptomatic patient
A positive MSU probably represents asymptomatic bacteriuria
No treatment is required
Observe patient

12. The Symptomatic patient
Treat with appropriate antibiotics

13. Long Term IDC Always colonised MSU/CSU Treat if symptomatic
May indicate what bacteria to treat if the patient becomes unwell
Ideally change IDC just before CSU for most accurate results
Treat if symptomatic
Fever, loin pain

14. Non-specific Decline (1)
The evidence for the correct course of action is poor
Assess the patient
History
Examination
Investigations
FBE, U&E, +/- CXR
FWT/MSU

15. Non-specific Decline (2)
FWT
Positive may be a false positive
Negative makes UTI less likely
MSU
Will guide antibiotic choice if LMO chooses to treat
May be treating asymptomatic bacteriuria
Treating a “UTI” should occur after other causes have been excluded if the situation requires it

16. Preventing Recurrent UTI (1)
Increased fluid intake
No evidence but it may be helpful
Cranberry juice
Some limited evidence
Limitations
Variable dose and duration
Calorie load
Not clear if cranberry tablets are of benefit

17. Preventing Recurrent UTI (2)
Topical oestrogen
Improves atrophic vaginitis
Encourages lactobacilli growth, decreases E. coli growth
Antibiotic prophylaxis
Useful if >3 symptomatic UTIs/year
Risk of resistant organisms

18. References
Up To Date
Recurrent UTI in women
Overview of acute cystitis in women
Approach to the patient with asymptomatic bacteriuria
UTI associated with indwelling catheter
UTI in geriatric and institutionalized patients L. E. Nicholle, Current Opinion in Urology 2002, 12:51-55