1. Ailsa Wilson Edwards Continence Matters
The infection question: Practical strategies for acute treatment and prevention of recurrent UTIs in the elderly
Ailsa Wilson Edwards
Continence Matters
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2. UTIs in elderly The problem In the elderly UTIs can be difficult to
Common
Most frequent infection in residential care
Point prevalence 2.6% in >75 y
Significant morbidity and mortality
In the elderly UTIs can be difficult to
Diagnose
Treat
Prevent
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3. UTIs in elderly Mechanism of UTI: Natural defences against infection
Ascending infection
Colonic bacteria: E coli, Klebsiella, Proteus, etc
Natural defences against infection
Urethral mucosa coapts
Urine inhibitory
Bladder wall impermeable
Periodic complete bladder emptying
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4. UTIs in elderly Elderly are more susceptible to UTIs Low oestrogen
Compromised immunity, comorbidities
Compromised urinary defences
Limitation of fluid intake
Catheters
Incontinence
Dementia
Poor mobility
Constipation/faecal incontinence
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5. Mixed presentation Usual symptoms
Dysuria
Frequency, urgency
Worsening incontinence
Suprapubic discomfort
Strangury
Loin pain
Haematuria
Rectal pain in men
Fever
Immune changes – may lack typical symptoms
Instead:
Confusion
Worsening memory
Delirium
Falls
Poor appetite
“Off”
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6. Diagnostic problems
Back pain, frequency, urgency, incontinence, smelly/cloudy urine are common in elderly and may not represent UTI
Elderly often can’t give good histories
Comorbid illnesses may have similar symptoms
Urine tests are often done for non-urinary symptoms (poor appetite, change in behaviour)
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7. Dipstick and Culture may be misleading
UTI
False negative
Test done too early
Post antibiotics
False positive
Squamous contamination
Asymptomatic bacteriuria
Mixed growth (contaminated/delayed processing)
Dipstick and Culture may be misleading
UTI =
Symptoms
Positive urine
Sig colony count
pyuria
ideally no epithelial
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15. Asymptomatic bacteriuria
Healthy premenopausal women %
Healthy postmenopausal women (50-70) %
Older community-dwelling patients
Women (older than 70 years) %
Men %
Older long-term care residents
Women %
Men %
Patients with an indwelling catheter
Short-term %
Long-term %
CID2005;40:
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16. What to do When the urine smells or is cloudy
When the dipstick is “positive”
With the MSU results
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17. “The urine smells”
No evidence that an offensive odour always correlates with a 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 always correlates with UTI
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18. Dipstick is positive Does a positive dipstick mean UTI?
High false positive rate
False negatives do occur
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19. Positive dipstick -> probability of UTI
Leukocyte esterase (LE): Enzyme found in WBCs
sensitivity ~75%, specificity ~98%
Nitrites: Certain bacteria reduce nitrates to nitrites
Sensitivity 30-85%, specificity 90%
Combined leukocyte esterase and nitrite:
sensitivity 88%-92%; specificity 66%-76% for detection of UTI
Dipstick acceptable for screening
Can be the sole urine test for otherwise healthy women if acute cystitis seems clear and no complicating factors
Infect Control Hosp Epidemiol 2007Am Fam Phys 2005
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20. Dipstick is positive In a symptomatic patient
Treat +/- proceed with culture
In an asymptomatic patient
Positive dipstick is probably a false positive
Negative dipstick means UTI unlikely
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21. The culture is positive
The symptomatic patient
The asymptomatic patient
Longterm IDC
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22. The symptomatic patient
Treat with appropriate antibiotics
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23. The asymptomatic patient
Positive MSU often represents asymptomatic bacteriuria or contamination
Why was the test done?
No treatment probably required
Observe
Consider repeating test if important
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24. Why not just treat anyway?
No benefit
No reduction in mortality
No increased adverse outcomes if not treated
Doesn’t prevent future infections
(followup less asymptomatic bacteriuria but not UTIs)
Cost
Antibiotic resistance ↑Hospitalisation ↑Mortality ↑Cost
Clostridium difficile Main risk factor is exposure to antibiotics
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25. Asymptomatic bacteriuria
When should you treat asymptomatic bacteriuria?
Pregnant women
Urologic interventions
TURP
Any urologic procedure with potential mucosal bleeding
Prosthetic surgery
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26. Nonspecific decline Little guidance how best to proceed
Assess the patient
History+Examination
Investigations
dipstick: positive may be false positive, negative=UTI unlikely
MSU will guide antibiotic choice – may be treating asym bacteriuria
Treating a “UTI” should include excluding other causes
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27. Collecting urine samples
Mid-stream or clean catch best
Sometimes in-out catheter
Indwelling catheters
Longterm: Change catheter prior to collection
short-term (< 30 days)
Can sample through catheter port using aseptic technique
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28. Catheters in elderly 5-10% of nursing home residents
Perturbs defences = easy access for bacteria into urinary tract
Always colonised (3-8% per day, 100% at a month)
Sometimes infected
Pyuria, smell, cloudiness cannot differentiate
Inappropriate antibiotics to treat catheter associated bacteriuria is wasteful and encourages resistance
Avoid testing “just in case”
Restrict catheters to only those who absolutely need them
Remove catheter as soon as no longer required
SPC no better than IDC at preventing UTIs
Keep bag below level bladder
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29. Management of Acute UTI
History+Examination+Urine test
Red flags:
Very Unwell/febrile
Loin pain ?upper tract infected/obstructed
Prostatitis in men
Urinary prosthesis (AUS) or recent surgery
Antibiotics
Supportive care
Symptom relief
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30. Which antibiotic? Culture appropriate (this UTI/last result)
Allergies?
What worked before?
Duration: 3-7 d uncomplicated women, 7 d men
Fail to respond: retest, change Ab, consider complication or alternative diagnosis
Problem
Warn or avoid
Thrush
Amoxycillin, augmentin (cephalexin)
Nausea/vomiting
Nitrofurantoin
Renal failure
Trimethoprim, nitrofurantoin
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31. Recurrent UTIs 3 in 12 months or 2 in 6 months Relapse
Same organism/strain
Short interval (<2 weeks)
Post treatment MSU may not be clear
Suggests uneradicated focus
Reinfection (most)
Longer interval
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32. What to do - recurrent History Examination Collate urine tests
Post treatment microurine
Post void residual
Other tests may be necessary
Imaging: ultrasound
Cystoscopy
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36. Recurrent – Prophylaxis
General:
Constipation
Increase fluid intake
Skin care
Change wet pads and briefs
Hygeine
Timed voiding
Catheter care
OTC/Prescribed
Cranberry, D-mannose
Vaginal oestrogen
Hiprex
Antibiotics
Post coital
Longterm lowdose
Intravesical
antibiotics
Ialuril
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37. Cranberry Usually tried first Some evidence Controversy
Procyanithidins interfere with P-fimbrial adhesion
Controversy
Juice vs tablets/capsules
variable dose
Unclear benefit
Calorie load
warfarin
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38. Vaginal oestrogen Good evidence
Improves atrophic vaginitis, encourages lactobacilli, decreases E. coli growth
Nightly for 2 weeks, then 2 nights a week ongoing
Ovestin cream periurethrally
Vagifem pessary (pellet)
Systemic HRT inadequate local effect
If history of breast cancer discuss with surgeon
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39. Hiprex Urinary “antiseptic” Concentrates in urine as formaldehyde
“It didn’t work before”
Preventative, not treatment
1 g bd
acid environment (Vitamin C)
SE: reflux, gout
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40. Antibiotics - postcoital
29% of men and 25% of women over 80 are sexually active
Single low dose prophylaxis within 2 hours after intercourse
Cephalexin 250 mg
Nitrofurantoin 50 mg
Low side effects
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41. Antibiotics – low dose longterm
Risk resistant organisms – appears to be low
Side effects higher
Single low dose at night
Cephalexin 250 mg
Nitrofurantoin 50 mg
if effective continuing 6 months initially may break cycle of infections
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42. Other Probiotics Intravesical Weak evidence in prophylaxis
Antibiotic ie gentamicin –self administer
Ialuril: early evidence
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43. Prophylaxis Combination commonly required
Review effectiveness regularly
12 weeks is adequate trial if not working
If failing consider underlying cause or alternative diagnosis and investigate further
Asymptomatic bacteriuria
Bladder emptying
Cancer, stone, fistula, diverticulum, obstruction
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44. Conclusions
Routine urine screening in asymptomatic elderly people without a good reason is not recommended
Treat symptomatic infections promptly using culture appropriate antibiotics
Antibiotics can cause problems
Recurrent infections, especially in men, need workup
Prophylaxis may take some trial and error
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45. Thank you
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