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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

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” CONTINENCE MATTERS

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) CONTINENCE MATTERS

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 CONTINENCE MATTERS

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Asymptomatic bacteriuria Healthy premenopausal women 1-5% Healthy postmenopausal women (50-70) 2.8-8.6% Older community-dwelling patients Women (older than 70 years) 10.8-16% Men 3.6-19% Older long-term care residents Women 25-50% Men 15-40% Patients with an indwelling catheter Short-term 9-23% Long-term 100% CID2005;40:643-654 CONTINENCE MATTERS

What to do When the urine smells or is cloudy When the dipstick is “positive” With the MSU results CONTINENCE MATTERS

“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 CONTINENCE MATTERS

Dipstick is positive Does a positive dipstick mean UTI? High false positive rate False negatives do occur CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

The culture is positive The symptomatic patient The asymptomatic patient Longterm IDC CONTINENCE MATTERS

The symptomatic patient Treat with appropriate antibiotics CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

Asymptomatic bacteriuria When should you treat asymptomatic bacteriuria? Pregnant women Urologic interventions TURP Any urologic procedure with potential mucosal bleeding Prosthetic surgery CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

What to do - recurrent History Examination Collate urine tests Post treatment microurine Post void residual Other tests may be necessary Imaging: ultrasound Cystoscopy CONTINENCE MATTERS

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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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

Other Probiotics Intravesical Weak evidence in prophylaxis Antibiotic ie gentamicin –self administer Ialuril: early evidence CONTINENCE MATTERS

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 CONTINENCE MATTERS

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 CONTINENCE MATTERS

Thank you CONTINENCE MATTERS