1. Urinalysis in the Elderly
The Good: The Bad: The Ugly

2. Can I Get a UA Mr. Smith is confused Mr. Jones fell
Mr. Walker is not acting like his normal self
Miss Foy is not eating well today
Mrs. Weber’s urine is dark or cloudy
etc

3. When to Order A Urine C&S
Must have S/S of UTI
Increased frequency or urgency
Burning with urination
Fever
Flank Pain
Gross Hematuria
Suprapubic Pain

4. Urine C&S
Should be ordered when it would affect Clinical Care

5. Interpretation of Analysis
Appearance cloudy
Leukocytes Esterace 1+
Blood 2+
UA Microscopic
WBC > 50
RBC 10-20
Occasional Bacteria

6. Microbiology Criteria
At least 10 5th cfu/ml of no more than 2 organisms in voided sample
At least 10 2nd of any number of organisms in a specimen collected by the in and out catheter

7. Minimal Inhibitory Concentration (MIC) Interpretation
Susceptible
Strain can be treated with conventional antibiotics
Intermediate
May work but the response may be reduced
Resistant
Not work

8. Urine CX Results Klebsiella Pneumoniae > 100,000
Antibiotic MIC Interpretation
Ampicillin >= 32 R
Cefazolin <=4 S
Cipro <=0.25 S
Nitrofurantoin S
Trimethaprim Sulfa <=20 S

9. UA Appearance Cloudy Leukocyte Esterase 2+ Nitrites Microscopic +
WBC > 50
Bacteria Rare +

10. C & S E Coli Antibiotic MIC Interpretation Ampicillin <= 2 S
Cefazolin <= S
Cipro <= S
Trimethoprim/Sulfa <= S

11. UA Appearance Turbid Leukocyte Esterase 3+ Protein +1 Blood +2
Microscopic
WBC > 50
RBC
Bacteria Numerous

12. Asymptomatic Bacteriuria
Pt does not have SXS, but presence of bacteria in urine micro or cx
Confirm in 2 consecutive samples?
Transient in older people
Not associated with increased mortality or morbidity
More common in cognitively impaired people

13. Increased in patients with incontinence and impaired bladder emptying
Do Not Screen
Do Not Treat

14. Urinary Tract Diagnosis
Dx is made with both clinical features and lab evidence
At least two sxs of the following
Acute Dysuria
Increased frequency or urgency
CVA tenderness
Suprapubic tenderness
+ CX 10 5th CFU/ML

15. No more than 2 pathogens
Pyuria
Leukocytes > 10 mm 3rd
Fever

16. Confusion is NOT a Urinary Tract sign or symptom

17. Patients Not Meeting Criteria
Perform a thorough systemic evaluation and assessment
Differential Diagnosis
Reassess

18. Current Guidelines The American Geriatric Society
Does not recommend antibiotics to treat bacteriuria unless specific urinary tract sxs are present

19. McGeer Criteria Without a Catheter
Must include criteria from both 1 and 2
1). At least one of the following
Fever or Leukocytosis
2). And at least 1 of the following
Acute CVA pain or tenderness
Suprapubic pain
Gross hematuria
New or marked increase in incontinence

20. New or marked increase in urgency
New or marked increase in frequency
In the absence of fever or leukocytes: Then must have 2 from the above list

21. Loeb Criteria Long Term Care Facilities
Acute dysuria alone
Fever 37.9 or .5 degrees above baseline and at least one of the following
New or worsening
Urgency/Frequency/Incontinence
Suprapubic Pain/ CVA tenderness
Gross Hematuria

22. Complicated VS Uncomplicated
Does not include the elderly
Complicated
Elderly
Functional or structural abnormality in urinary tract

23. Antibiotic Stewardship
Urine CX aids in narrowing the spectrum of antibiotics - when you choose to treat
Most common bacteria is ??
Know local resistance rates
Risk VS Benefit
Side effects
Increased antibiotic resistance
Drug/Drug interaction

24. Treatment Failure VS Reinfection

25. Recurrent UTI Risk Factors
Diabetes
Functional Disability
Sexual Intercourse
HX of urological problems
Urinary Retention or incontinence
Postmenopausal Estrogen Deficiency
Prostate DZ or Kidney Stones

26. Prophylactic Antibiotic
When to use
2 or > UTI in 6 months
3 or > UTI in 1 yr
What to choose?

27. UTI Reduction Increase Fluids Routine Post Bathroom Care
B/B training every 2 hrs during the day and every 4 hrs at night
Cranberry capsules still controversial

28. The Good
UTI
Treat and patient feels better
Prevent Urosepsis

29. The Bad
Side effects
Medication compliance
Cost

30. The Ugly Clostridium Difficile Urosepsis
Antibiotics
Isolation
Diarrhea
Weakness etc
Urosepsis
Increased antibiotic resistance

31. Take Home Points
UTI is commonly overdiagnosed and therefore overtreated. Contributing to antibiotic resistance
No sxs present do not test
Educate staff and families
Confusion is not a sxs of UTI

32. Questions?

33. Thank You