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The infection question: Practical strategies for acute treatment and prevention of recurrent UTIs in the elderly Ailsa Wilson Edwards Continence Matters CONTINENCE MATTERS

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UTIs in elderly The problem 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

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UTIs in elderly Mechanism of UTI: 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

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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

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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

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Diagnostic problems Back pain, frequency, urgency, incontinence, smelly/cloudy urine are common in elderly and may not represent UTI Elderly often cant 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

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Dipstick and Culture may be misleading UTI = Symptoms Positive urine Sig colony count pyuria ideally no epithelial CONTINENCE MATTERS UTI False negative Test done too early Post antibiotics False positive Squamous contamination Asymptomatic bacteriuria Mixed growth (contaminated/del ayed processing)

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Asymptomatic bacteriuria Healthy premenopausal women1-5% Healthy postmenopausal women (50-70)2.8-8.6% Older community-dwelling patients Women (older than 70 years)10.8-16% Men3.6-19% Older long-term care residents Women25-50% Men15-40% Patients with an indwelling catheter Short-term9-23% Long-term100% CID2005;40:643-654 CONTINENCE MATTERS

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

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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

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

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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

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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

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

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The symptomatic patient Treat with appropriate antibiotics CONTINENCE MATTERS

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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

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Why not just treat anyway? No benefit No reduction in mortality No increased adverse outcomes if not treated Doesnt 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

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

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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

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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

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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

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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

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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 CONTINENCE MATTERS ProblemWarn or avoid ThrushAmoxycillin, augmentin (cephalexin) Nausea/vomitingNitrofurantoin Renal failureTrimethoprim, nitrofurantoin

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Recurrent UTIs 3 in 12 months or 2 in 6 months Relapse Same organism/strain Short interval (