The infection question: Practical strategies for acute treatment and prevention of recurrent UTIs in...
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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
The infection question: Practical strategies for acute
treatment and prevention of recurrent UTIs in the elderly Ailsa
Wilson Edwards Continence Matters CONTINENCE MATTERS
Slide 2
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
Slide 3
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
Slide 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 CONTINENCE
MATTERS
Slide 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 CONTINENCE MATTERS
Slide 6
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
Slide 7
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)
Slide 8
CONTINENCE MATTERS
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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
Slide 16
What to do When the urine smells or is cloudy When the dipstick
is positive With the MSU results CONTINENCE MATTERS
Slide 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 CONTINENCE MATTERS
Slide 18
Dipstick is positive Does a positive dipstick mean UTI? High
false positive rate False negatives do occur CONTINENCE
MATTERS
Slide 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 CONTINENCE MATTERS
Slide 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
CONTINENCE MATTERS
Slide 21
The culture is positive The symptomatic patient The
asymptomatic patient Longterm IDC CONTINENCE MATTERS
Slide 22
The symptomatic patient Treat with appropriate antibiotics
CONTINENCE MATTERS
Slide 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 CONTINENCE MATTERS
Slide 24
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
Slide 25
Asymptomatic bacteriuria When should you treat asymptomatic
bacteriuria? Pregnant women Urologic interventions TURP Any
urologic procedure with potential mucosal bleeding Prosthetic
surgery CONTINENCE MATTERS
Slide 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 CONTINENCE MATTERS
Slide 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 CONTINENCE
MATTERS
Slide 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 CONTINENCE MATTERS
Slide 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
CONTINENCE MATTERS
Slide 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 CONTINENCE MATTERS ProblemWarn or avoid
ThrushAmoxycillin, augmentin (cephalexin)
Nausea/vomitingNitrofurantoin Renal failureTrimethoprim,
nitrofurantoin
Slide 31
Recurrent UTIs 3 in 12 months or 2 in 6 months Relapse Same
organism/strain Short interval (