Urinary Tract Infection: Guidelines to assessment, treatment, and prevention in the older adult

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Urinary Tract InfectionGuidelines to
assessment, treatment, and prevention in the
older adult

• 33610 Gerontological Nursing
• University of Massachusetts Lowell
• Mary Ellen Powers, BSN, RN
• March 30, 2006

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Urinary Tract Infection

• The Agency for Healthcare Research and Quality
  (AHRQ) and the U.S. Preventive Services Task
  Force (USPSTF)

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Urinary Tract Infection
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Urinary Tract Infection

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Urinary Tract Infection Defined

• Definition
• Women Presence of at least 100,000 colony-
• forming units (cfu)/mL in a pure
• culture of voided clean-catch urine
• Men Presence of just 1,000 cfu/mL
• indicates urinary tract infection
• Some labs do not routinely identify determine
  the
• sensitivity of organisms for specimens with
  lt10,000
• cfu/mL. May have to special request.
• Swart, Soler Holman, 2004

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Urinary Tract Infection
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Urinary Tract InfectionPhysiologic Changes
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UTIPhysiologic Changes
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Age-Related Changes in the Urinary System
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History Physical Examination

• Age-related Risk Factors for UTI
• Advanced Age
• Fecal incontinence/impaction
• Incomplete bladder emptying or neurogenic bladder
• Vaginal atrophy/estrogen deficiency
• Pelvic prolapse/cystocele
• Insufficient fluid intake/dehydration
• Indwelling foley catheter or urinary
  catheterization or instrumentation procedures

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H P, contd

• Age-related Risk Factors for UTI
• Diabetes or immunosuppression
• Benign prostatic hypertrophy
• Bladder or prostate cancer
• Urinary tract obstruction
• Spinal cord injury
• Mahan-Buttaro, Aznavorian Dick, 2006

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H P, contd
Female vs. Male Complicating Factors
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H P, contd
Female vs. Male Complicating Factors
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Complicated vs Uncomplicated UTI

• UTIs in elderly men are always considered
  complicated
• UTIs in women are complicated when
• Hx of recurrent UTI
• Secondary to structural abnormalities
• Catheters
• Stones
• Urinary retention
• Abscess formation or urosepsis
• Primary diagnostic and treatment focus in
  research studies have been related to the elderly
  female population
• Swart, Soler Holman, 2004

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Complicated vs Uncomplicated UTI

• Recurrent UTIsculture-confirmed UTIs
• gt3 in 1 year or
• gt 2 in 6 months
• Relapse UTI occurs within 2 weeks of Rx
• of an earlier UTI
• same pathogen
• Re-infection UTI occurs gt4 weeks after earlier
  UTI
• different pathogen
• Swart, Soler Holman, 2004

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Causative Pathogens

• UTI in Women
• Escherichia coligram (-) etiologic agent in
  80 of all UTIs
• Research indicates primary source of microbial
  invasion is retrograde colonization by intestinal
  pathogens
• Other factors influencing colonization vaginal
  pH, urethral length, capacity of bacteria to
  adhere to urothelium
• Osborne, 2004

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Causative Pathogens, contd

• Polymicromial bacteriuria
• Contamination most frequent cause of multiple
  microorganisms
• 25-33 in LTCFs may be polymicrobic due to
  fistulas, urinary retention, infected stones, or
  catheters
• Midthun, 2004

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Causative Pathogens, contd

• Age/Type Specific Pathogens
• Younger patients, rare in elderlyStaphylcoccus,
  saprophyticus (gram pos.) 10-15
• Elderly diabetics
• Klebsiella species (gram neg.) most common
• LTCF elderly
• E. coli 30
• Proteus species (part of host flori in GI tract)
  30
• Staphylcoccus aureus, Klebsiella, Pseudomonas
  (gram neg.) and Enterococcus (gram pos.) 40
• Swart, Soler Holman, 2004

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Symptoms versus Asymptomatic Bacteriuria

• Asymptomatic Bacteriuria (ASB)
• Defined as the presence of bacteria in urine of
  patients who do not have dysuria, urinary
  frequency, urgency, fever, flank pain, or other
  symptoms related to irritation of the urethra,
  bladder, or kidney
• Swart, Soler Holman, 2004
• Strictly definedexists when 2 urine cultures
  done with clean-catch specimens are positive in a
  patient who has no urinary tract symptoms
• Foxman, 2003

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Symptomatic vs Asymptomatic Bacteriuria, contd

• ASB
• Frequent in elderly, even gt prevalent in
  residents of LTCF
• elderly gt70 yrs old
• women 16-18
• men 6

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Symptomatic vs. Asymptomatic Bacteriuria, contd

• Asymptomatic Bacteriuria (ASB)
• Most ASB in the elderly is associated with
  complicating factors such as
• Hormonal post-menopausal women
• Anatomical prostatic obstruction in men,
  cystocele in women
• Functional CNS, i.e., P.D. dementia
• Metabolic diabetics (ASB females with Type 2
  diabetes29)
• Immunological ?s in inflammatory mediators
  (cytokines, acute
• phase proteins)
• Instrumental indwelling catheter?always
  bacteriuric symptoms
• Wagenlehner, Naber Weidner, 2005

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UTI Signs and Symptoms in Elderly

• Very difficult to assess and recognize, even when
  present in the older adult.
• Signs Symptoms that indicate further evaluation
  for UTI elicited from HP
• New or increased urgency, frequency, dysyuria
• gt in younger patients, still can be present in
  elderly
• These complaints can be common chronic without
  bacteriuria
• Requires careful interpretationmay not be due to
  UTI
• Change in character of urine
• One study found cloudy, bloody, or malodorous
  urine in gt85 symptomatic UTIs
• Others less predictive
• Midthun, 2004

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Signs and Symptoms, contd

• Clarity of urine
• Clear ? no bacteria cloudy, milky or turbid ?
  bacteriuria
• Cloudiness, however, can occur in normal
  urinemucus, epithelial cells
• Cloudy character, alone or with () dipstick
  analysis ? further lab analysis
• Study by Loeb et al. (2001) as consensus
  criteriacloudy urine not an indication for
  antibiotics
• Bloody
• Hematuria not always indicative of infection
  possibly
• irritation or medication related
• Malodorous
• Not a valid indicatormay be caused by bacteria,
  but
• could be hygiene-related
• Often considered an indicator, however
• Midthun, 2004

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Signs and Symptoms, contd

• Elevated temperature(vital signs)
• Elderly require gt time to present with fever, may
  not have any increase in temperature ? may even
  be hypothermic
• Elderly at ?d risk for masked or absent fever
  response due to antipyretics, corticosteroids,
  chemo Rx, alcoholism, hypothyroidism,
  malnutrition and renal insufficiency
• Studies indicate fever is a marker for serious
  infection most important clinical indicator for
  antibiotic treatment
• Other studies, fevers can resolve without
  treatment antibiotics did not improve outcomes
  in elderly
• Not always due to UTIconsider differential
  diagnoses pulmonary or skin infections
• Lack of fever may delay diagnosis
• Midthun, 2004

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Signs and Symptoms, contd

• Pain
• Despite limitations of assessment in the elderly,
  suprapubic,
• flank or CVA pain can indicate UTI
• (abdominal, rectal vaginal exam)
• Agitation, irritability, restlessness, decreased
  appetite,
• increased confusion, or even falls may indicate
  pain
• (Neuro GI exam)
• Cultural differences in interpretation of pain,
  symptoms
• Incontinence
• May be caused by UTI or the altered mental status
  that
• that occurs with the elderly
• Commonly caused by other conditions
• Symptom and a risk factor of UTI
• Midthun, 2004

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Signs and Symptoms, contd

• Decline or Sudden Change in Mental Status
• (Neuro, MMSE)
• Hallmark symptom of UTI in elderly in most
  studies
• Altered mental status, lethargy confusion are
  the most common indicators of bacteremia in
  elderly UTI
• Falls
• Not specific to UTI, but may indicate a change in
  status, evaluate clinical picture
• Appearance(general survey)
• Vague assessment
• General decline in status
• Listen to family and staff that know the patient
  well
• Midthun, 2004

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Signs and Symptoms, contd

• Other Possible Signs Symptoms of UTI
• Signs of sepsis other than fever or decline in
  M.S.
• Hypotension
• Tachycardia
• Tachypnea
• Rales
• Respiratory distress
• Anorexia, nausea, vomiting
• Abdominal tenderness
• Midthun, 2004

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Diagnostic Criteria

• Pyuria
• A host response to infecting bacteria causing an
  increase of white blood cells or pus in the urine
• Associated with presence of both symptomatic and
  asymptomatic UTIs in elderly
• Level of pyuria is ? when infected with a gram
  negative organism
• Most research finds this is so common that it has
  questionable value in UTI detection and as an
  indicator for Rx in the absence of clinical
  symptoms
• McGeer et al. (one of the most commonly used
  consensus criteria in LTCF for UTI detection in
  Canada) rejects it as being a reliable predictor
  of bacteriuria or symptomatic infection
• Midthun, 2004
• Juthani-Mehta,, 2005

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Screening/Diagnosis

• Asymptomatic Bacteriuria
• No universally accepted criteria for the
  diagnosis, treatment, or surveillance of UTI,
  specifically in LTCF residents
• Treatment of ASB is associated with ? adverse
  antimicrobial effects, re-infection with
  organisms or increasing resistance
• Nicolle, et al., 2005

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Screening/Diagnosis
Infectious Disease Society of AmericaGuidelines
for Dx Rx of ASB in adults

• ASB Dx based on results of a culture from
  clean-catch specimen ( important to minimize
  contamination)
• Women bacteriuria 2 consecutive voided urine
  samples w/isolation of same strain in cfu/mL
  gt100,000
• Men bacteria single, clean-catch specimen with
  1
• bacterial species isolated in gt 100,000 cfu/mL
• Both single catheterized urine specimen with 1
  bacterial species isolated in a count of gt
  1,000 cfu/mL

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Screening/DiagnosisGuidelines, continued

• Pyuria accompanying ASB not an indication for
  antimicrobial Rx (A-2)
• Pregnant women should be screened in early
  pregnancy, at least once treated if positive
  (A-1)
• Screening of ASB Rx if positive before these
  urological procedures
• Transurethral resection of prostate (A3)
• Procedures anticipated to cause possible mucosal
• bleeding (A-3)

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Screening/DiagnosisGuidelines, continued

• No screening for ASB (A-1 A-2 strongly
  recommended via research evidence)
• Pre-menopausal, non-pregnant women (A-1)
• Diabetic women (A-1)
• Community older adults (A-2)
• Institutionalized elderly (A-1)
• Spinal cord injury (A-2)
• Indwelling-catheterized patients (A-1)
• Antimicrobial Rx of asymptomatic women with
  catheter-acquired bacteriuria persisting 48 hrs
  after removed, should be considered (B-1/good)
• No screening or Rx of ASB ? renal transplant or
  solid organ transplant recipients (C-3/weak)
• Infectious Disease Society of America, 2005
• Nicolle et al. 2005
• www.guideline.gov/summary/summary

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Screening/DiagnosisGuidelines, continued

• Guide to Clinical Preventive Services, 2005
• Similar consensus of IDSA recommendations
• Clinical considerations
• Dipstick analysis direct microscopy have poor
  positive negative predictive value for
  detecting ASB
• Urine culture gold standard, but expensive for
  routine screening in populations of low
  prevalence
• New enzymatic urine screening test (UriscreenTM)
  showed 100 sensitivity specificity of 81
• No clinical benefit to screen individuals other
  than pregnant womendid not improve clinical
  outcomes.
• Guide to Clinical Preventive Services, 2005
• http//www.ahrq.gov/clinic/ppcletgp/geps2b.htmbac
  teriaria

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Screening DiagnosisGuideline Criteria for
Treatment

• The following are a recommended minimum set of
  criteria adapted from the McGeer (1991) and Loeb
  et al. (2001) studies necessary to initiate
  diagnostics and AB Rx.

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Laboratory Analysis

• Dipstick Testing
• Used in primary care LTC settings. But for
  institutionalized adults, urinalysis is
  preferable.
• Chemically impregnated reagent strips (UA
  Chemstrip Screen) provide
• preliminary/quick determinations of
• pH bilirubin
• protein blood
• glucose nitrite
• ketones leukocyte esterase
• urobilinogen specific gravity
• Fischback, 2004
• Fairly reliable, although U.S. Preventive
  Services Task Force (USPSTF)
• report from research studies these have poor
  positive negative
• predictive value for detecting bacteriuria in
  asymptomatic patients.
• www.ahrq.gov/clinic (2005)

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Laboratory Analysis, continued

• Routine UrinalysisKey Indicators of Infection

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Laboratory Analysis, continued

• Routine Urinalysis, continued

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Laboratory Analysis, continued

• Routine Urinalysis, continued

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Urine Culture and Sensitivity

• Traditional gold standard for significant
  bacteriuria gt100,000 cfu/mL of urine. Some argue
  criteria for bacteriuria is only 100 cfu/mL of a
  uropathogen in symptomatic females or 1,000 in
  symptomatic males.
• Bacterial identification from urine CS, key in
  males and females with complicated UTIs.

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Other Laboratory Tests

• Complete Blood Count with Differential
• Indicated to R/O bacterial infection supports
  treatment plan
• Careful evaluation of WBC differential (left
  shift)
• Electrolytes
• R/O dehydration if IV fluids replacement needed
• BUN, Creatinine
• Determine ? renal function for nephrotoxic
  medications
• Blood Culture
• Identify bacteremic organism in suspected
  urosepsis

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Treatment Plan

• Early detection/Rx ? goal is to prevent systemic
  infection, bacteremia
• Initiation of antibiotic treatment is recommended
  for a clinically-diagnosed UTI. Adjust medication
  when urine CS is final
• Selection of antibiotic must be individualized
  and consider
• Side effect profile
• Cost
• Bacterial resistance
• Likelihood of compliance (convenience, fewer
  pills/day ?s compliance)
• Effect of impaired renal function on dosing
• Possible adverse drug reactions ? in elderly
  (multiple drugs, co-morbidities.
• Osborne, 2004
• Swart et al. 2004

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Treatment Plan

• Recommended Treatment Regimens for Acute,
  Uncomplicated UTIs in the Elderly

Data adapted from Swart et al. (2004), Osborne
(2004), Wagenlehner et al. (2005), Mahan-Buttaro
et al. (2006) and Evercare Corp (2004) I
inexpensive E expensive VE very expensive
NR not recommended
Longer duration for complicated UTI per
individuals clinical status
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Treatment Plan

• Duration of Antibiotic Therapy Ongoing Debate
• Research

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Treatment Plan

• AB Rx for at least 10 days for institutionalized
• elderly, as short-term therapy may not be as
• effective.
• Ten-14 days, if indicated, for complicated UTI.
• (recommended for males)
• Evercare, 2004
• Conventional regimen of 7-10 days duration is
• usually recommended.
• Wagenlehner et al. 2005

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Treatment Plan

• Complicated UTI
• Can be common in LTC patients
• Associated with azotemia, obstruction, or
  indwelling foley
• Can lead to bacteremia, life-threatening systemic
  infection
• Recommended Treatment for Acute Complicated UTI
• IV antibiotic therapy--consider renal hepatic
  elimination, creatinine clearance for dosage
  adjustment
• 3rd generation cephalosporin (Ceftriaxone
  Rocephin) Rx 1 gram IV every 24 hours
• Or if fluoroquinolones (Levofloxacin Levaquin)
  250-500 mg IV every 24 hours
• Continue until afebrile, minimum of 48 hrs, then
  start oral therapy and fluids x 14 days.
• Mahan-Buttaro et al., 2006

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Prevention Treatment Plan

• Recommendations/Considerations/Prevention
• Indwelling-Catheterization
• Foley catheterization should be avoided if at all
  possible
• Most effective means of UTI prevention is
  limitation of chronic indwelling catheters.
• Wagenlehner et al. 2005

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Prevention TreatmentRecommendations/Considerati
ons/Prevention
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Alternative Therapies in UTI Prevention

• Old adage An ounce of prevention is worth a
  pound of cure.

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Prevention TreatmentRecommendations/Considerati
ons/Prevention

• Post-menopausal women w/recurrent infection may
  require estrogen replacement to restore atrophic
  vaginal mucosa, ? vaginal pH (topical creams)
• Always adjust antibiotic dosage for renal
  impairment/insufficiency using the
  Cockcroft-Gault equation
• (140-Age) x weight in Kg (0.85 if
  female)
• 72 x serum creatinine
• http//www.fhea.com/op/ch14.htm
• Ensure adequate hydration
• Recommended 2.5 L/day in patients with recurrent
  UTI
• Often signs symptoms similar to UTI in elderly
  are actually caused by dehydration

X
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Alternative Therapies for Prevention Cranberry
juice, dried cranberries, raisins
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Key Points in Cranberry Therapy, contd
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Urinary Tract Infections in the
ElderlyGuidelines for Assessment, Diagnosis,
Treatment and Prevention
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UTI in the Elderly GuidelinesDiagnosis,
Treatment Prevention
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GNP Implications

• Overuse of antibiotics is problematic in UTI
  management in elderly
• Careful individualized assessment evaluation of
  elder. Must consider differential diagnoses
  before treatment, even when urine culture is
  positive.
• Identification of subtle, atypical symptoms of
  UTI is critical. Listen to family and staff
• UTI most common nosocomial infection in LTCFs.
  Opportunity to educate staff and implement
  preventative measures to ? incidence.
• Lack of consensus criteria related to UTI
  management in elderly emphasizes need for further
  research in urinary health promotion. Be
  proactive!