Urinary Infections In The Elderly

8/14/2019 Urinary Infections In The Elderly

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Urinary Infections in theElderly

Christopher FrenchBMedSci MD FRCSC

Adult and Pediatric Urology

Clinical Assistant Professor of Surgery

May 2009


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Objectives

Rationale for Treating Positive UrinaryCultures

Simple vs Complicated Infections Rationale for Prophylactic Antibiotics

Optimal Catheter Management

Evaluate risk factors for urinaryinfections in the elderly


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Cystitis

Localized symptoms with positiveurine culture (and inflammation)

The only group that receiveabbreviated treatment (3 day) isyoung healthy women

Uncomplicated Complicated urinary infectionsrequire upper tract investigations


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Complicated Cystitis

In the elderly assume there isresidual urine

Bladder power decreases with age Men usually have a component of

BPH, women atrophy (low estrogen)

Failure to eradicate is commonlyassociated with a foreign body suchas stone or catheter


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Febrile Urinary Infections

in the elderly Assume there is Pyelonephritis

Obstruction is common

Catheter, ureter, prostate High Morbidity

Associated confusion, falls, CHF, poor

host response, mortality


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Prostatitis

Patterns in medicine Men in 40s

90% culture negative Association with pelvic pain

Chronic

Failure to identify organism associated withcyclical natural history leads to false beliefthat long courses of antibiotics will beeffective

Unusual in the elderly


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Asymptomatic Bacteruria

Urinalysis done for other reasons

Limitations of obtaining samples

Difficulty with reliable history If frail and poor mental status-treat

If well, treat conservatively, repeat

culture and consider treatment ifsymptoms appear


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1) Pregnant

2) Debilitated, older patients

3) Severely diabetic

4) Child with VUR5) Obstruction

6) Patients who feel better with sterile urine

7) Patients about to undergo a GU procedure (TURP, etc.)

When do you treat asymptomatic bacteriuria?


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Why are the elderly at increased risk of UTI?

Systemic1) Dehydrated2) Malnourished3) Other intercurrent illness e.g.,

diabetes4) Decreased immunity to infection

(decreased cell-mediated immunity)5) Multiple medications - some may be

immune suppressing6) Frequent antibiotic use - promote

resistant organisms

Renal1) GFR and decreased urine flow rate2) Renal failure - poor excretion of

antibiotics3) Stones ( risk)4) Renal diseases e.g., hypertension,

DM

Organism Factors1) More virulent pathogen2) Hospital acquired infections more

common

Bladder1) Poor emptying due to BPH or

detrussor contractility2) Epithelial cell receptivity to bacteria3) Acquired outlet obstruction

4) Urethral instrumentation5) Indwelling catheter6) Stones

Urine1) Decreased immunoglobulins

In men: Prostatic factors

In women: Vaginal factors1) Atrophic vaginitis

2) Decreased lactobacillus


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Case Study

73 year old Diabetic Female

Develops suprapubic pain, low

grade fever

No voided sample available.

Foley inserted for 800cc cloudyurine.

Micro wbcs many, rbcs few


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Case Study

Cultures sent

Started emperically on Cipro 250

bid

US--small kidneys, no hydro orstones

Culture E. Coli resistant to septra


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Case Study

What next?

1) Look for cause of Urinary retention

Diabetic Autonomic Dysfunction(weak bladder)

Constipation

Altered Mental Status (early

dementia)

Medical Comorbidities (recentpneumonia)


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Case Study

What next?

2) How long should she be treated?

Upper tract vs Lower tract infection10-14d vs 3-7d

When is her foley likely to be removed?


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Case Study

She has had a similar episode 10years ago. Had a bladder

suspension 30 years ago. Herdaughter says she feels her momis depressed.

Constipation Altered mental status


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Case Study

Cipro is given for 14 days.

Reculture negative

Foley removed days 2, 5, 10. Finallyvoiding on her own.

Culture drawn monthly for 3 months.

3rd culture is positive for Enterococcuswithout symptoms.


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Case Study

Is this Asymptomatic Bacteriuria in theelderly? Yes but,

because of history of recent urinary retentionand complicated UTI we are suspect.

U/S PVR 300 mls

Why Enterococcus?

Treated with culture specific antibiotic(amoxil)


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Case Study

Over the past year she continues to getmonthly UTIs, each time associated withaltered mental status.

Referred to Urology Repeat US Normal

Cysto atrophy, thin bladder, some debris, PVR 200

Is she a good candidate for prophylaxis? Which one?


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Catheter Associated UTI

24hrs 5%

48 15%

72 25%

5 days 95%


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Case 2

90 year old veteran with severedisabling arthritis. Indwelling foley.

He had the foley out but was troubledby nocturia times 4 and daytime urgeincontinence.

Complains the foley is bothering him

UA 2+ wbcs Culture mixed organisms including E. Coli


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Case 2

90 year old veteran

Treated with a 7 day course of Cipro

Reculture clear, micro less wbcs

Should he have routine cutures drawn?

Is there a role for treating his nocturia andtrying to remove foley?


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Case 2

90 year old veteran

Repeat Cultures grow various coliforms, for which he is treatedeach for 7 days.

3 months later the Urine grows candida

He is having problems with blocked catheters.

Is there an accociation of blocked catheters and Candida?

Received 8 weeks of fluconazole in order to obtain a negativeculture.

What else can we do?


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Case 2

90 year old veteran- Trial without Foley

Bowel regime

Urinal at bedside

Push daytime fluids

Trial of DDAVP for nocturia

Success.

Manage expectations- The catheter was convenient but Charlie, youhad so many infections.

PVR 30cc

Check Urine only is symptomatic


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Colonisation vs Infection

Some estimates of 5% of elderly havea positive urine culture without

symptomsPatients on intermittent or indwellingfoley are all colonized

In the absence of symptoms catheter

associated positive cultures can bemanaged conservatively


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Conservative treatments

Increase fluid intake

mechanical flushing of bladder

Keep Bowels softConstipation leads to poor pelvic floorrelaxation

Timed voiding

Cranberryjuice is more effective than extract(volume)


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Antibiotics

Enterobacter common

E Coli

Enterococcus common in failure of first lineStrep Faecalis

Proteus (urea splitting think Struvite stone)

Candida in the urine is usually the result of

long term antibiotic use. If a foreign body ispresent will not clear.


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Antibiotics


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Antibiotics Pearls

30 % of E Coli resistant to AMP

20% of E Coli resistant to Septra

10% of E Coli resistant to Cipro

The longer an antibiotic has been usedthe higher the resistance


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Antibiotics Pearls

All Proteus are resistant to Nitrofurantoin

Enterococcus require Amp ornitrofurantoin and while are lowvirulence are commonly associated withtreatment failure

B Lactam antibiotics are poor when usedas low dose suppressive therapy


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Conclusions

Urinary infections in the elderly can be a sourceof morbidity

Prevention by minimizing catheter use is most

effectiveAssume all elderly have some degree of impaired

bladder emptying

Complicated UTIs in the elderly warrant upper

tract investigationsProphylaxis is required in few for recurrenturinary infections

Documents

Urinary Infections In The Elderly