Urinary Infections In The Elderly
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Transcript of 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