UTIs in Older People

1
UTIs in Older People

• Dr Rohan Wee
• Aged Care Physician
• Northern Health

2
Are UTIs Important?

• Most frequent infection in residential care
• Dementia, incontinence decreased mobility are
  risk factors for developing UTIs
• Asymptomatic bacteriuria is common
• 15-30 in men
• 25-50 in women
• Long term IDCs are always colonised

3
How do we diagnose a UTI?

• Symptoms
• Dysuria, frequency, lower abdominal pain,
  urgency, haematuria
• Absence of vaginal discharge or irritation
• Probability of UTI in women 90
• Urinalysis
• Pyuria
• MSU

4
The problem is

• Residential care residents often cant give
  reliable histories
• Urinalysis and culture are often done for
  atypical symptoms
• Change in behaviour
• Decrease in appetite etc
• Asymptomatic bacteriuria is common

5
Asymptomatic bacteriuria (1)

• Is more common in
• Diabetics
• The elderly
• Long term IDCs
• Pyuria is not a reliable predictor of bacteriuria
• Urinalysis is not useful in predicting bacteriuria

6
Asymptomatic bacteriuria (2)

• Why would we treat if asymptomatic?
• Prevent later infections
• Not evidence to suggest this works
• Less asymptomatic bacteriuria in follow up but
  not UTIs
• Survival benefit
• Increased mortality in patients with bacteriuria
• No improvement in mortality if treated
• Probably reflects differences in patient groups
• Improve continence
• No benefit in a residential care population

7
What to do

• When the urine smells or is cloudy
• When the FWT is positive
• With the MSU results

8
Doctor - the urine smells

• No evidence that an offensive odour correlates
  with 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 correlates to UTI

9
Urinalysis in Residential Care

• Does a positive FWT mean UTI?
• High false positive rate
• False negatives do occur
• In an asymptomatic patient
• Positive FWT is probably a false positive
• Negative FWT means UTI unlikely

10
The MSU is Positive

• The asymptomatic patient
• The symptomatic patient
• Long term IDC

11
The Asymptomatic patient

• A positive MSU probably represents asymptomatic
  bacteriuria
• No treatment is required
• Observe patient

12
The Symptomatic patient

• Treat with appropriate antibiotics

13
Long Term IDC

• Always colonised
• MSU/CSU
• May indicate what bacteria to treat if the
  patient becomes unwell
• Ideally change IDC just before CSU for most
  accurate results
• Treat if symptomatic
• Fever, loin pain

14
Non-specific Decline (1)

• The evidence for the correct course of action is
  poor
• Assess the patient
• History
• Examination
• Investigations
• FBE, UE, /- CXR
• FWT/MSU

15
Non-specific Decline (2)

• FWT
• Positive may be a false positive
• Negative makes UTI less likely
• MSU
• Will guide antibiotic choice if LMO chooses to
  treat
• May be treating asymptomatic bacteriuria
• Treating a UTI should occur after other causes
  have been excluded if the situation requires it

16
Preventing Recurrent UTI (1)

• Increased fluid intake
• No evidence but it may be helpful
• Cranberry juice
• Some limited evidence
• Limitations
• Variable dose and duration
• Calorie load
• Not clear if cranberry tablets are of benefit

17
Preventing Recurrent UTI (2)

• Topical oestrogen
• Improves atrophic vaginitis
• Encourages lactobacilli growth, decreases E. coli
  growth
• Antibiotic prophylaxis
• Useful if gt3 symptomatic UTIs/year
• Risk of resistant organisms

18
References

• Up To Date
• Recurrent UTI in women
• Overview of acute cystitis in women
• Approach to the patient with asymptomatic
  bacteriuria
• UTI associated with indwelling catheter
• UTI in geriatric and institutionalized patients
  L. E. Nicholle, Current Opinion in Urology 2002,
  1251-55