When should UTIs be treated in the Elderly? Shelby L. Wentworth, MS4 University of Florida College of Medicine 29 AUG 2018
UTIs in Patients >/ 65 yo - Most common infectious illness [1]. - Urinary tract infections are responsible for 15.5% of hospitalizations [2] - Women > Men (2:1) - Risk factors: Incontinence (urinary or fecal), urinary retention, catheters, hospitalizations, care facilities, waning immunity, comorbidities (eg. DM), medications (eg. SGLT-2 inhibitors), vaginal atrophy, intercourse - Organisms: - Gram-neg bacilli are most common (E. coli, Enterobacter spp, Klebsiella spp, Proteus spp) - More resistant = Pseudomonas aeruginosa, gram-pos organisms (eg. E. fecalis), gram-neg staph and GBS - Presentation can be subtle and difficult to catch (eg. demented patients/impaired cognition)
Diagnostic Guidelines [3] Urine dipstick analysis Do not screen if asymptomatic If low pre-test probability to rule out UTI NPV 92-100% [2] In asymptomatic patient, a positive leukocyte esterase or nitrites doe NOT rule in UTI Clinically insignificant High false positive rate Urine Culture Only if UA positive for leukocyte esterase and/or nitrites Send for culture and susceptibility Positive if >/ 10 5 CFU in 2 consecutive clean catch urine samples with </2 organisms Recommendations from Infectious Disease Society of America
Classification Asymptomatic bacteriuria: Urine culture grows >/ 10 5 CFU/mL 2 samples (clean-catch) required in women No indwelling catheter within 7 days Symptomatic UTI : Cystitis, pyelo, sepsis, septic shock, or combination Positive urine culture with </ 2 uropathogens + pyuria Defined by at least 2 of the following [4*] : - Fever > 38 C - Worsening urinary urgency/frequency - Acute dysuria - Suprapubic tenderness - CVA pain/tenderness *Disclaimer: Clinical review based only on women >/ 65 yo
Therapy vs. No Therapy in Asymptomatic Bacteriuria Current recommendation = no treatment for asymptomatic bacteriuria Prospective randomized study [5]: - 50 elderly institutionalized women - 2 arms: 1. Checked urine culture monthly Received abx every time if culture positive 2. Checked urine culture monthly No therapy unless patient had symptoms - Followed for 1 yr - Outcomes: - Lower prevalence of bacteriuria in arm 1, but no differences in GU morbidity or mortality - Increased risk of resistant organisms - Increased risk of reinfection - Increased risk of drug-drug interactions - Adverse effects from antimicrobials
Treatment of symptomatic UTI - Always treat - Antibiotic selection depends on location (upper vs. lower urinary tract) - Acute uncomplicated cystitis (lower tract): 3-6 day course of abx is sufficient per systemic review done on antibiotic duration [6]. - Acute pyelonephritis (upper tract) requires a longer duration of antibiotics - Start broad narrow based on susceptibility - Duration depends on abx selection 7-14 days
Summary Urinary tract infections are common in the elderly Numerous risk factors and more resistant organisms Urinary dipstick analysis is good for low-test probability Current guidelines recommend against treating asymptomatic bacteriuria Treatment of asymptomatic bacteriuria is associated with increased risk of resistance, reinfection, drug-drug interactions, and antibiotic side effects in elderly population Treatment of symptomatic UTI depends on location of infection
References 1. Foxman B, Brown P. Epidemiology of UTIs: transmission and risk factors, incidence, and costs. Infect Dis Clin North Am 2003; 17:227 2. Juthani-Mehta M. Asymptomatic bacteriuria and urinary tract infection in older adults. Clin Geriatr Med 2007; 23:585 3. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteria in adults. Clin Infect Dis 2005; 40:463 4. Mody L. Juthani-Mehta M. Urinary tract infections in older women: A clinical review. JAMA 2014; 311:844 5. Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med 1987; 83:27 6. Lutters M, Vogt-Ferrier NB. Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women. Cochrane Database Syst Rev 2008; :CD001535