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Which is urinary tract infection (UTI) How is urinary tract infection How is the diagnosis of UTI in the elderly Clinical features of UTI in the elderly Therapeutic considerations in the elderly Preventive measures in the elderly
What is urinary tract infection? Is usually bacterial infection that affects the urinary system. It is the colonization and microbial multiplication of the urinary tract surpassing the local defense mechanisms with inflammatory response of the host. A urinary tract infection can affect any part of the urinary tract.
OVERVIEW of Urinary Tract Infection (UTI) UTI is one of the most commonly diagnosd infections in older adults accounting for over 30% of all infections. Second most frequent infectious process after respiratory infections. 1-6% of general practitioner visit are for UTIs. 2/3 are women (ratio 20/1 in adulthood, ½ in newborn) More than 50% of adult women report having had in his life some episode of UTI. Frequent in both sexes of more than 65 years, and continues being more frequent in women (ratio 2/1) Large socio-economic expenses (over 2 million) and more than 3 million prescription drugs (2002 EU)
Urinary Tract Infection (UTI) in adulthood and older adults For its location: CLASSIFICATION * Lower Tract Infection Cystitis Urethritis Prostatitis * Upper Tract Infection: Acute pyelonephritis Acute bacterial interstitial (focal, diffuse) nephritis, NIBA Intrarenal abscess (Pionefrosis) Perinephric abscess For your Clinic: Acute Chronic Not complicated Complicated Asymptomatic bacteriuria Recurrent: Relapse Reinfection
Urinary Tract Infection (UTI) in adulthood and older adults PHYSIOPATHOLOGY ROUTES OF CONTAMINATION 1.Ascending path 2. Hematogenous 3. Intestinal lymphatic / contiguity Vaginal introitus Nat Rev Microbiol Feb 2004
Risk factors for UTI in Adulthood female uncircumcised male vesicoureteral reflux toilet training voiding dysfunction obstructive uropathy urethral instrumentation wiping from back to front bubble bath tight underwear pinworm infestation constipation P fimbriated bacteria anatomic abnormallity neuropathic bladder sexual activity pregnancy incontinence comorbidities Dra. Crisbert I. Cualteros
Urinary Tract Infection (UTI) in adulthood ETIOLOGY UTI out of Hospital: Escherichia Coli (87%) Proteus Mirabilis Klebsiella Enterococo Staphilococus saprophyticus Staphiloccocus epidermidis Streptocco grupos B y D Streptoccocus Bovis UTI at the hospital: Escherichia Coli (47%) Pseudomonas aeruginosa Serratia Citrobacter Shigela Enterococo Morganella morgani Providencia suarti Proteus Mirabilis Staphiloccocus coagulasa - Staphilococcus aureus: discard vía hematica Corynebacterium urealyticum: Is found in long-term probes, catheters or nephrostomies Gardnerella vaginalis: Are seen especially in pregnancy.
Some conditioners of the age Decreased muscle tone and elasticity: prolapse, cystocele, incontinence, residual volume increase Changes in prostatic function, hypertrophy... Post-menopause atrophic changes: ph, dryness, vaginal flora... Immune system dysfunction Decreased estrogens Thermoregulation alteration Cognitive impairment Comorbid disease and Drug interactions Impaired functional and personal hygiene All of them favor the Urinary Tract Infection
Urinary Tract Infection older adults Elderly patients with no cognitive impairment show a behavior similar to that of adulthood before an UTI. They can clearly tell what happens, a KEY element for diagnosis.
Urinary Tract Infection in older adults TA Rowe And M.Juthani Mehta. 2013
Risk Factor UTI. Older Adults >65 years old Female Prior history of UTI younger age Residual urine Uro-surgycal procedures Cystophaty Gynecologycal desease Incontinence Urinary catheter Comorbid disease Impaired personal hygiene Reduced mental status Immunological changes Drug interaction Male Prostatic obstruction Residual urine Uro-surgycal procedures Incontinence Urinary catheter Comorbid disease Cognitive impairment Immunological changes Drug interaction
CLINICAL MANIFESTATIONS IN ADULTHOOD and older adults with normal mental state Pyelonephritis Involvement of renal parenchyma. Not renal failure Characterized by: Early Onset Fever. Chills and sweating Abdominal Pain or Flank Pain. General Malaise. Nausea and Vomiting. Diarrhea. Cystitis Involves bladder. Characterized by: Dysuria. Urgency. Frequency. Suprapubic Pain. Smelly and cloudy Urine. Laxity and weakness No fever and does not result in renal injury 15
CLINICAL MANIFESTATIONS IN OLDER ADULTS Typical symptoms of, dysuria, increased frequency, suprapubic, costovertebral, or flank pain, fever, cloudy or smelly urine, hematuria, laxity and weakness.. (It can be explained by patients with normal mental status) Atypical symptoms must be added, general malaise, new or increase incontinence new or increase in urgency or frequency worsening of functional or mental state unexplained falls dysphoria fever (>37.9º) shaking chills worsening of mental or functional status delirium
Urinary Tract Infection older adults DIAGNOSIS. In older adults without catheter or abnormalities of the genitourinary tract REQUIRING THE PRESENCE OF urinary symptoms (typical or atypical suggestive of UTI) a positive urinary dipstick or urine culture. 1. CLINIC. Most important 2. Urinoculture/Urinary dipstisk positive 3. Radiological and other studies
Mody L. JAMA 2014
Simple algorithm for UTI for older adults Fever or leukocytosis + Typical symptoms one or more Fever>38º,chills + Atypical symptoms two or more STOP Dipstick or Urine culture + + consider other diagnoses Urine culture and in/out catheter specimen and consider therapy while awaiting antibiotic sensitivities
INTERPRETATION OF RESULTS OF URINARY DIPSTICK Urine tests Recommended performance Diagnosis of UTI. Justified treatment High probability of UTI. It may be justified to treat Indicate or not urine culture according to clinical judgment. Consider other diagnoses. Carry out close tracking Very likely not UTI Not justified to treat Indicate or not urine culture according to clinical judgment
Antibacterial sensitivity of the main antibiotics commonly used. 2003
Waiting for the result of the urine culture... Take into account the spectrum and cost of the antibiotic Treat only the indicated cases The duration of treatment will depend on the antibiotic and clinical diagnosis Short guidelines favor compliance and reduce the occurrence of resistance but the rate of eradication is usually lower
Waiting for the result of the urine culture... Obliged to take into account the most common germs and the resistance map of the area Do not use a drug if the resistance of the area exceeds 20% In Spain the resistance of E. coli to amoxicillin is 40-60% and for SMX-TMP it is 25-35% Resistances to quinolones are > 20% especially in older women and are NOT FIRST-ELECTION DRUGS
Recommendations for the treatment of uncomplicated UTIs in elderly patients according to SOMAMFYC (2015) IDSA and ESMID (2010). Firts option Nitrofurantoina 50mg/6h. 5-7 dias Fosfomicina trometamol 3g/2 sobre/72 h. Cotrimoxazol800/160 por 12h. 5-7 dias Second option Amoxi/clavulanico 500/125 /8h. 3-7 dias Cefisima 400mg/24h. 3-5dias Cefuroxima 250-500mg/12h. 3-5 dias Third option Ciprofloxacino 250mg/12h. 3-7 dias Norfloxacino 400mg/12h. 3-7 dias
Asymptomatic bacteriuria (ASB) Is defined as the presence of bacteria in the urine in 105 cfu/ml or more in 2 consecutive urine specimen in women or 1 urine specimen in men, without any manifestation of infection. Occurs exclusively in girls, but increase significantly with age in both men and women. 10-25% are polymicrobial Benign and does not cause renal injury.
Asymptomatic bacteriuria.how often is it?
Age related factors associated with ASB ;Incontinence,fecal Wagenlehner FME. Drugs Aging 2005
RECOMMENDATIONS OF IDSA AND ESMID (2005) Detection and Beneficial Treatment Pregnant Before manipulation or urological surgery Renal transplants (first 6 months) Women with persistent bacteriuria after visceral catheter removal Patients with uncorrectable urologic anomaly with frequent symptomatic infections (consider nocturnal prophylaxis 6-12 months)
RECOMMENDATIONS OF IDSA AND ESMID (2005) Probably beneficial treatment and detection Before surgery near the perineal area Severe neutropenia after chemotherapy Permanent bladder catheter replacement if traumatic Germs Infections Producing Calculation
RECOMMENDATIONS OF IDSA AND ESMID (2005) Detection and Treatment not beneficial Healthy children and adults Older adults who reside in community-welling Elderly residing in Long Term Care Facilities Patients with indwelling catheter Patients with a short urinary catheter (<1 month) Intermittent urethral catheterization Patients with other foreign bodies (stent, ureteral catheters...) Patients with neurogenic bladder Women with DM (men??) Patients with HIV
GENERAL RECOMMENDATION. SUMMARY is not recommended screening and treatment of ASB in premenopausal women, the older adults, the older resident in long term care, patients with catheter indwellin, diabetic patients, patients with neurogenic bladder
Preventive measures useful in all types of Urinary Incontinence Increase fluid intake Daily exercise Actively combating constipation Frequent urination Washing perineal region after defecation Micturition and washing after intercourse Avoid use of spermicides and diaphragms
Strategies without antibiotics (1) The power of the cranberries High concentration of proanthocyanidins type A (family of polyphenols). Blocks the filaments and prevents the bacteris from attaching to the epithelial cells of the mucosa
Strategies without antibiotics (2) Antibacterial vaccines Vaginal Vaccine Dead strains of uropathogens (E. coli, Proteus, Enterococcus, Klebsiella) Vaginal suppository: 3 weeks and 3 months Oral Vaccine Lyophilized protein extracts from 18 strains of uropathogens 1 capsule per day / 3 months. Following with 1 capsule per day / 10 days / 3 months Test data 18-84 years. None exceeds the results of prolonged treatment with ABS Between 25-50% of the sample exceeds 3 months without relapse None exceeds the results of prolonged treatment with ABS
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