Transcript Powerpoint 'UTIs in Older People' Dr Rohan Wee

UTIs in Older People
Dr Rohan Wee
Aged Care Physician
Northern Health
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
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
The problem is…
 Residential care residents often can’t give
reliable histories
 Urinalysis and culture are often done for
atypical symptoms
– Change in behaviour
– Decrease in appetite etc
 Asymptomatic bacteriuria is common
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
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
What to do …
 When the urine smells or is cloudy
 When the FWT is “positive”
 With the MSU results
“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
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
The MSU is Positive
 The asymptomatic patient
 The symptomatic patient
 Long term IDC
The Asymptomatic patient
 A positive MSU probably represents
asymptomatic bacteriuria
 No treatment is required
 Observe patient
The Symptomatic patient
 Treat with appropriate antibiotics
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
Non-specific Decline (1)
 The evidence for the correct course of
action is poor
 Assess the patient
– History
– Examination
– Investigations
 FBE, U&E, +/- CXR
 FWT/MSU
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
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
Preventing Recurrent UTI (2)
 Topical oestrogen
– Improves atrophic vaginitis
– Encourages lactobacilli growth, decreases E.
coli growth
 Antibiotic prophylaxis
– Useful if >3 symptomatic UTIs/year
– Risk of resistant organisms
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, 12:51-55