Infectious Disease in the Elderly and Long Term-Care Facilities Module 3 Urinary Tract Infections

1. Infectious Disease in the Elderly and Long Term-Care FacilitiesModule 3Urinary Tract Infections UNMC Section of Infectious Diseases Brandi L. Lesiak, PA-C, MPAS Kim Meyer, PA-C, MPAS Claudia Chaperon APRN, Phd Ed Vandenberg, M.D. CMD Updated 11-23-06

2. PROCESS A series of modules and questions Step #1: Powerpoint module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

3. Objectives for module two Upon completion the learner will be able to: • List the aging physiologic changes that predispose elder’s to UTIs • Describe the prevention and diagnosis of UTIs in catheterized and non-catheterized patients • Contrast asymptomatic bacteriuria from urinary tract infections

4. UTIs Elderly risk: factors: All: -Decreased bladder capacity -Increased PVR Women: -Short length of urethra -Decreased estrogen -Fecal incontinence -Cystoceles, & rectoceles, atonic bladders increase PVR Men: BPH /obstruction leads to: -Decreased flow -Increased PVR

5. WHAT IS A UTI? (1) • Cardinal symptoms: dysuria, pain, frequency, fever • May be absent in elderly! example: 100 community acquired sepsis 34%(34)-----urinary source; 6/34 had dysuria, urgency or other urinary sx. In elderly, look for: new incontinence, confusion, anorexia, lethargy and falls. • Catheterized patient: are at increased risk of infection secondary to bacteruria, this can account for increased risk of nosocomial UTIs. • Use your clinical judgment; systemic symptoms and CBC with differential. in diagnosis of catherized patients!

6. WHAT IS A UTI? • Diagnosis: (Non-catheterized patient) UTI = symptoms of UTI +clean catch urinalysis with few epithelial cells, many WBCs + nitrites + leukocyte esterase +culture with >105 cfu/ml organisms

7. WHAT IS A UTI? • Diagnosis (catheterized patient) UTI = symptoms of UTI plus; urinalysis with no epithelial cells, many WBCs nitrites, leukocyte esterase +culture with >105 cfu/ml organisms + good clinical judgment + attention of systemic symptoms + use of CBC with differential.

8. UTIs • Most important risk factor for infection is: INDWELLING CATHETER A CONDUIT FOR BACTERIA TO GET INTO BLADDER! How to avoid? Both sexes: • avoid putting them in. • avoid constipation • increase physical activity • increase hydration. • monitor their PVR For men with impaired emptying; • add alpha blockers and alpha reductase inhibitors (eg finasteride) to improve emptying

9. INDWELLING CATHETERS • Risk of bacteriuria with one straight catheterization is 1-20% • In catheterized patient, incidence of bacteriuria is 5% for each day . . . At 1 month, 100% have bacteriuria • In a hospitalized patient, average catheterization is 2-3 days and in LTCF many patients have chronic indwelling catheters, or suprapubic catheters, stents • Increased risk of nosocomial infection, bacteremia, and urosepsis

10. CATHETERSInfection prevention (2) Prevent infections by: • Hydration. • Excellent perineal care • Standard precautions • Maintenance of the closed drainage systems. • Silver-coated urinary catheters may reduce the incidence of bacteruria and UTIs in patients. • May reduce cost of associated infection. • May have an affect on decreasing nosocomial infection in patients. • Are readily used now as a result in many facilities when catheters are required What does not change infection rates are: • topical antibiotic at meatus, • collection bag disinfectants • antimicroobial bladder disinfectants • antibiotics as chronic suppresants

11. KEY POINT: BACTERIURIA DOES NOT EQUAL INFECTION

12. What is Asymptomatic Bacteriuria? • Colonization of bacteria in the bladder without infection, may or may not have associated pyuria • Incidence: • Women, ages 20-50: 3 – 7% • Women over 60: 15% - 30% • Young men: rare • Men over 70: 20% • Chronic foley: 100% and can have pyuria • Use clinical judgment, signs of systemic infection and occasionally a CBC with differential.

13. Asymptomatic bacteriuria THERE IS NO INCREASED RISK OF INFECTION WITH CHRONIC ASYMPTOMATIC BACTERIURIA IN THIS POPULATION AND NO EFFECT ON SURVIVAL. SO DON’T CHECK FOR IT AND DON’T TREAT IT!

14. ASYMPTOMATIC BACTERIURIA • Pyuria accompanying asymptomatic bacteriuria is not an indication for antibiotic treatment. • Over treatment of asymptomatic bacteriuria is associated with increased risk of reinfection with resistant organisms. • Screening residents in LTCF is not recommended

15. The End of Module Three on Urinary Tract Infections in the Elderly

16. post-test • A 70-year-old woman has had recurrent urinary tract infections (UTI) for many years. The patient is otherwise healthy and is sexually active with one male partner on a regular basis, without pain or discomfort. Symptoms tend to occur a day or two following intercourse. She has not had pyelonephritis or required hospitalization. When urine cultures have been obtained, antibiotic-susceptible Escherichia coli and Staphylococcussaprophyticus have been isolated. Which of the following should you do first? Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

17. Which of the following should you do first? A. Encourage the patient to drink cranberry juice. B. Perform pelvic examination and measure postvoid residual volume. C. Begin postcoital antibiotic prophylaxis. D. Begin daily, low-dose, suppressive antibiotic therapy. E. Begin estrogen supplementation.

18. Answer; B. Perform pelvic examination and measure postvoid residual volume. In young women, risk factors for recurrent UTI are sexual intercourse, use of diaphragms or spermicides, and history of UTI. In frail older women, risk factors are poor functional status, requirement for skilled care, and catheterization. Risk factors in healthy older women include prior history of UTI, genetic predisposition, cystocele, elevated postvoid residual volume, and incontinence. Lack of estrogen effect and sexual activity also may play a role, but these have not been fully evaluated in this age group. Initial examination of a patient should document the presence of incomplete voiding, incontinence, or gynecologic abnormalities. Treatment of incontinence, bladder obstruction, or urinary stasis may help to alleviate the condition.

19. The efficacy of cranberry juice in preventing adhesion of bacteria to urinary epithelial cells, bacteriuria, and UTI has not been proven convincingly. Postcoital antibiotic prophylaxis has been studied primarily in premenopausal women. Daily suppressive antibiotic therapy also has been assessed mostly in younger women; routine use should be avoided because of the potential to develop resistant organisms. Topical estrogens may be efficacious in restoring normal colonizing lactobacilli and reducing pathogenic gram-negative bacilli in the vaginal flora of older women. However, a pelvic examination and measurement of postvoid residual volume would be a first step to identify a treatable predisposing cause. end

20. Readings and resources Resources • Mccue JD, Gram negative bacillary bacteremia in the elderly: incidence, ecology, etiology, and mortality. J Am Geriatric Soc. 1987:35:213-8 • Rupp ME, et al.  Effect of silver-coated urinary catheters: efficacy, cost-effectiveness, and antimicrobial resistance. Am J Infect Control 2004 Dec 32;8, 445-450