Understanding Urinary Tract Infections – Focus on Prevention

1. Understanding Urinary Tract Infections – Focus on Prevention John Gotelli, NP University of North Carolina Health Care

2. Continuing Nursing Education (CNE) Credit • CCME is accredited as an approved provider of CNE by the North Carolina Nurses Association, an accredited approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. • CCME utilizes industry accepted mechanisms to identify and resolve conflicts of interest. The planners, faculty, and speakers for this activity have no unresolved relevant financial relationships with commercial interests that could be perceived as a conflict of interest. • CCME has received no commercial support related to this educational activity.

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4. Objectives • Learn geriatric “pearls” in identifying, preventing and treating Urinary Tract Infections (UTIs) in elderly • Review antibiotic treatment guidelines for UTIs in elderly • Discuss techniques in preventing both complicated and uncomplicated UTIs in elderly • Understand risks associated with use of Indwelling Urinary (foley) catheters • Differentiate between asymptomatic bacteriuria and Urinary Tract Infection (UTI)

5. Introduction - Definitions • Urinary Tract Infection (UTI) aka Acute Uncomplicated Cystitis – infection of the bladder (lower urinary tract) • Pyelonephritis – infection of the upper urinary tract (ureters / renal collecting system / kidneys). • Asymptomatic Bacteriuria – Isolation of a specific count of bacteria in a urine specimen from an individual w/o signs or symptoms of UTI

6. Definitions, cont Note – These may be localized to either lower or upper urinary tract • Complicated UTI (cystitis) • Diabetes • Pregnancy • H/O pyelo • Hospital acquired infection • Urinary Tract Obstruction (men) • Catheter (or recent catheterization in prior 48 hours) • Childhood h/o UTIs • Immunosuppression • Renal Transplant

7. Definitions, cont • Long Term Care Facility (LTC) • “Encompasses an array of medical, social, personal and supportive specialized housing for individuals who have lost some capacity for self care due to illness / disabling condition” (Family Care Giving Alliance, 2000) • ADL / IADL support • Medicare / Medicaid

8. Definitions, cont • Population • 63% are 65 or > • Current population in LTC is 6.3 million • By 2050 total number of individuals needing paid LTC/Institutional LTC will double to around 27 million • Infection / Illness often times presents differently in aged >> lack of fever / blunted white cell count / mental status changes / functional decline / anorexia / agitation

9. UTI in Long Term Care Facility • Primary cause of bacteremia in LTC residents is due to UTIs • Incidence of symptomatic UTIs in elderly in LTC around 10% • Prevalence of asymptomatic bacteriuria in women approx. 30% and 10% in men • Why so common?

10. UTI in Long Term Care Facility, cont • Risk Factors • Physiologic changes of bladder / urethral flora w/ age (post/menopausal women) • Use of indwelling catheters • Congregate living • Functional / Cognitive Impairment • Decrease self care • Decrease cues to void • Difficulty finding bathroom / suitable location to void • ?Elevated Post Void Residual Volume of Urine?

11. Urinary Tract Infections (uncomplicated) • Diagnosis • Symptoms >>dysuria, suprapubic pain,frequency,urgency,hematuria + clean catch culture growing >_ 10 (3) cfu/ml of no more than 2 species of uropathogens (Barber, et al 2013) • CDC Alternative Definition >> 2 of following • (a) Fever ( 38c), dysuria, frequency, urgency, or suprapubic pain AND at least one of following: + gram stain, pyuria >_10wbc/ml, +Leukocyte Esterace (b)AND/OR nitrite by dipstick, or 2 + urine cultures w/ same uropathogen >_ 10 (2) in a non voided sample

12. Urinary Tract Infection (uncomplicated) • Resistance can be high >> e. coli resistance to trimethoprim/sulfamethoxazole and cipro ranged from as high as 45% for bactrim and 13% for cipro. • Length – for uncomplicated UTI in elderly women favors short course (3-6 days). For men – 7 to 14 days • 2010 IDSA guidelines suggest nitrofurantoin 100mg bid x 5 days or trimethoprim / sulfamethoxazole 160/80 bid x 3 days for initial empiric therapy • My Clinical practice is cipro 250 bid x 3 days • Some (Mouten, 2010) suggest all elderly should receive 7 to 14 day treatment • Parenteral therapy for clinically unstable patients or those presenting as very ill -- 3rd generation cephalosporin w/ hospital admission (IV ceftazadime)

13. Complicated Urinary Tract Infection: Indwelling Urinary Catheter • Big deal in hospital • #1 site of HAI • 15% to 25% of hospitalized patients get a catheter • Estimated 13,000 attributable deaths / year • Increases LOS by 2-4 days • Incidence of bacteriuria is 3% to 8% per day • In LTC • 7.5% to 10% • Often times unclear indications for use • Care givers become lax in approach to catheter care • Infection usually occurs at time of insertion / extra/ intraluminal migration of bacteria.

14. Complicated Urinary Tract Infection : Indwelling Urinary Catheter • Diagnosis • Difficult >> true pathogenic infection from colonization. Traditional symptoms in UTIs in those w/ catheters not present • Symptomatic catheter-related bacteriuria (UTI) >> fever (>38c), suprapubic tenderness, cva tenderness, OR altered mental status, hypotension, SIRS w/ one of following lab. Profiles • Urine culture w > 10(5) cfu/ml (ISD guidelines say 10(3) • Urine culture w > 10 (3) cfu/ml w pyuria, LE / Nitrite + • Ideally >> remove catheter obtain midstream urine OR replace, collect sample from foley (not bag), begin empiric treatment OR separate catheter from drainage bag and collect

15. Asymptomatic Bacteriuria • ASB in LTC • Women • 2 consecutive clean catch midstream urine samples of > _ 10 (5) cfu/ml w/o symptoms associated w/ UTI and no catheter within 7 days of first sample • Men • Single clean catch midstream of >_ 10 (5) cfu/ml w/o symptoms associated with UTI and no catheter • Longer term sequela of bacteriuria not known • Treatment not shown to reduce symptomatic UTI, improve mortality nor decrease in prevalence of bacteriuria (i.e. no indication for eradication therapy). • Common – perhaps 55% of women in LTC and 30% of men

16. Prevention • Prevention of UTI in LTC • Most studies have focused on younger / pre-menopausal women • (McMurdo study age 45 to 92 – see below) • General • Hygiene • Prompted / assisted voiding • Bowel regimen

17. Prevention, cont • McMurdo (2009) 500mg daily of cranberry extract vs 100mg of trimethoprim daily x 6 months. In adult women w/ recurrent UTIs, cranberry no different than trimethoprim in reducing developing new uti. • Prophylaxis against recurrent UTI (>_3 utis within 12 mos. OR >_2 within 6 mos). Studies have shown benefit of co-trimoxazole, nitrufurantoin, quinolones, b-lactams in reducing recurrent utis vs placebo. No guidelines. • Oral Estrogens not shown to be beneficial. Topical, vaginally applied estrogens have been shown to be effective in smaller studies (though sample was post-menopausal) • Summary – consider cranberry extract 100mg to 500mg daily and or intravaginal topical estrogens, applied daily x 2 weeks, then 2-3 days per week

18. Prevention, cont • Practical Methodologies • Bowel regimen • Bladder hygiene • Perineal care • Timed and prompted voids • Infection control practices • Anticholinergic medication reduction • Issues surrounding post void residuals (still unanswered) • Indwelling catheter removal protocols

19. References Centers for Disease Control and Prevention (CDC) . CDC/NHSN Surveillance Definition of Healthcare Associated Infections and Specific Types of Infections in the Acute Care Setting, April 2013 Updates Cohen, KR; Frank, J; Israel, I (2011). UTIS in the geriatric population: challenges for clinicians. US Pharmacist. 36 (6) p. 46-54 Family CareGiver Alliance: National Center on Caregiving. (2012). Fact Sheet: Selected Long-Term Care Statistics. Fekete,T ; Calderwood, SB; Baron, E (2011) Urinary tract infection associated with urethral catheters. UpToDate. Accessed online January, 2012 Garner, JS; Jarvis, WR, Emori, TG, et al (1988) CDC Definitions of Nosocomial Infections. Journal of Infection Control, 16. p 128-140 Gupta, K; Hooton, TM; Naber, KG; Wult, B; Colgan, R; Miller, LG; Moran, GJ; Nicolle, LE; Raz, R; Schaeffer, AJ; Soper, DE (2011). International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the infectious disease society of america and the european society for microbiology and infectious disease. Clinical Practice Guidelines. 2011:52, March

20. References, cont Hooton, TM; Calderwood, SB; Baron, E (2011) Acute Uncomplicated cycstitis, pyelonephritis, and asymptomatic bacteriuria in men. UpToDate. Accessed online January, 2012 Hooton, TM; Bradley, SF; Cardenas, DD; Colgan, R; Geerlings, SE; Rice, JE; Saint, S; Schaeffer, AJ; Tambayh, PA; Nicolle, LE (2010) Diagnosis, prevention, and treatment of of catheter associated urinary tract infection in adults: 2009 international clinical practice guidelines from the infectious disease society of america. Clinical Practice Guidelines. 2010: 50 March Mathews, JS; Lancaster, JW (2011) Urinary tract infection in the elderly population. The American Journal of Geriatric Pharmacotherapy. 9 (5) p. 286-309 McMurdo, ME; Argo, I; Phillips, G; Daly, F; Davey P. (2009) Cranberry or trimethoprim for the prevention of recurrent urinary tract infections? A randomized controlled trial in older women. Journal of Antimicrobial Chemotherapy 63, p 389-395 Mouton, C; Adenuga, B; Vijayan, J (2010). Urinary tract infections in long-term care. Annals of Long-Term Care 18 (2) p. 35-39