urinary tract infection in the elderly - brown university · urinary tract infection in the elderly...
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Urinary tract infection in the
elderly
Aurora Pop-Vicas, MD, MPH
Infectious Diseases
Memorial Hospital of RI
Brown University
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Outline
• Asymptomatic bacteriuria • Pathogenesis
• Diagnosis
• Treatment
• Urinary tract infection • Diagnosis
• Treatment
• Prevention
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Asymptomatic bacteriuria
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Definition
• Asymptomatic bacteriuria
• > 105 cfu uropathogenic bacteria (CDC)
» Regardless of indwelling catheters or not
• > 102 cfu single organism
» When urine obtained by fresh catheterization
OR
» By bladder puncture (IDSA)
» NOT applicable for chronic indwelling catheters
• No fever > 38°C, suprapubic or CVA tenderness
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Definition
• Women: • Same bacterial strain
• 2 consecutive clean-catch voided specimens
• ≥ 105 cfu/mL
• Men • Single clean-catch voided specimen
• ≥ 105 cfu/mL
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Pathogenesis
• Host determinants
– Women: • Prior history of UTI in earlier age
• Less vaginal lactobacilli higher pH increased colonization with uropathogenic strains
• Impaired voiding (i.e. cystocele, bladder diverticuli)
– Men: • Prostate hypertrophy urethral
obstruction/turbulent urine flow bacterial ascension into the bladder
• Increased post-void urine residual volume
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Pathogenesis
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Nature Reviews - Microbiology
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Prevalence of asymptomatic bacteriuria
Category Percent
Young women 1-2%
Women age 65 – 90 6-16%
Women ≥ 90 22 – 43%
Men ≥ 65 5-21%
Women in LTCF 25 -50%
Men in LTCF 15-35%
Juthani-Mehta, Clin Geriatr Med 23 (2007): 585
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Asymptomatic bacteriuria
• Often associated with pyuria • Especially in LTCF residents
• Virtually universal in patients with
indwelling catheters
Nicolle LE. Infect Control Hosp Epidemiol 2001;22:167–75.
Warren JW, Tenney JH, Hoopes JM, et al. J Infect Dis 1982;146:719–23.
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Most common bacterial species
Category Bacterial species
Most common E. coli
Community-dwelling elderly E. Coli
Staph coagulase-negative
NH residents Proteus mirabilis
Providencia stuarti
Klebsiella pneumoniae
Chronic catheters (biofilms) Proteus mirabilis
Providencia stuarti
Pseudomonas aeruginosa
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Prognosis
• Progression to bacteremia is rare • Prospective study of 1497 patients with urinary
catheters
• Bacteriuria: 15%
• Bacteremia: 0.3% (4 patients)
Archives Internal Medicine, March 13 (160), 2000
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Asymptomatic bacteriuria – Treatment not
recommended
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Asymptomatic bacteriuria – Treatment not
reccomended
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Asymptomatic bacteriuria
• Treatment recommended: • Pregnant women
• Patients prior to urologic procedures where
mucosal bleeding is anticipated
• Patients prior to TURP
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Urinary Tract Infection
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Infectious disease hospitalizations among
elderly in US
234
78.761.7
39.1
0
50
100
150
200
250
Rate
per
10,0
00 a
du
lts
LRT UTI Septicemia Cellulitis
ARCH INTERN MED/VOL 165, NOV 28, 2005
Study period: 2000-2002
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UTI - Epidemiology
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UTI – Chronic indwelling catheters
• Chronic indwelling catheters • Bacteriuria universal
• More likely to develop infection
• More likely to have fever from a urinary source,
bacteremia, and pyelonephritis
• Increased mortality likely due to poorer functional
status and more comorbidities
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UTI - Prevention
• Options for prevention of recurrent UTIs: • Intravaginal estriol for postmenopausal women?
• Antibiotic prophylaxis
– If ≥ 2 symptomatic UTIs over 6 months
– Agents used: Bactrim, Keflex, Macrobid
• Factors that increase risk of recurrent UTIs • History of UTI at younger age
• Incontinence
• Cystocele
• Postvoid residual urine
• Poor functional status, NH residence, catheterization
• Severe BPH
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UTI - Diagnosis
• Diagnosis:
– Ambulatory, outpatient elderly:
• Bacteriuria ≥105 cfu/mL PLUS genito-urinary symptoms
• Cystitis: dysuria, frequency, urgency, nocturia, suprapubic
discomfort, occasional hematuria
• Pyelonephritis: CVA pain, fever, and variable GU symptoms
– Institutionalized elderly adults with cognitive
impairment
• Difficult to distinguish asymptomatic bacteriuria from UTI
• Laboratory criteria plus symptoms
• ? Which symptoms?
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Urinary Symptoms
Incontinence
Frequency
Urgency
Suprapubic pain
Flank pain
Fever
Lack of well-being symptoms
Anorexia
Difficulty in falling asleep
Difficulty in staying asleep
Fatigue
Malaise
Weakness
No difference found in the prevalence of these symptoms during
periods of bacteriuria versus nonbacteriuria in the elderly
Boscia JA, KobasaWD, Abrutyn E, et al. Am J Med 1986;81:979–82.
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UTI in NH residents - definition
• The McGeer criteria:
– If no indwelling catheter, 3 or more of:
• fever ≥ 100.4°F
• new or increased burning on urination, frequency,
or urgency;
• new flank or suprapubic pain or tenderness;
• change in character of urine;
• worsening of mental or functional status.
– If indwelling catheter, 2 or more
McGeer A, Campbell B, Emori TG, et al.. Am J Infect Control 1991;19:1–7.
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UTI in NH residents - diagnosis
• The Loeb criteria
– NH residents without catheters:
• Acute dysuria OR fever (≥ 100°F) plus 1 or more:
– New or worsening urgency or frequency
– Suprapubic pain
– Hematuria
– CVA tenderness
– Urinary incontinence
Infect Control Hosp Epidemiol 2001;22:120–124
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UTI - Diagnosis
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UTI - Microbiology
Category Bacterial species
Outpatient elderly
(UTI with
bacteremia)
GNR (E coli, etc): 80%
GPR (Enterococcus, S. aureus): 20%
NH residents E coli
P. Aeruginosa
VRE
Candida
Other GNR
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Treatment
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UTI - Treatment
• Duration – Outpatient women – acute cystitis:
• FQ – 3 days as effective as 7 days
• TMP – SMX – 3 days
• Nitrofurantoin – 5 days
– Outpatient men – acute cystitis • 7 days
– Outpatient men – recurrent cystits – chronic bacterial prostatitis
• 6 -12 weeks
– Pyelonephritis – men and women • 10-14 days
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Figure 1. Patterns of empiric antimicrobial use at
hospital admission among patients with community-
onset Clostridium difficile infections
Pop-Vicas et al, SHEA 2011 abstract
N = 88 patients
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Characteristic Cases (N = 30)
N (%)
Controls (N = 58)
N (%)
Odds Ratio
P value
Age ≥ 80 years 16 (53) 16 (28) 3 (1.1 – 8.3) 0.017
NH residence 17 (57) 15 (26) 3.8 (1.3 – 10.5) 0.004
Nonverbal on admission 10 (33) 3 (5) 9.2 (2.0 – 55.4) < 0.005
Dementia 7 (23) 4 (7) 4.1 (0.9 – 20.7) 0.027
Suspected UTI 12 (40) 6 (10) 5.8 (1.7 – 21.2) 0.001
Acute renal failure 13 (43) 8 (14) 4.8 (1.5 – 15.5) 0.002
Severe CDI 23 (77) 29 (50) 3.2 (1.1 – 10.4) 0.016
Table 1. Risk factors for injudicious antimicrobial use at hospital admission
among patients with community-onset CDI (univariate analysis)
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Risk factor Adjusted Odds Ratio ( 95% Confidence Interval)
P value
Suspected UTI 7.0 (2.0 – 23.7) 0.002
Acute renal failure 4.5 (1.5 – 13.7) 0.009
Severe CDI 3.2 (1.0 – 10.3) 0.046
Independent risk factors associated with injudicious antimicrobial use at
hospital admission for patients with community-onset CDI
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Judicious antimicrobial use