Urinary Tract Infection - Guidelines to assessment

Urinary Tract Infection: Guidelines to assessment, treatment, and prevention in the older adult 33:610 Gerontological Nursing University of Massachusetts Lowell Mary Ellen Powers, BSN, RN March 30, 2006 Urinary Tract Infection The Agency for Healthcare Research and Quality (AHRQ) and the U.S. Preventive Services Task Force (USPSTF) Mission  Improve quality, efficiency and effectiveness of healthcare for all Americans  Supports health services research that will improve the quality of healthcare & promote evidence-based decision making Urinary Tract Infection GNP’s Role  Develop and implement evidence-based health promotion strategies, as well as prevention and treatment criteria in UTI management of the older adult, both in the community and long-term care setting Urinary Tract Infection Prevalence  Community-dwelling elders – 25% Swart, Soler & Holman, 2004  Long-term care elders (chronically bacteriuric) } 25-50% of women 15-40% of men Juthani-Mehta et al., 2005  Marked increases in women & men after age 65 Wagenlehner, Naber & Weidner, 2005 Urinary Tract Infection Defined Definition Women: Presence of at least 100,000 colonyforming units (cfu)/mL in a pure culture of voided clean-catch urine Presence of just 1,000 cfu/mL indicates urinary tract infection Men: *Some labs do not routinely identify & determine the sensitivity of organisms for specimens with <10,000 cfu/mL. May have to special request. Swart, Soler & Holman, 2004 Urinary Tract Infection  Urinary tract infection—most common source of bacteremia, a dangerous systemic infection in long-term care facilities Bacteremia—40 times more likely to occur in catheterized than non-catheterized residents Bacteremia leads to significant morbidity and mortality in the vulnerable elderly Nicolle, 2005   Urinary Tract Infection Physiologic Changes Physiologic changes with aging in the urinary tract Age-Related Changes Decreased bladder capacity and increased urine production (especially at night) Decreased voided volume Decreased estrogen w/menopause leads to thinning of vaginal & urethral mucosa Decreased lower urinary tract sensory threshold Men √ √ Women √ √ √ √ Palmer, 2004 UTI—Physiologic Changes Physiologic changes with aging in the urinary tract Age-Related Changes Problems of urinary storage & emptying Men Women √ √ ↑incidence of overflow incontinence from urethral obstruction or stricture Decreased estrogen levels leads to pH changes in vagina, favoring colonization of E. coli, ↑risk of UTI Prostatic enlargement can lead to urinary obstruction, increased residual urine & infection √ √ √ √ Palmer, 2004 Age-Related Changes in the Urinary System Structure Change Glomeruli ↓number ↑surface area thickened membrane fatty degeneration shortening stiffening narrowing ↓expandability & compressibility of bladder Impact   ↓filtration of blood ↓glomerular filtration rate by 30-40% ↓tubule transport ↓urine-concentrating capacity ↓Na conservation ↓renal acidification ↓blood flow ↓efficiency in removal of waste product ↓bladder capacity ↑residual urine volume after voiding Palmer, 2004 Tubules     Renal vasculature   Connective tissue   History & Physical Examination Age-related Risk Factors for UTI        Advanced Age Fecal incontinence/impaction Incomplete bladder emptying or neurogenic bladder Vaginal atrophy/estrogen deficiency Pelvic prolapse/cystocele Insufficient fluid intake/dehydration Indwelling foley catheter or urinary catheterization or instrumentation procedures H & P, cont’d Age-related Risk Factors for UTI      Diabetes or immunosuppression Benign prostatic hypertrophy Bladder or prostate cancer Urinary tract obstruction Spinal cord injury Mahan-Buttaro, Aznavorian & Dick, 2006 H & P, cont’d Female vs. Male Complicating Factors Age Group (years) 50-70 Female Risk Factors Estrogen deficiency Diabetes Gynecological diseases— cystocele & related surgical procedures Male Risk Factors Prostatic obstruction Diabetes Urological/surgical procedures H & P, cont’d Female vs. Male Complicating Factors Age Group (years) >70 Female Risk Factors Estrogen deficiency Diabetes Gynecological diseases (cystocele & related surgical procedures) Urological diseases (incontinence, residual urine, cystopathy) & related surgical procedures Urinary catheter Reduced mental status Co-morbid diseases Immunological changes Male Risk Factors Prostatic obstruction Diabetes Urological/surgical procedures Urinary catheter Reduced mental status Co-morbid diseases Immunological changes Wagenlehner, et al., 2005 Complicated vs Uncomplicated UTI   UTI’s in elderly men are always considered complicated UTI’s in women are complicated when:       Hx of recurrent UTI Secondary to structural abnormalities Catheters Stones Urinary retention Abscess formation or urosepsis  Primary diagnostic and treatment focus in research studies have been related to the elderly female population Swart, Soler & Holman, 2004 Complicated vs Uncomplicated UTI Recurrent UTI’s—culture-confirmed UTI’s * >3 in 1 year or * > 2 in 6 months  Relapse UTI—  occurs within 2 weeks of Rx of an earlier UTI same pathogen Re-infection UTI— occurs >4 weeks after earlier UTI different pathogen Swart, Soler & Holman, 2004 Causative Pathogens UTI in Women  Escherichia coli—gram (-) etiologic = agent in ~ 80% of all UTI’s  Research indicates primary source of microbial invasion is retrograde colonization by intestinal pathogens  Other factors influencing colonization: vaginal pH, urethral length, capacity of bacteria to adhere to urothelium Osborne, 2004 Causative Pathogens, cont’d Polymicromial bacteriuria   Contamination most frequent cause of multiple microorganisms 25-33% in LTCF’s may be polymicrobic due to fistulas, urinary retention, infected stones, or catheters Midthun, 2004 Causative Pathogens, cont’d Age/Type Specific Pathogens    Younger patients, rare in elderly—Staphylcoccus, saprophyticus (gram pos.) – 10-15% Elderly diabetics  Klebsiella species (gram neg.) most common E. coli ~ 30% Proteus species (part of host flori in GI tract) ~ 30% Staphylcoccus aureus, Klebsiella, Pseudomonas (gram neg.) and Enterococcus (gram pos.) ~ 40% Swart, Soler & Holman, 2004 LTCF elderly    Symptoms versus Asymptomatic Bacteriuria Asymptomatic Bacteriuria (ASB)  Defined as the presence of bacteria in urine of patients who do not have dysuria, urinary frequency, urgency, fever, flank pain, or other symptoms related to irritation of the urethra, bladder, or kidney Swart, Soler & Holman, 2004  Strictly defined—exists when 2 urine cultures done with clean-catch specimens are positive in a patient who has no urinary tract symptoms Foxman, 2003 Symptomatic vs Asymptomatic Bacteriuria, cont’d ASB  Frequent in elderly, even > prevalent in residents of LTCF: elderly >70 yrs old women: 16-18% men: 6% Symptomatic vs. Asymptomatic Bacteriuria, cont’d Asymptomatic Bacteriuria (ASB)  Most ASB in the elderly is associated with complicating factors such as:      Hormonal: Anatomical: Functional: Metabolic: Immunological: Instrumental:  post-menopausal women prostatic obstruction in men, cystocele in women CNS, i.e., P.D. & dementia diabetics (ASB females with Type 2 diabetes—29%) ↑’s in inflammatory mediators (cytokines, acute phase proteins) indwelling catheter→always bacteriuric symptoms Wagenlehner, Naber & Weidner, 2005 UTI Signs and Symptoms in Elderly Very difficult to assess and recognize, even when present in the older adult. Signs & Symptoms that indicate further evaluation for UTI elicited from H&P: New or increased urgency, frequency, dysyuria:  > in younger patients, still can be present in elderly  These complaints can be common & chronic without bacteriuria  Requires careful interpretation—may not be due to UTI  Change in character of urine  One study found cloudy, bloody, or malodorous urine in >85% symptomatic UTI’s  Others less predictive  Midthun, 2004 Signs and Symptoms, cont’d  Clarity of urine  Clear → no bacteria; cloudy, milky or turbid → bacteriuria    Cloudiness, however, can occur in normal urine—mucus, epithelial cells Cloudy character, alone or with (+) dipstick analysis → further lab analysis Study by Loeb et al. (2001) as consensus criteria—cloudy urine not an indication for antibiotics  Bloody  Hematuria not always indicative of infection; possibly irritation or medication related  Malodorous Not a valid indicator—may be caused by bacteria, but could be hygiene-related  Often considered an indicator, however  Midthun, 2004 Signs and Symptoms, cont’d   Elevated temperature—(vital signs) Elderly require > time to present with fever, may not have any increase in temperature → may even be hypothermic  Elderly at ↑’d risk for masked or absent fever response due to antipyretics, corticosteroids, chemo Rx, alcoholism, hypothyroidism, malnutrition and renal insufficiency  Studies indicate fever is a marker for serious infection & most important clinical indicator for antibiotic treatment  Other studies, fevers can resolve without treatment; antibiotics did not improve outcomes in elderly  Not always due to UTI—consider differential diagnoses: pulmonary or skin infections  Lack of fever may delay diagnosis Midthun, 2004 Signs and Symptoms, cont’d  Pain Despite limitations of assessment in the elderly, suprapubic, flank or CVA pain can indicate UTI (abdominal, rectal & vaginal exam)  Agitation, irritability, restlessness, decreased appetite, increased confusion, or even falls may indicate pain (Neuro & GI exam)  Cultural differences in interpretation of pain, symptoms   Incontinence May be caused by UTI or the altered mental status that  that occurs with the elderly  Commonly caused by other conditions  Symptom and a risk factor of UTI  Midthun, 2004 Signs and Symptoms, cont’d  Decline or Sudden Change in Mental Status (Neuro, MMSE) Hallmark symptom of UTI in elderly in most studies  Altered mental status, lethargy & confusion are the most common indicators of bacteremia in elderly UTI   Falls  Not specific to UTI, but may indicate a change in status, evaluate clinical picture  Appearance—(general survey) Vague assessment  General decline in status  Listen to family and staff that know the patient well  Midthun, 2004 Signs and Symptoms, cont’d  Other Possible Signs & Symptoms of UTI  Signs of sepsis other than fever or decline in M.S.  Hypotension  Tachycardia  Tachypnea  Rales  Respiratory distress  Anorexia, nausea, vomiting  Abdominal tenderness Midthun, 2004 Diagnostic Criteria Pyuria     A host response to infecting bacteria causing an increase of white blood cells or pus in the urine Associated with presence of both symptomatic and asymptomatic UTI’s in elderly Level of pyuria is ↑ when infected with a gram negative organism Most research finds this is so common that it has questionable value in UTI detection and as an indicator for Rx in the absence of clinical symptoms  McGeer et al. (one of the most commonly used consensus criteria in LTCF for UTI detection in Canada) rejects it as being a reliable predictor of bacteriuria or symptomatic infection Midthun, 2004 Juthani-Mehta,, 2005 Screening/Diagnosis Asymptomatic Bacteriuria  No universally accepted criteria for the diagnosis, treatment, or surveillance of UTI, specifically in LTCF residents Treatment of ASB is associated with ↑ adverse antimicrobial effects, re-infection with organisms or increasing resistance Nicolle, et al., 2005  Screening/Diagnosis Infectious Disease Society of America: Guidelines for Dx & Rx of ASB in adults 1. ASB Dx based on results of a culture from clean-catch specimen (* important to minimize contamination)  Women: bacteriuria = 2 consecutive voided urine samples w/isolation of same strain in cfu/mL >100,000  Men: bacteria = single, clean-catch specimen with 1 bacterial species isolated in > 100,000 cfu/mL  Both: single catheterized urine specimen with 1 bacterial species isolated in a count of > 1,000 cfu/mL Screening/Diagnosis Guidelines, continued 2. Pyuria accompanying ASB not an indication for antimicrobial Rx (A-2) 3. Pregnant women should be screened in early pregnancy, at least once & treated if positive (A-1) 4. Screening of ASB & Rx if positive before these urological procedures:  Transurethral resection of prostate (A3)  Procedures anticipated to cause possible mucosal bleeding (A-3) Screening/Diagnosis Guidelines, continued 5. No screening for ASB: (A-1 & A-2 strongly recommended via research evidence)       Pre-menopausal, non-pregnant women (A-1) Diabetic women (A-1) Community older adults (A-2) Institutionalized elderly (A-1) Spinal cord injury (A-2) Indwelling-catheterized patients (A-1) 6. 7. Antimicrobial Rx of asymptomatic women with catheteracquired bacteriuria persisting 48 hrs after removed, should be considered (B-1/good) No screening or Rx of ASB → renal transplant or solid organ transplant recipients (C-3/weak) Infectious Disease Society of America, 2005 Nicolle et al. 2005 www.guideline.gov/summary/summary Screening/Diagnosis Guidelines, continued Guide to Clinical Preventive Services, 2005  Similar consensus of IDSA recommendations  Clinical considerations     Dipstick analysis & direct microscopy have poor positive & negative predictive value for detecting ASB Urine culture = gold standard, but expensive for routine screening in populations of low prevalence New enzymatic urine screening test (Uriscreen TM) showed 100% sensitivity & specificity of 81% No clinical benefit to screen individuals other than pregnant women—did not improve clinical outcomes. Guide to Clinical Preventive Services, 2005 http://www.ahrq.gov/clinic/ppcletgp/geps2b.htm#bacteriaria Screening & Diagnosis Guideline Criteria for Treatment The following are a recommended minimum set of criteria adapted from the McGeer (1991) and Loeb et al. (2001) studies necessary to initiate diagnostics and AB Rx. Indwelling catheter present: two of the following must be met  Catheter is not present: three of the following must be met       Fever (>38°C/100.4°F) or increase of 1.5°C (2.4°F) above baseline temperature. Chills New costovertebral angle tenderness New suprapubic pain, flank pain or tenderness Decreased mental or functional status (delirium) New-onset hematuria, foul-smelling urine, or amount of sediment      Acute dysuria alone (key indicator) or fever (>38°C/100.4°F) or increase of 1.5°C (2.4°F) above baseline temperature Chills Frequency Urgency New costovertebral angle tenderness Decreased mental or functional status (may be new or increased incontinence related) * New-onset hematuria, foul-smelling urine or (+) sediment New suprapubic pain, flank pain or tenderness   Laboratory Analysis Dipstick Testing Used in primary care & LTC settings. But for institutionalized adults, urinalysis is preferable.  Chemically impregnated reagent strips (UA Chemstrip Screen) provide preliminary/quick determinations of: pH protein glucose ketones urobilinogen bilirubin blood *nitrite *leukocyte esterase specific gravity Fischback, 2004  Fairly reliable, although U.S. Preventive Services Task Force (USPSTF) report from research studies these have ―poor positive & negative predictive value‖ for detecting bacteriuria in asymptomatic patients. www.ahrq.gov/clinic (2005) Laboratory Analysis, continued Routine Urinalysis—Key Indicators of Infection Urine collection 1st morning specimen is best Straight catherization for those incontinent, functionally or cognitively impaired Measure of kidney’s abiltiy to concentrte urine Range of SG depends on state of hydration Specific gravity Appearance Cloudy, may not indicate WBC’s Could indicate a change in urine pH → causes precipitation Alkaline urine → phosphates → cloudy Acid urine → urates → cloudy Pale yellow to amber Variations can be caused by medications, disease processes (*nl urine darkens on standing 30 min. after voiding—oxidation of urobilinogen to urobilin) Color Odor nl → faint odor when freshly voided Foul-smelling—often presence of bacteria which splits urea to form ammonia Fischbach, 2004 Laboratory Analysis, continued Routine Urinalysis, continued pH Acid or base—measures free H+ ion concentration in urine 7.0—neutral. Indicates kidney function Determines if systemic acid-base disorders of metabolic/resp. origin  control of pH → manages bacteriuria, renal calculi & drug Rx  bacteria from a UTI → produce alkaline urine Always an indicator of kidney/UT damage Blood or Hemoglobin Protein (Albumin) Microalbuminuria Single most important indication of renal disease Below dipstick range of detection Detects deteriorating renal function in diabetic patients (standard screener) Fischbach, 2004 Laboratory Analysis, continued Routine Urinalysis, continued *Nitrite (Bacteria) Dipstick - rapid, indirect method to detect bacteria  common gram-negative organisms contain enzymes → reduce nitrate in urine to nitrite  some UTI’s are caused by organisms that do not convert nitrate to nitrite (e.g., staphylococcus, streptococci) Esterase is released by leukocytes (WBC’s) in urine Microscopic exam & chemical test *Leukocyte Esterase __________ *U/A testing positive for nitrite & leukocyte esterase should be cultured for bacterial pathogen Fischbach, 2004 Urine Culture and Sensitivity  Traditional gold standard for significant bacteriuria >100,000 cfu/mL of urine. Some argue criteria for bacteriuria is only 100 cfu/mL of a uropathogen in symptomatic females or 1,000 in symptomatic males. Bacterial identification from urine C&S, key in males and females with complicated UTI’s.  Other Laboratory Tests Complete Blood Count with Differential   Indicated to R/O bacterial infection supports treatment plan Careful evaluation of WBC & differential (left shift) R/O dehydration & if IV fluids replacement needed Determine ↓ renal function for nephrotoxic medications Identify bacteremic organism in suspected urosepsis Electrolytes  BUN, Creatinine  Blood Culture  Treatment Plan    Early detection/Rx → goal is to prevent systemic infection, bacteremia Initiation of antibiotic treatment is recommended for a clinically-diagnosed UTI. Adjust medication when urine C&S is final Selection of antibiotic must be individualized and consider:       Side effect profile Cost Bacterial resistance Likelihood of compliance (convenience, fewer pills/day ↑’s compliance) Effect of impaired renal function on dosing Possible adverse drug reactions ↑ in elderly (multiple drugs, comorbidities. Osborne, 2004 Swart et al. 2004 Treatment Plan Recommended Treatment Regimens for Acute, Uncomplicated UTI’s in the Elderly Treatment Sulfonamide TrimethoprimSulfamethoxazole TMP-SMX Fluoroquinolones Ciprofloxacin (2nd gen) Levofloxacin (3rd gen) Dosage/Duration 160/800 mg po bid x 3-14* days *available in a syrup If CrCl <15-30 mL/min, ↓in half Bacterial Coverage/ Resistance (E. coli 20% ) ↑ resistance Less effective Common Side Effects nausea, rash Compliance/ Convenience Fair/Good longer duration of bid ↓ compliance Cost I/E I Men √ Women √ 100- 250 mg po bid x 3-14* days If CrCL <30mL/min ↓ by half 250 mg po daily x 10 days (complicated upper and lower UTI) 3 g powder, dissolved in water *single dose gram (-) effective gram (+) only fair headache, dizziness, nausea, diarrhea Good/Good bid, longer duration ↓ compliance Excellent E √ √ Fosfomycin gram (-) effective gram (+) less effective diarrhea, vaginitis, nausea, rhinitis Excellent VE, often not on formularies √ √ Nitrofurantoin (Macrobid) 100 mg po bid x 7 days If CrCL <40 mL/min not recommended Narrow spectrum gram (-) effective gram (+) effective nausea, vaginitis, diarrhea ↑ rate of severe pulmonary & hepatotoxicity PCN-anaphylaxis Abdominal cramping diarrhea Fair 7-day regimen & bid, ↓ compliance I Prostatitis NR √ Miscellaneous Beta Lactam AB’s: Cephalosporins (Cefuroxime, cefpodoxime) Penicillins (ampicillin), Carbapenems (imipenem) Phenazopyridine (Pyridium)—not appropriate for elderly or patients with renal insufficiency ↑ resistance 2° Beta Lactamase enzymes in resistant bacteria 2nd/3rd gen Cephalosporins >resistant to beta lactamase Fair for bid dosing I Prostatitis NR √ Data adapted from Swart et al. (2004), Osborne (2004), Wagenlehner et al. (2005), Mahan-Buttaro et al. (2006) and Evercare Corp (2004) I = inexpensive; E = expensive; VE = very expensive; NR = not recommended *Longer duration for complicated UTI per individual’s clinical status Treatment Plan Duration of Antibiotic Therapy: Ongoing Debate Research Vogel et al., 2004 Double-blind randomized controlled trial compared 3-and 7-day courses of oral ciprofloxacin, 250mg bid. 183 elderly women > 65 yrs old. Acute, uncomplicated UTI. *Outcome—bacterial eradiation @ 2 days, Rx was 98% in 3-day group; 93% in 7 day group.    3-day course not inferior to 7 day Better tolerated Rates of relapse & re-infection 6 weeks later, both groups similar Brumfitt et al./ Proposed long term prophylaxis of recurrent UTI— Stromm et al., 1980 demonstrated benefits from low dose, long term Rx with nitrofurantoin macrocrystals 100 mg po at bedtime. There was minimal/no association w/development of resistance in susceptible strains. Treatment Plan  AB Rx for at least 10 days for institutionalized elderly, as short-term therapy may not be as effective.  Ten-14 days, if indicated, for complicated UTI. (recommended for males) Evercare, 2004  Conventional regimen of 7-10 days duration is usually recommended. Wagenlehner et al. 2005 Treatment Plan Complicated UTI    Can be common in LTC patients Associated with azotemia, obstruction, or indwelling foley Can lead to bacteremia, life-threatening systemic infection Recommended Treatment for Acute Complicated UTI IV antibiotic therapy--*consider renal & hepatic elimination, creatinine clearance for dosage adjustment    3rd generation cephalosporin (Ceftriaxone = Rocephin) Rx 1 gram IV every 24 hours Or if fluoroquinolones (Levofloxacin = Levaquin) 250-500 mg IV every 24 hours Continue until afebrile, minimum of 48 hrs, then start oral therapy and fluids x 14 days. Mahan-Buttaro et al., 2006 Prevention & Treatment Plan Recommendations/Considerations/Prevention Indwelling-Catheterization Foley catheterization should be avoided if at all possible  Most effective means of UTI prevention is limitation of chronic indwelling catheters. Wagenlehner et al. 2005 Prevention & Treatment Recommendations/Considerations/Prevention Research Studies Findings Wilde & Carrigan (2003) Patients with indwelling catheters, maintaining urine flow was a key finding in preventing UTI Muder et al. (2006)    Urinary catheterization is a major risk factor for S. aureus bacteriuria in long-term care patients, so reducing prevalence of indwelling catheters is key. Majority of these cases are methicillin-resistant S. aureus, which can lead to bacteremia Need for optimal infection-control measures & limit unnecessary AB admin. in LTCF. Focus on urine as potential infection reservoir, may be effective preventive strategy Nicolle ( 2005) Study focused on catheter-related UTI. Catheter infection rate of 5% /day *Formation of biofilm on catheters leads to infection as this protects pathogens from antimicrobials & host immune response Johnson et al (2006) Studied efficacy of antimicrobial urinary catheters in hospitalized patients.  prevent or delay onset of catheter-associated bacteriuria Alternative Therapies in UTI Prevention Old adage: ―An ounce of prevention is worth a pound of cure.‖ Cranberry (Vaccinium macrocarpon, fruit) Central in folk medicine beneficial effects on urinary Leading cranberry juice cocktail: juice sweetener, water & added Vit. C Mechanism tract health. Longstanding Rx for UTI prophylaxis Well-tolerated, key factor with older adults Cranberry prevents bacterial (E. coli & other gramnegative uropathogens) binding to host cell surface membranes 1984—Sobota demonstrated a mode of action in cranberry juice that interferes with the adherence of E. coli and other bacteria to uroepithelial cells Scientific Rationale E. coli & other bacteria have different types of adhesins on their fimbriae that allow the organism to adhere to epithelial cells & proliferate. Cranberries unique compound, proanthocyanidins (PAC’s) adhesins inhibit this process Prevention & Treatment Recommendations/Considerations/Prevention   Post-menopausal women w/recurrent infection may require estrogen replacement to restore atrophic vaginal mucosa, ↓ vaginal pH (topical creams) Always adjust antibiotic dosage for renal impairment/insufficiency using the Cockcroft-Gault equation: (140-Age) x weight in Kg X (0.85 if female) 72 x serum creatinine http://www.fhea.com/op/ch14.htm Ensure adequate hydration   Recommended 2.5 L/day in patients with recurrent UTI Often signs & symptoms similar to UTI in elderly are actually caused by dehydration Alternative Therapies for Prevention Cranberry juice, dried cranberries, raisins Research Studies Greenberg et al. (2005) Findings/Evidence Boston pilot-study on 5 subjects. Some evidence of anti-adherence activity using dried cranberry consumption. Raisins—none Small study Jepson et al (2004) Cochrane Database 2004 Reviews— Some evidence from RCT’s to show cranberries (juice & capsules) can prevent recurrent infections in women (especially older women). No significant difference between juice or capsules. Safe & well-tolerated May alter or even prevent formation of calcium oxalate kidney stones vs. just water consumption (upper UT) McHarg et al. (2005) Multiple studies Pilot, double-blind crossover design, prospective, RCT’s.  All support a moderately preventive role for cranberry juice or capsule concentrates against UTI  No significant findings or support in treatment of bacteriuria Key Points in Cranberry Therapy, cont’d Interactions Dosage No significant herb-drug reactions reported Varies. Cranberry extract tablets/capsules: 1 tablet (300400mg) twice daily. CranMax—500mg once daily (potent cranberry supplement) Tablets: $10-$15/30-day supply Unsweetened juice: varies Cost *Safe botanical alternative, effective in UTI prophylaxis Other Alternative Therapies in UTI Management Grapefruit Seeds Case study by Oyelami et al (2005)—4 middle-aged patients treated w/seeds x 2 weeks upon dx of UTI. Concluded: adequate clinical response 5-6 seeds every 8 hrs comparable to antibacterials May reduce rate of UTIs in elderly. Possible mechanism: increase in fecal Lactobacillus organisms & avoidance of constipation Oral Lactulose Urinary Tract Infections in the Elderly: Guidelines for Assessment, Diagnosis, Treatment and Prevention Assessment Past medical history Personal & Social history Key Determinants Age-related changes and risk factors Co-morbidities (diabetes, cancer, GU dx) Pregnancies Urological & gynecological procedures History of UTI, recurrent UTI Medication/allergies Cultural S&S interpretation Evaluation Indwelling catheter present (2 S&S):  Fever (>38°C/100.4°F) or increase of 1.5°C (2.4°F) above baseline temperature.  Chills  New CVA tenderness  New suprapubic/flank pain or tenderness  Decreased mental or functional status (delirium)  New-onset hematuria, foul-smelling urine, or (+) sediment Catheter is not present (3 S&S):  Acute dysuria alone (key indicator) or fever (>38 °C/100.4°F) or increase of 1.5°C (2.4°F) above baseline temperature  Chills  Frequency  Urgency  New costovertebral angle tenderness  Decreased mental or functional status (may be new or increased incontinence related) *  New-onset hematuria, foul-smelling urine or (+) sediment  New suprapubic/flank pain or tenderness Review of Systems Physical Examination *General appearance Skin/hydration *Fever, vital signs Cardiac-↑BP, AP, arrhythmias Pulmonary-lung sounds, DOE *CVA tenderness Appetite, *abdominal pain, bowel pattern *Urine—color, character, odor, catheter, continence changes, dysuria *Mental status—cognition, memory, reporting reliability, decline, ↑ confusion, agitation/restlessness UTI in the Elderly: Guidelines—Diagnosis, Treatment & Prevention Clinical Plan Urinalysis Lab urinalysis w/microscopic exam Key Determinants Indirect dipstick U/A for bacteriuria (+) nitrite Leukocyte esterase Pyuria—WBC’s in urine Useful Rationale for screening asymptomatic individuals R/o’s urinary source of infection/less reliable Indicates inflammatory response, not used as indicator to treat ASB Pyuria alone not specific for infection Organisms count must be sufficient to r/o contamination Identify antimicrobial effective against organism To support treatment decision Urine C&S Identifies organisms in urine and antimicrobial sensitivity Suspect bacterial infection Elevated WBC with left shift CBC w/Diff Evaluate WBC & Diff Electrolytes BUN, Cr Blood culture Current status Current renal status Identify organism in suspected bacteremia R/o dehydration, ? need for fluid replacement Baseline for nephrotoxic meds Documents urosepsis AB Rx determination Calculate CrCl: (140-Age) x weight in Kg (0.85 if female) Treatment *See guidelines for empirical Rx Other supports:  hydration/fluid replacement/IV therapy  fever—treat if present  pain, discomfort—relieve symptoms 72 x serum creatinine Prevention Strategies extract tablets, 300-400 mg po bid and/or juice, minimum of 240 mL/day  ensure hydration of 2.5 L/day  strict hand and perineal hygiene  Staff ed r/t early detection of UTI S&S  cranberry Asymptomatic bacteriuria Rx not indicated due to risk of AB resistance Confirm with 2nd urine specimen Monitor clinical status, assess for contributing factors, urinary incontinence GNP Implications      Overuse of antibiotics is problematic in UTI management in elderly Careful individualized assessment & evaluation of elder. Must consider differential diagnoses before treatment, even when urine culture is positive. Identification of subtle, atypical symptoms of UTI is critical. Listen to family and staff UTI most common nosocomial infection in LTCF’s. Opportunity to educate staff and implement preventative measures to ↓ incidence. Lack of consensus criteria related to UTI management in elderly emphasizes need for further research in urinary health promotion. Be proactive!