Urinalysis in the Elderly The Good: The Bad: The Ugly

Can I Get a UA Mr. Smith is confused Mr. Jones fell Mr. Walker is not acting like his normal self Miss Foy is not eating well today Mrs. Weber’s urine is dark or cloudy etc

When to Order A Urine C&S Must have S/S of UTI Increased frequency or urgency Burning with urination Fever Flank Pain Gross Hematuria Suprapubic Pain

Urine C&S Should be ordered when it would affect Clinical Care

Interpretation of Analysis Appearance cloudy Leukocytes Esterace 1+ Blood 2+ UA Microscopic WBC > 50 RBC 10-20 Occasional Bacteria

Microbiology Criteria At least 10 5th cfu/ml of no more than 2 organisms in voided sample At least 10 2nd of any number of organisms in a specimen collected by the in and out catheter

Minimal Inhibitory Concentration (MIC) Interpretation Susceptible Strain can be treated with conventional antibiotics Intermediate May work but the response may be reduced Resistant Not work

Urine CX Results Klebsiella Pneumoniae > 100,000 Antibiotic MIC Interpretation Ampicillin >= 32 R Cefazolin <=4 S Cipro <=0.25 S Nitrofurantoin 32 S Trimethaprim Sulfa <=20 S

UA Appearance Cloudy Leukocyte Esterase 2+ Nitrites Microscopic + WBC > 50 Bacteria Rare +

C & S E Coli Antibiotic MIC Interpretation Ampicillin <= 2 S Cefazolin <= 4 S Cipro <=0.25 S Trimethoprim/Sulfa <=20 S

UA Appearance Turbid Leukocyte Esterase 3+ Protein +1 Blood +2 Microscopic WBC > 50 RBC 5-10 Bacteria Numerous

Asymptomatic Bacteriuria Pt does not have SXS, but presence of bacteria in urine micro or cx Confirm in 2 consecutive samples? Transient in older people Not associated with increased mortality or morbidity More common in cognitively impaired people

Increased in patients with incontinence and impaired bladder emptying Do Not Screen Do Not Treat

Urinary Tract Diagnosis Dx is made with both clinical features and lab evidence At least two sxs of the following Acute Dysuria Increased frequency or urgency CVA tenderness Suprapubic tenderness + CX 10 5th CFU/ML

No more than 2 pathogens Pyuria Leukocytes > 10 mm 3rd Fever

Confusion is NOT a Urinary Tract sign or symptom

Patients Not Meeting Criteria Perform a thorough systemic evaluation and assessment Differential Diagnosis Reassess

Current Guidelines The American Geriatric Society Does not recommend antibiotics to treat bacteriuria unless specific urinary tract sxs are present

McGeer Criteria Without a Catheter Must include criteria from both 1 and 2 1). At least one of the following Fever or Leukocytosis 2). And at least 1 of the following Acute CVA pain or tenderness Suprapubic pain Gross hematuria New or marked increase in incontinence

New or marked increase in urgency New or marked increase in frequency In the absence of fever or leukocytes: Then must have 2 from the above list

Loeb Criteria Long Term Care Facilities Acute dysuria alone Fever 37.9 or .5 degrees above baseline and at least one of the following New or worsening Urgency/Frequency/Incontinence Suprapubic Pain/ CVA tenderness Gross Hematuria

Complicated VS Uncomplicated Does not include the elderly Complicated Elderly Functional or structural abnormality in urinary tract

Antibiotic Stewardship Urine CX aids in narrowing the spectrum of antibiotics - when you choose to treat Most common bacteria is ?? Know local resistance rates Risk VS Benefit Side effects Increased antibiotic resistance Drug/Drug interaction

Treatment Failure VS Reinfection

Recurrent UTI Risk Factors Diabetes Functional Disability Sexual Intercourse HX of urological problems Urinary Retention or incontinence Postmenopausal Estrogen Deficiency Prostate DZ or Kidney Stones

Prophylactic Antibiotic When to use 2 or > UTI in 6 months 3 or > UTI in 1 yr What to choose?

UTI Reduction Increase Fluids Routine Post Bathroom Care B/B training every 2 hrs during the day and every 4 hrs at night Cranberry capsules still controversial

The Good UTI Treat and patient feels better Prevent Urosepsis

The Bad Side effects Medication compliance Cost

The Ugly Clostridium Difficile Urosepsis Antibiotics Isolation Diarrhea Weakness etc Urosepsis Increased antibiotic resistance

Take Home Points UTI is commonly overdiagnosed and therefore overtreated. Contributing to antibiotic resistance No sxs present do not test Educate staff and families Confusion is not a sxs of UTI

Questions?

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