Dr Rohan Wee Aged Care Physician Northern Health UTIs in Older People Dr Rohan Wee Aged Care Physician Northern Health

Are UTIs Important? Most frequent infection in residential care Dementia, incontinence & decreased mobility are risk factors for developing UTIs Asymptomatic bacteriuria is common 15-30% in men 25-50% in women Long term IDCs are always colonised

How do we diagnose a UTI? Symptoms Probability of UTI in women 90% Dysuria, frequency, lower abdominal pain, urgency, haematuria Absence of vaginal discharge or irritation Probability of UTI in women 90% Urinalysis Pyuria MSU

The problem is… Residential care residents often can’t give reliable histories Urinalysis and culture are often done for atypical symptoms Change in behaviour Decrease in appetite etc Asymptomatic bacteriuria is common

Asymptomatic bacteriuria (1) Is more common in Diabetics The elderly Long term IDCs Pyuria is not a reliable predictor of bacteriuria Urinalysis is not useful in predicting bacteriuria

Asymptomatic bacteriuria (2) Why would we treat if asymptomatic? Prevent later infections Not evidence to suggest this works Less asymptomatic bacteriuria in follow up but not UTIs Survival benefit Increased mortality in patients with bacteriuria No improvement in mortality if treated Probably reflects differences in patient groups Improve continence No benefit in a residential care population

What to do … When the urine smells or is cloudy When the FWT is “positive” With the MSU results

“Doctor - the urine smells” No evidence that an offensive odour correlates with UTI Prospective trial comparing diagnosis by smell to clean catch urine did not find that smell was reliable in identifying UTI No evidence that cloudy urine correlates to UTI

Urinalysis in Residential Care Does a “positive” FWT mean UTI? High false positive rate False negatives do occur In an asymptomatic patient Positive FWT is probably a false positive Negative FWT means UTI unlikely

The MSU is Positive The asymptomatic patient The symptomatic patient Long term IDC

The Asymptomatic patient A positive MSU probably represents asymptomatic bacteriuria No treatment is required Observe patient

The Symptomatic patient Treat with appropriate antibiotics

Long Term IDC Always colonised MSU/CSU Treat if symptomatic May indicate what bacteria to treat if the patient becomes unwell Ideally change IDC just before CSU for most accurate results Treat if symptomatic Fever, loin pain

Non-specific Decline (1) The evidence for the correct course of action is poor Assess the patient History Examination Investigations FBE, U&E, +/- CXR FWT/MSU

Non-specific Decline (2) FWT Positive may be a false positive Negative makes UTI less likely MSU Will guide antibiotic choice if LMO chooses to treat May be treating asymptomatic bacteriuria Treating a “UTI” should occur after other causes have been excluded if the situation requires it

Preventing Recurrent UTI (1) Increased fluid intake No evidence but it may be helpful Cranberry juice Some limited evidence Limitations Variable dose and duration Calorie load Not clear if cranberry tablets are of benefit

Preventing Recurrent UTI (2) Topical oestrogen Improves atrophic vaginitis Encourages lactobacilli growth, decreases E. coli growth Antibiotic prophylaxis Useful if >3 symptomatic UTIs/year Risk of resistant organisms

References Up To Date Recurrent UTI in women Overview of acute cystitis in women Approach to the patient with asymptomatic bacteriuria UTI associated with indwelling catheter UTI in geriatric and institutionalized patients L. E. Nicholle, Current Opinion in Urology 2002, 12:51-55