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Urinalysis in the Elderly
The Good: The Bad: The Ugly
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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
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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
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Urine C&S Should be ordered when it would affect Clinical Care
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Interpretation of Analysis
Appearance cloudy Leukocytes Esterace 1+ Blood 2+ UA Microscopic WBC > 50 RBC 10-20 Occasional Bacteria
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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
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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
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Urine CX Results Klebsiella Pneumoniae > 100,000
Antibiotic MIC Interpretation Ampicillin >= 32 R Cefazolin <=4 S Cipro <=0.25 S Nitrofurantoin S Trimethaprim Sulfa <=20 S
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UA Appearance Cloudy Leukocyte Esterase 2+ Nitrites Microscopic +
WBC > 50 Bacteria Rare +
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C & S E Coli Antibiotic MIC Interpretation Ampicillin <= 2 S
Cefazolin <= S Cipro <= S Trimethoprim/Sulfa <= S
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UA Appearance Turbid Leukocyte Esterase 3+ Protein +1 Blood +2
Microscopic WBC > 50 RBC Bacteria Numerous
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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
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Increased in patients with incontinence and impaired bladder emptying
Do Not Screen Do Not Treat
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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
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No more than 2 pathogens Pyuria Leukocytes > 10 mm 3rd Fever
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Confusion is NOT a Urinary Tract sign or symptom
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Patients Not Meeting Criteria
Perform a thorough systemic evaluation and assessment Differential Diagnosis Reassess
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Current Guidelines The American Geriatric Society
Does not recommend antibiotics to treat bacteriuria unless specific urinary tract sxs are present
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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
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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
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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
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Complicated VS Uncomplicated
Does not include the elderly Complicated Elderly Functional or structural abnormality in urinary tract
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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
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Treatment Failure VS Reinfection
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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
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Prophylactic Antibiotic
When to use 2 or > UTI in 6 months 3 or > UTI in 1 yr What to choose?
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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
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The Good UTI Treat and patient feels better Prevent Urosepsis
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The Bad Side effects Medication compliance Cost
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The Ugly Clostridium Difficile Urosepsis
Antibiotics Isolation Diarrhea Weakness etc Urosepsis Increased antibiotic resistance
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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
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Questions?
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Thank You
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