• UTI: Urinary Tract Infection
• IUC: Indwelling Urinary Catheter
• CAUTI: Catheter-Associated UTI
• Pyuria: white blood cells in urine
• Asymptomatic bacteriuria: presence of bacteria in urine without clinical signs suggestive of UTI -> really difficult in older adults as they may not present with symptoms the same way younger folks do.
• Symptomatic UTI: symptom + pyuria + urine culture identifying pathogen

In the older adult population at large, the incidence of UTIs in population is about 10% of women over 65 and 30% of women over 85 by self report in preceding 12 months. It is the second most common diagnosed infection in acute hospital setting (pneumonia first, bacteremia third). 5% of all ED visits in adults over 65 are due to UTIs. The numbers jump extraordinarily when discussing long term care facilities. Beyond the risk factor of having had a previous UTI, these patients are more commonly cognitively impaired, have issues with regular voiding, suboptimal self hygiene, and are at risk for needing catheterization.

There is often confusion regarding urinalysis in diagnosing UTIs. Sterile pyuria is frequent in older adults, as well as colonization. Urine cultures are the most important, but should not be sent unless there is clinical concern for a UTI.

A high percentage of older adults have colonized urine (ASB)

• Starts low (lower in men) and increases with age.
• Men over 80 = 10%
• Women over 80 = 20%. This number doubles in SNFs.
• After antibiotics, 25% of these patients have persistent bacteriuria, hence the term colonization.
• Indwelling catheters: 3-10%/day risk, up to 100% with chronic indwelling IUCs…which we’ll discuss more coming up

Pyuria with bacteriuria also increases with age and is close to 90% in men and women over 80

There are criteria out there for treating UTIs in older adults (by McGeer and Loeb and colleagues), however those criteria are rarely followed. Either acute dysuria or fever with worsening urological symptoms (incontinence, smell, frequency, urgency, pain, CVA tenderness, hematuria).  Some people include mental status changes. Ultimately the urine culture is the most important piece.

Overuse of antibiotics is leading to more virulent strains of multidrug resistant pathogens. Hence the importance of making educated decisions about when to treat. Also many of the medications have drug-drug interactions with other medications such as fluorquinolones and warfarin. Or they may cause acute renal failure, such as with Bactrim (TMP/SMX) or other adverse drug reactions.

The most common pathogen is E.coli. If a prior culture exists with sensitivities, use that to guide your choice while the current urine culture is pending. Each institution will have specific sensitivities and treatment should be guided by the local antibiogram. Cephalexin, nitrofurantoin, and fosfomycin (in women) are common choices for simple, uncomplicated UTI (ie. not pyelonephritis, sepsis, or catheter-associated UTIs).

Catheter-associated urinary tract infections, or C-A-U-T-Is, are common, especially in our older adult patients. Catheter-associated UTIs account for 11-40% of hospital-acquired bacteremic episodes. The risk of developing a catheter-associated UTI is directly related to the amount of time the IUC is in place, with the risk of infection increasing by approximately 5% per 24-hour period that the catheter is in place. As of October 1, 2008, CMS no longer reimburses hospitals for CAUTIs. This is one of eleven hospital acquired conditions for which this applies.

Placement of an indwelling urinary catheter, or I-U-C, is one of the most frequently performed procedures in the hospital, and often initiated in the emergency department. This is a decision that is infrequently reversed once the patient is transferred to the floor. In fact, per a study done in 2000, 28% of the time the inpatient provider does not know that a patient under their care has an IUC. Much of the conundrum around whether or not to place an IUC is related to the anticipated risk/benefit ratio when considering the individual patient scenario.

Risks of IUC placement include infection, delirium, falls, discomfort to the patient, traumatic removal, and immobility. Nearly half of all hospitalizations originate in the ED, and 8-23% of ED patients who are admitted receive urinary catheters with the highest rates in older adults. In one study, 91% of IUCs placed in the first 24 hours of admission were placed in the ED. Recent literature suggests that as many as 64% of these IUCs placed in the ED are done so inappropriately. Thus, an intervention focused on geriatric patients in the ED, the “front door” or “point of entry” of a hospital stay, may have a significant impact on IUC placement practices and CAUTI rates.

Dr. Mulcare and team developed a protocol focused on the different stages of decision making when considering an IUC in older adults in the Emergency Department. These include:

• diagnosis-based recommendations for placement,
• critical actions when placing the IUC,
• alternative modes for urine collection,
• assuring agreement within the team for IUC placement,
• reassessment of the IUC for removal.

Overall a Cochrane review from 2012 found no statistically significant benefit to cranberry juice. For older women who have recurrent UTIs, who may have vaginal atrophy topical estrogen to the perineum may help reduce UTIs. Improving mobility may help prevent future infections