Urinary tract infections in the elderly

Urinary tract infections in the elderly

Mark W. Zilkoski

Urinary Tract Infections in the Elderly Urinary tract infections in the elderly present many diagnostic and therapeutic challenges. Signs and symptoms may be confusing, and complications are more likely to occur. Prompt recognition, appropriate treatment and thorough follow-up are essential to minimize morbidity and mortality. After upper respiratory tract infections, urinary tract infections are the most common cause of fever in persons over 65 years of age.(1) The typical presentation of dysuria, frequency and urgency, with or without fever, in a healthy individual of any age generally poses few problems in diagnosis or treatment. In some elderly patients, however, the atypical presentation of urinary tract disease and the chronic illnesses that often occur with aging make diagnosis more difficult, treatment more urgent and complications more common. A rational and thorough diagnostic evaluation is mandatory in these patients, because a delay in diagnosis may increase morbidity and mortality.

Risk Factors

Although a number of age-and disease-related factors may be responsible for the increased incidence of urinary tract infections in elderly patients, the most important factors are neuropathic and obstructive emptying disorders of the bladder (Table 1).(2) Bladder-emptying disorders are underreported and hence undertreated in both ambulatory and nursing home populations.(3,4) Estimates suggest that incontinence affects 5 to 10 percent of elderly individuals residing in the community and as many as 50 percent of the institutionalized elderly.(4-6)

Other major risk factors for urinary tract infections in the elderly include chronic illness or debility associated with immobility, kidney or bladder stones, and the chronic use of an indwelling urinary catheter.

Urinalysis and Culture

Microscopic analysis of a clean-voided or catheter-obtained urine specimen is the first step in the laboratory diagnosis of a suspected urinary tract infection. Pyuria is significant if more than 5 to 10 white blood cells are seen per high-power field in the sediment of 10 mL of centrifuged urine or if more than 10 white blood cells per mm(3) are counted using a hemocytometer and uncentrifuged urine.(2)

Sterile pyuria is defined as 5 to 10 white blood cells per high-power field in the absence of apparent urinary tract infection or urethral discharge.(7) Although an undiagnosed urinary tract infection is one of the most common causes of sterile pyuria, other etiologies also should be considered (Table 2).

Although 70 percent of patients with a true bacterial urinary tract infection have more than 10(5) colony-forming units (CFU) per mL from a urine culture, 30 percent have a much lower concentration.(8,9) For women with acute dysuria, a much better indication of true infection is the presence of a single bacterial pathogen on a culture of at least 10(2) CFU per mL from a urine culture (Table 3).(10)

Various factors may be responsible for spuriously low bacterial counts in urine cultures (Table 3). In any case, the presence of one or more organisms per high-power field on gram-stained culture of unspun urine is highly suggestive of a urinary tract infection.(2,9,10)

More than 95 percent of urinary tract infections are caused by a single bacterial pathogen. Most cases of polymicrobial infection are the result of urine contamination, but more than one organism on culture may be present with long-term catheterization, a vesical-vaginal fistula or incomplete bladder emptying secondary to neurologic dysfunction.(2,9)

Lower Urinary Tract Infection

The symptoms of lower urinary tract infection in an elderly individual are often the same as those in a younger person. Many patients present with frequency, dysuria and urgency. Elderly patients with cystitis often have atypical symptoms, including new-onset urinary incontinence, gastrointestinal upset or a change in mental status.

Escherichia coli is the pathogen most commonly isolated in lower urinary tract infections. The relative frequency of other urinary pathogens varies with patient age, sex and domicile (community hospital or long-term care facility).(11,12) Klebsiella, Proteus and Enterococcus species are seen more often in the elderly than in younger patients.(11,13) Pseudomonas aeruginosa is often seen in females with leukemia or aplastic anemia, or after genitourinary tract manipulation.

Except in the first year of life, lower urinary tract infections are much more common in females than in males.(14) Cystitis in elderly men is almost always the result of acute or chronic infection of the prostate gland. Males have an increased incidence of Proteus infections.(13)

When cystitis develops, a knowledge of the bacterial susceptibility patterns for a particular institution and the recent use of antibiotics by the patient is helpful in choosing the most appropriate initial antibiotic. Many effective oral antibiotics are available for the treatment of cystitis (Table 4).

In uncomplicated cystitis, there is no consensus on duration of therapy.(15,16) In many females, one day or three days of antibiotics may be as effective as a seven-or ten-day course.(16-19) In elderly women with bacterial cystitis, single-dose therapy using trimethoprim with sulfamethoxazole (Bactrim, Septra) or amoxicillin is often sufficient.(15) Patients who do not respond to single-dose therapy require a full seven-to ten-day course of oral antibiotics, with the selection of antibiotic based on the culture results. Single-dose antibiotic therapy is not appropriate for males, pregnant patients or patients with renal insufficiency, structural urinary tract abnormalities or long-term urethral catheterization.

Norfloxacin (Noroxin), a new antibiotic with a broad spectrum of activity that includes P. aeruginosa, was developed as an oral agent for the treatment of bacterial urinary tract infections. To date, single-dose norfloxacin therapy has not been adequately studied. Because of the possibility of bacterial resistance, norfloxacin is not the initial drug of choice in uncomplicated urinary tract infections. It is helpful, however, in the treatment of resistant acute and recurrent urinary tract infections.(20-22)

In younger patients and in elderly patients who live in the community, post-treatment urine cultures are probably not cost-effective for typical bacterial cystitis. The incidence of resistant pathogens and urinary tract abnormalities is higher in hospitalized or institutionalized patients, in the very elderly (over 80 years of age) and in elderly patients with chronic illnesses. In these patients, urine cultures before and after treatment are more likely to influence treatment and further diagnostic decisions.

Relapse or Reinfection

As indicated in Table 5,(15) the reappearance of bacteria in the urine following treatment for cystitis may represent either recurrent infection with the same organism (relapse) or infection with a different organism (reinfection). Relapse infections occur more often in men with a prostatic nidus of infection and in patients of any age with structural urinary tract abnormalities, diabetes mellitus or subclinical pyelonephritis. If relapse of cystitis occurs, four to six weeks of therapy with a culture-specific oral antibiotic is indicated. Reinfection should be treated with a ten-day course of oral antibiotics.

Further urologic investigation, beginning with an intravenous urogram, should be considered in elderly patients with relapse or reinfection. If reinfection occurs frequently in an otherwise normal urinary tract, long-term suppressive therapy may be beneficial (Table 6).

Asymptomatic Bacteriuria

Most elderly patients with bacteriuria have no symptoms. Asymptomatic bacteriuria is diagnosed by two urine cultures with more than 10(5) CFU per mL of the same organism in the absence of urinary tract symptoms.(23) Nicolle and associates(24) noted an overdiagnosis of 10 percent when only one urine culture was used.

Asymptomatic bacteriuria is common in the elderly, and its incidence increases with age, disability and type of domicile. In patients between the ages of 40 and 60, the prevalence of bacteriuria is less than 0.1 percent for men and less than 5 percent for women.(13) In patients older than 80 years, the incidence of bacteriuria increases to 21 percent in men and 25 to 50 percent in women.(11,13) The prevalence of asymptomatic bacteriuria in an ambulatory population over age 65 increases from 6 percent in men and 18 percent in women to 23 percent of patients in nursing homes and 32 percent of hospitalized men and women.(13)

Because some studies appeared to show a correlation between asymptomatic bacteriuria and increased mortality, the routine treatment of asymptomatic bacteriuria was once encouraged.(25) More recently, however, bacteriuria and increased mortality have been shown to have no direct causal association.(23,24,26) Instead, it is more likely that bacteriuria is a marker for those at risk for mortality from other significant disease.(4) One study(26) showed that although bacteriuria was associated with higher functional disability, it was not associated with increased mortality.

Pyuria is a poor predictor of bacteriuria in elderly women who have no symptoms of urinary tract infection. However, the absence of pyuria is highly predictive of the absence of bacteriuria.(27)

If an elderly patient does not have diabetes mellitus or obstructive disease of the urinary tract and is not immunologically compromised, routine screening and treatment of asymptomatic bacteriuria are not beneficial and are not recommended because of cost and the possibility of bacterial resistance. However, it may be wise to consider the treatment of asymptomatic bacteriuria before surgical instrumentation is performed or a prosthetic device (e.g., hip or cardiac valve) is placed.(15,23,24,28)

Acute Bacterial Prostatitis

Acute bacterial prostatitis, the rarest form of prostatitis, presents as an acute febrile illness associated with chills, urgency, dysuria and muscle aches, including perineal pain and low back pain localized to the low sacral region. In acute bacterial prostatitis, the prostate is tender, swollen and warm to the touch.

Since cystitis is usually associated with acute bacterial prostatitis, the bacteria responsible for the illness often can be cultured from the urine. The massaging of an acutely inflamed prostate should be discouraged, because it can lead to bacteremia.(29)

True acute bacterial prostatitis is uncommon in the elderly. When it does occur, hospitalization is usually indicated, with bed rest, hydration, analgesics and the administration of appropriate intravenous antibiotics, including an aminoglycoside. Urethral instrumentation should be avoided. If obstruction occurs secondary to a large swollen prostate, suprapubic catheterization may be indicated to avoid trauma to the gland and to allow the bladder to empty.(30)

E. coli is the pathogen in 80 percent of the cases of acute bacterial prostatitis.(29) Other pathogens in acute bacterial prostatitis include Klebsiella, Enterobacter, Proteus and Pseudomonas species. Gram-positive organisms are rarely implicated.

Chronic Bacterial Prostatitis

Chronic bacterial prostatitis is considered the most common cause of relapsing urinary tract infections in elderly men.(15,30) Unlike acute bacterial prostatitis, which generally has a clear-cut clinical picture, chronic bacterial prostatitis has a varied presentation. Some patients may present with only asymptomatic bacteriuria.(29) In other patients, the only symptoms may be persistent perineal pain and dysuria.

As in acute bacterial prostatitis, E. coli is the most common cause of infection. E. coli may be cultured from ejaculate fluid or from secretions of urine after prostatic massage.

Treatment of chronic bacterial prostatitis should begin with an antimicrobial agent, such as trimethoprim with sulfamethoxazole, which penetrates the inflamed prostate. The antibiotic should be continued for at least six to 12 weeks. Long-term suppressant therapy may also be indicated. Symptomatic treatment failures may benefit from a transurethral resection of the prostate.(13) A promising new approach to the treatment of resistant chronic bacterial prostatitis is the intraprostate injection of antibiotics under echographic control.(31)

Pyelonephritis

The leading cause of gram-negative bacteremia and death due to sepsis in hospitalized patients is pyelonephritis or urosepsis.(2) Complicated urinary tract infections are responsible for much of the increased morbidity and mortality in patients with chronic neurologic disease, the debilitated and the aged. According to the National Center for Health Statistics, the number of deaths attributed to infections of the kidney per 100,000 population was 0.2 for those less than one year of age, 0.7 for those between the ages of 55 and 64, and 29.3 for those 85 years of age and older.(2)

Almost one-half of hospitalized bacteremic patients are over 60 years of age, and one-third to two-thirds of these patients die of acute bacteremia. Factors that may predispose the elderly to upper urinary tract infections and urosepsis are presented in Table 7.(32)

It has long been known that bacteremia due to Streptococcus pneumoniae or Salmonella species occurs more frequently in the elderly than in younger patients.(33,34) Recently, it has been shown that bacteremia from nonobstructive pyelonephritis also occurs more often in elderly patients.(35) The elderly suffer more complications from bacteremia, regardless of the site of infection.(36) Shock occurs more frequently in elderly patiens with pyelonephritis than in younger patients with the same disorder.

One of the greatest diagnostic challenges is the elderly individual who presents with an unknown underlying infection. An atypical clinical presentation, which may range from fever, confusion and lethargy to nausea and vomiting, is often of little help in the search for a focus of infection.

The presence of pyuria and bacteriuria in the acutely ill elderly patient usually indicates pyelonephritis and urosepsis. Because of the increased prevalence of asymptomatic bacteriuria in the elderly, positive urinalysis and culture results do not ensure that the urinary tract is the focus of an overwhelming infection. Therefore, a thorough search for other possible causes of sepsis should be conducted in every critically ill patient.

The prognosis in the elderly patient with urosepsis depends on the presence of underlying abnormalities in the voiding mechanism or urinary tract and on the prompt administration of appropriate intravenous antibiotics.(2) In a prospective study,(37) 11 of 34 elderly patients admitted with community-acquired bacteremic urosepsis developed septic shock; two of these patients died. The two patients who died were either treated with no antibiotics or with antibiotics to which the infecting organism was not sensitive. Excretory urography and/or renal ultrasonography was performed in 21 of the 34 patients. Most of the patients demonstrated some type of urinary tract abnormality, such as obstruction to urine flow, calculous disease or abscess.

Before antibiotic therapy is initiated, all patients suspected of having symptomatic pyelonephritis should have three sets of blood cultures and one urine culture. Prompt administration of appropriate antibiotics decreases mortality from gram-negative sepsis.(38) Therapy should begin immediately with intravenous antibiotics that have extended gram-negative coverage. A third-generation cephalosporin or an aminoglycoside should be included in the initial antibiotic regimen. A third-generation cephalosporin may be preferable in a patient with renal disease.

Until culture results are available, a second intravenous antibiotic should be added in most patients, especially when shock is present. The choice of the second antibiotic is determined by the history, the clinical findings and the gram-stained urine culture.(39) In the majority of treated patients, fever subsides within 72 hours and the urine becomes sterile within four days.(37) If fever or bacteremia persists, a search for abscess, obstruction distal to the infection or a separate focus of infection should be undertaken.

When pyelonephritis is not associated with trauma, bacteremia emerges as a marker for kidney or bladder stones, an abscess or obstruction to urine flow. Radiographic studies to look for structural abnormalities of the upper and lower urinary tract are usually indicated in elderly patients with bacteremic pyelonephritis.(37) Investigational techniques such as cystoscopy, intravenous pyelography, ultra-sound or computed tomography are also indicated in patients with recurrent infections and in men with infection who have not been previously studied. To avoid dye-associated nephropathy, all elderly patients should be properly hydrated before intravenous pyelography.

Catheter-Related Urosepsis

The use of indwelling catheters is the single most important risk factor for nursing home-acquired urinary tract infections.(36) It is the leading cause of nosocomial urinary tract infection and the most common predisposing factor in gram-negative sepsis among hospitalized patients.(40) Although 100 percent of patients with indwelling urinary catheters eventually become colonized with bacteria, a much smaller percentage develop catheter-related community-acquired urosepsis.

In the nursing home setting, at least 85 percent of patients with indwelling catheters have asymptomatic bacteriuria, and many are colonized with antibiotic-resistant bacteria.(37,40,41) In the absence of symptoms, bacteriuria in a catheterized patient should not be treated. Antibiotic treatment will only lead to resistant organisms and a higher mortality rate if urosepsis occurs.

Without an indwelling catheter, the incidence of acute symptomatic pyelonephritis is higher in women than in men, but there is no predilection for either sex if a catheter is present. Most patients who are admitted with catheter-related urosepsis have had obstruction, manipulation or removal of a catheter with its bulb still inflated within 72 hours of hospital admission.(38)

Polymicrobial urine cultures occur more often in catheterized patients, and it is frequently necessary to isolate the pathogen from the blood to determine the most appropriate antibiotic. The pathogens in catheter-related urosepsis are usually more resistant to antibiotics than are those in noncatheter-related urosepsis.(38,41)

Since the timely administration of appropriate antibiotics decreases mortality in gram-negative sepsis and shock,(38) broad-spectrum coverage, including coverage for Enterococcus and Pseudomonas species, is indicated. If blood cultures are positive or only one pathogen grows in the urine culture, the antibiotic regimen can then be simplified to a regimen that maintains effectiveness but keeps toxicity potential and cost to a minimum. Antibiotic treatment should continue for ten to 14 days after the patient is afebrile. The antibiotic may be changed from intravenous to oral administration 48 hours after the fever has resolved.

Final Comment

Urinary tract infections are a common cause of morbidity and mortality in the elderly. The management of uncomplicated lower urinary tract infections in elderly patients is similar to that in younger patients. Asymptomatic bacteriuria occurs frequently in the elderly and generally does not require treatment. Acute pyelonephritis in an elderly patient is a life-threatening illness that requires the prompt administration of appropriate intravenous antibiotics.

TABLE 1

Factors Associated with Increased Incidence of Urinary Tract Infections in the Elderly Men Prostatic disease

Benign prostatic hypertrophy

Prostatic carcinoma

Prostatic calculi Decreased bactericidal prostatic secretions Urethral strictures and other anatomic abnormalities Women Changes in anatomy and function of the bladder Incomplete emptying of the bladder Increased introital colonization with gram-negative bacteria Tendency for decreased vaginal glycogen and increased vaginal pH Men and women Coexisting diseases

Diabetes mellitus

Cerebrovascular accidents

Dementia Increased hospitalizations Instrumentation Management of incontinence with urinary catheters Alterations in immune response

TABLE 2

Differential Diagnosis of Sterile Pyuria Undiagnosed bacterial urinary tract infection Renal tuberculosis Interstitial nephritis Kidney or bladder stones Renal papillary necrosis Chronic bacterial prostatitis Chlamydial infection (more frequent in younger

age groups) Gonorrhea (more frequent in younger age groups)

TABLE 3

Causes of Spuriously Low Bacterial Counts in Urine Cultures Vigorous diuresis Prior antibiotic administration Antibiotic detergent in collection container Obstruction distal to site of infection Infection not directly accessible to collecting

system

TABLE 4

Initial Treatment Options for Bacterial Cystitis(*)

Treatment option Dose

Single-dose therapy{

Trimethoprim with sulfamethoxazole, double-strength Two tablets

(Bactrim, Septra)

or

Amoxicillin Six 500-mg capsules

Three-day therapy

Trimethoprim with sulfamethoxazole, double-strength One tablet every 12 hours

or

Amoxicillin One 500-mg capsule every 8 hours

Initial full-course therapy (7 to 10 days)

Trimethoprim with sulfamethoxazole, double-strength One tablet every

12 hours

Amoxicillin 250 or 500 mg ev

ery 8 hours

Cephalexin (Keflex) 250 or 500 mg ev

ery 8 hours

Nitrofurantoin macrocrystals (Macrodantin) 50-100 mg every

6 hours

Sulfisoxazole (Gantrisin) 1 g every 6 hour

s

Trimethoprim (Proloprim, Trimpex) 100 mg every 12

hours

Therapy for complicated or recurrent cystitis (7 to 10 days)

Norfloxacin (Noroxin) 400 mg every 12

hours

Ciprofloxacin (Cipro) 750 mg every 12

hours

TABLE 5

Bacteriuric Syndromes(*)

Syndrome Definition

Lower urinary tract infection Lower urinary tract symptoms (dysuria, urgency

, frequency,

suprapubic pain) and urine culture with less t

han or minus 10(3)

bacteria/mL

Acute cystitis Lower urinary tract symptoms and urine cultu

re with less than or

minus 10(5) bacteria/mL

Acute urethral syndrome Lower urinary tract symptoms and 10(2) to 10

(5) bacteria/mL or

sexually transmitted agent (e.g., Neisseri

a gonorrhoeae,

Chlamydia trachomatis, herpesvirus) or no

identifiable

pathogen

Acute pyelonephritis Upper urinary tract symptoms (fever, rigors, f

lank pain, nausea,

prostration) and urine culture with less than

or minus 10(5)

bacteria/mL

Asymptomatic bacteriuria No symptoms and urine culture with less than o

r minus 10(5)

bacteria/mL

Recurrent bacteriuria No symptoms or recurrent lower urinary tract s

ymptoms and urine

culture with less than or minus 10(2) bacteria

/mL

Relapse Recurrent infection with same bacterial stra

in

Reinfection Recurrent infection with different bacterial

strain

Complicated bacteriuria Urine culture with 10(5) bacteria/mL and assoc

iated structural

abnormality of the urinary tract (e.g., involv

ement with urinary

tract stones or catheter); may be asymptomatic

TABLE 6

Regimens for Long-Term Prophylaxis of Urinary Tract Infections in the Elderly(*)

Drug Dose

Trimethoprim with sulfamethoxazole, One-half tablet every evening

single strength (Bactrim, Septra)

Nitrofurantoin macrocrystals 50 mg every evening

(Macrodantin)

Trimethoprim (Proloprim, Trimpex) 50 mg every evening

Cephalexin (Keflex) 250 mg every evening

TABLE 7

Factors Associated with Increased Risk of Upper Urinary Tract Infection Detrusor sphincter dyssynergia Vesicoureteric reflux Preexisting upper urinary tract anomalies Kidney or bladder stones Systemic disease Immunosuppressant therapy Recumbent, immobilized condition Indwelling urinary catheter REFERENCES (1)Smith IM. Infections in the elderly. Hosp Pract [Off] 1982;17:69-77,81-5. (2)Kunin CM. Detection, prevention, and management of urinary tract infections. 4th ed. Philadelphia: Lea & Febiger, 1987. (3)Ouslander JG, Kane RL. The costs of urinary incontinence in nursing homes.Med Care 1984;22:69-79. (4)Campbell AJ, Reinken J, McCosh L. Incontinence in the elderly: prevalence and prognosis. Age Ageing 1985;14:65-70. (5)Ouslander JG, Kane RL, Abrass IB. Urinary incontinence in elderly nursing home patients. JAMA 1982;248:1194-8. (6)Mohr JA, Rogers J Jr, Brown TN, Starkweather G. Stress urinary incontinence: a simple and practical approach to diagnosis and treatment. J Am Geriatr Soc 1983;31:476-8. (7)Gleckman R, Esposito A. Sterile pyuria in the elderly. Am Fam Physician 1979;19(6):109-11. (8)Stamm WE, Counts GW, Running KR, Fihn S, Turck M, Holmes KK. Diagnosis of coliform infection in acutely dysuric women. N Engl J Med 1982;307:463-8. (9)Rubenstein E, Federman DD, eds. Scientific American medicine. New York: Scientific American, 1988. (10)Jenkins RD, Fenn JP, Matsen JM. Review of urine microscopy for bacteriuria. JAMA 1986;255:3397-403. (11)Akhtar AJ, Andrews GR, Caird FI, Fallon RJ. Urinary tract infection in the elderly: a population study. Age Ageing 1972;1:48-54. (12)Boscia JA, Abrutyn E, Kaye D. Asymptomatic bacteriuria in elderly persons: treat or do not treat? [Editorial] Ann Intern Med 1987;106:764-6. (13)Kaye D. Urinary tract infections in the elderly. Bull NY Acad Med 1980;56:209-20. (14)Ginsburg CM, McCracken GH Jr. Urinary tract infections in young infants. Pediatrics 1982;69:409-12. (15)Wilhelm MP, Edson RS. Antimicrobial agents in urinary tract infections. Mayo Clin Proc 1987;62:1025-31. (16)Kunin CM. Duration of treatment of urinary tract infections. Am J Med 1981;71:849-54. (17)Counts GW, Stamm WE, McKevitt M, Running K, Holmes KK, Turck M. Treatment of cystitis in women with a single dose of trimethoprim-sulfamethoxazole. Rev Infect Dis 1982;4:484-90. (18)Tolkoff-Rubin NE, Weber D, Fang LS, Kelly M, Wilkinson R, Rubin RH. Single-dose therapy with trimethoprim-sulfamethoxazole for urinary tract infection in women. Rev Infect Dis 1982;4:444-8. (19)Gossius G, Vorland L. A randomised comparison of single-dose vs. three-day and ten-day therapy with trimethoprim-sulfamethoxazole for acute cystitis in women. Scand J Infect Dis 1984;16:373-9. (20)Wolfson JS, Hooper DC. Norfloxacin: a new targeted fluoroquinolone antimicrobial agent. Ann Intern Med 1988;108:238-51. (21)Wang C, Sabbaj J, Corrado M, Hoagland V. World-wide clinical experience with norfloxacin: efficacy and safety. Scand J Infect Dis 1986;48(Suppl):81-9. (22)Haase DA, Harding GK, Thomson MJ, Kennedy JK, Urias BA, Ronald AR. Comparative trial of norfloxacin and trimethoprim-sulfamethoxazole in the treatment of women with localized, acute, symptomatic urinary tract infections and antimicrobial effect on periurethral and fecal microflora. Antimicrob Agents Chemother 1984;26:481-4. (23)Abrutyn E, Boscia JA, Kaye D. The treatment of asymptomatic bacteriuria in the elderly. J Am Geriatr Soc 1988;36:473-5. (24)Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized

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