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CLEARING UP THE GERIATRIC UTI

CLEARING UP THE GERIATRIC UTI. Jennifer Yang, MD May 9, 2014 Swedish R3 Talks. 95yo F with dementia, hx urosepsis who has cloudy, foul-smelling urine. She seems “more confused” ROS: ? AFVSS Gen: AAOx1, NAD Abdom : Soft, ?TTP Back: ?CVAT . Should you check a UA/ UCx ?

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CLEARING UP THE GERIATRIC UTI

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  1. CLEARING UP THE GERIATRIC UTI Jennifer Yang, MD May 9, 2014 Swedish R3 Talks

  2. 95yo F with dementia, hxurosepsis who has cloudy, foul-smelling urine. She seems “more confused” ROS: ? AFVSS Gen: AAOx1, NAD Abdom: Soft, ?TTP Back: ?CVAT • Should you check a UA/UCx? • Does she have a UTI?

  3. BACKGROUND • UTI the most common reason for Abx in geriatrics • Elderly at higher risk • Asymptomatic bacteriuria (ASB) highly prevalent, vastly overtreated

  4. IDSA, AMDA, 2013 AGS CHOOSING WISELY Do not screen/treat for ASB in asymptomatic elderly • Screening Treatment • Does not UTI frequency • Bacteriuria + nonspecific symptoms NOT predictive of UTI

  5. 2012 REVISED MCGEER CRITERIA Acute dysuria or acute painful teste/epididymis/prostate OR Fever* orLeukocytosis AND 1 urinary sx: - Acute CVAT -Suprapubicpain - Gross hematuria • - New/incontinence • - New/urgency • - New/frequency OR 2 localizing urinary sx UCx >105CFU/mL(2 bugs) OR 102CFU/mL any bugs (catheterized) *Fever in LTCF: • One temp >100F (PO) • Repeated 99F (PO) or 99.5F (PR) • One temp 2F over baseline

  6. GERIATRIC UTI(Dementia, LTCF) • “Urinary symptoms” can be difficult • Dementia • Chronic GU sx • Altered mental status is most common reason for suspected UTI in LTCF • Fever is variable

  7. SHOULD I TREAT? • What about the UA? • LE + nitrite • NPV 100%! • PPV 37% • Pyuria unreliable • Watch and wait if uncertain • Consider delay empiric Abx for 48h

  8. TREATMENT (uncomplicated UTI)

  9. PREVENTION • Vaginal estrogen cream • Cranberry? • Cochrane 2012: same as placebo • 2014 RCT: 26% reduction in high UTI risk LTCF residents • D-mannose? • Probiotics? • Chronic suppressive Abx – controversial • Condom catheter

  10. TAKE HOME POINTS • Cloudy urine + nonspecific sx do not a UTI make • Revised McGeer Criteria for LTCF • Watch and wait if uncertain • Treat when you have the data

  11. REFERENCES • 2013 AGS Choosing Wisely Campaign • Caljouw, et al. Effectiveness of Cranberry Capsules to Prevent Urinary Tract Infections in Vulnerable Older Persons: A Double-Blind Randomized Placebo-Controlled Trial in Long-Term Care Facilities. JAGS 2014. 62:103-110. • D’Agata, et al. Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. JAGS 2013. 61:62-66. • Gordon, et al. Overtreatment of presumed urinary tract infection in older women presenting to the emergency department. JAGS 2013.61:788-792. • Gupta, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. CID 2011.52:103-120. • Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD001321. DOI: 10.1002/14651858.CD001321.pub5 • Juthani-Mehta, Manisha. “Update in Infectious Diseases in Older Adults: UTI”. AGS Annual Scientific Meeting 2013 presentation. • Mody & Juthani-Mehta. Urinary tract infections in older women: a clinical review. JAMA 2014.311(8):844-854. • Nace, et al. Clinical uncertainties in the approach to long term care residents with possible urinary tract infection. JAMDA 2014.15(2):133-139. • Nicolle, et al. Infectious Diseases Society of America Guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. CID 2005.40:643-654. • Rowe & Juthani-Mehta. Diagnosis and management of urinary tract infection in older adults. Infectious Disease Clinics of North America 2014. 28(1):75-89. • Saint, et al. Condom versus indwelling urinary catheters: a randomized control trial. JAGS 2006.54(7):1055-1061. • Stahlmann & Lode. Safety considerations of fluoroquinolones in the elderly: an update. Drugs Aging 2010. 27(3):193-209. • Stone, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer Criteria. Infection Control and Hospital Epidemiology 2012.33(10):965-977.

  12. THANK YOU

  13. 2012 REVISED MCGEER CRITERIA Acute dysuria or acute painful teste/epidid/prostate OR Fever* or WBC>11 AND 1 urinary sx: - Acute CVAT -Suprapubicpain - Gross hematuria • - New/incontinence • - New/urgency • - New/frequency OR 2 localizing urinary sx UCx >105CFU/mL(2 bugs) OR 102 CFU/mL any bugs (catheterized) Fever*, rigors, acute hypotension (no alt source) OR AMS/Acute functional decline + WBC >11 OR Acute suprapubic pain or CVAT OR Catheter purulent discharge or acute painful teste/epidid/prostate (Indwelling catheter) UCx >105CFU/mL (collect from new cath if >14d)

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