UTI in Elderly

Urinary Tract Infections in
the Elderly
Objectives
1. Differentiate between asymptomatic bacteruria and UTI
2. Learn geriatric “pearls” in identifying, preventing and
treating UTIs in elderly
3. Review antibiotic treatment guidelines for UTIs in elderly
4. Discuss techniques in preventing both complicated and
uncomplicated UTIs in elderly
5. Understand risks associated with use of Indwelling Urinary
(foley) catheters
Definitions
Acute Uncomplicated Cystitis – infection of the bladder (lower
urinary tract)
○ Symptomatic UTI (SUTI)- occurs with manifestation of

signs/symptoms of infection which localize to urinary tract. These
same signs/symptoms in those with an indwelling urinary catheter are
○ Catheter Associated UTI (CAUTI) – manifestation of signs symptoms

of infection localized to urinary tract in those with indwelling catheter
or removed within 2 days.
○ Cather Asymptomatic Bacteriuria (CA-ASB) – Presence of > or = 10(5)

cfu/ml of > or = 1 bacterial species in a catheter urine specimen in
patient with an indwelling urethral or suprapubic catheter without
symptoms
Definitions, cont
Pyelonephritis – infection of the upper urinary tract

(ureters / renal collecting system / kidneys).
Asymptomatic Bacteriuria (ASB)– Isolation of a

specific count of bacteria in a urine specimen from
an individual w/o signs or symptoms of UTI
Definitions, cont
Complicated UTI (cystitis)
 Diabetes
 Pregnancy
 H/O pyelonephritis
 Hospital acquired infection
 Urinary Tract Obstruction (men)
 Catheter (or recent catheterization in prior 48
hours)
 Childhood h/o UTIs
 Immunosupression
 Renal Transplant
UTI in LTC
 Primary cause of bacteremia in LTC
residents is due to UTIs
 Incidence of symptomatic UTIs in elderly in

LTC around 10%
 Prevalence of asymptomatic bacteriuria in

women approx. 30% and 10% in men
 Why so common?
UTI in LTC
Risk Factors
 Physiologic changes of bladder / urethral flora w/
age (post/menopausal women)
 Use of indwelling catheters
 Congregate living
 Functional / Cognitive Impairment
○ Decrease self care
○ Decrease cues to void
○ Difficulty finding bathroom / suitable location to void
○ Elevated Post Void Residual Volume of Urine?
UTI Surveillance Criteria
Diagnostic Criteria for symptomatic UTI
in those w/o indwelling catheter (1a
OR 2a OR 3a)
 Criteria 1a
○Acute dysuria, pain, swelling/tenderness of
prostate/testes
 Criteria 2a
○Fever or leukocytosis AND at least 1 of
following
 CVA tenderness
 Suprapubic pain
 Hematuria
 Marked increase/new onset incontinence
Criteria 3a
 Suprapubic pain
 Hematuria
 Marked increase/new onset incontinence
○AND
 At least 10(5) cfu/ml of no more than 2 species of bacteria
in voided urine
 At least 10(2) cfu/ml of any number of organisms in a
straight cath.
Guidelines, cont
In patients with Indwelling catheters
 Must demonstrate at least one of the following
○ Fever/chills or new onset hypotension without evidence of other
source of infection
○ Acute change in mental status or functional decline AND
leukocytosis without alternate site of infection
○ New onset suprapubic pain or CVA pain
○ Purulent discharge from catheter site OR acute
pain/swelling/tenderness of tests/prostate.
 AND if catheter removed within last 2 calendar days

○ At least 10(5) cfu/ml of no more than 2 organisms from voided
urine OR positive culture of at least 10(2) of any organisms from
straight catheterization
○ IF catheter still in place then culture with at least 10(5) of any
organisms from an indwelling catheter specimen.
Treatment – with catheter
 Treatment
 Empiric Tx based on gram stain.
 Gram (-) bacilli - 3rd gen cephalospirin
(ceftriaxone, cefpodoxime) OR cipro/levo. P.
Aeruginosa may use cipro / ceftazadime.
 Gram (+) vancomycin pending susceptibility
 Usually 10 to 14 days of tx
Asymptomatic Bacteriuria (ASB)
ASB in LTC
 Women
 2 consecutive clean catch midstream urine samples of > _ 10 (5) cfu/ml
w/o symptoms associated w/ UTI and no catheter within 7 days of first
sample
 Men
 Single clean catch midstream of >_ 10 (5) cfu/ml w/o symptoms
associated with UTI and no catheter
 Longer term sequela of bacteriuria not known
 Treatment not shown to reduce symptomatic UTI, improve mortality nor
decrease in prevalence of bacteriuria (i.e. no indication for eradication
therapy).
Common – perhaps 55% of women in LTC and 30% of men

Prevention and Other Issues
 Prevention of UTI in LTC
 Most studies have focused on younger / pre-
menopausal women
 General
○ Hygiene
○ Prompted / assisted voiding
○ Bowel regimen
Prophylaxis, cont.
○ Prophylaxis against recurrent UTI (>_3 utis within
12 mos. OR >_2 within 6 mos). Studies have
shown benefit of co-trimoxazole, nitrufurantoin,
quinolones, b-lactams in reducing recurrent utis vs
placebo.
○ No guidelines. Reasonable approach is TMP-SX

40/200 tablet 3 days a week.
○ Topical, vaginally applied estrogens have been

shown to be effective in smaller studies (though
sample was post-menopausal)
Prevention of CA-UTI
 Identify those patients who meet clinical criteria for
long / short term placement of indwelling
○ Neurogenic bladder
○ Hematuria (short term)
○ Surgery (short term)
○ Wounds stage 3 or >
○ Terminally ill for comfort measures
 Develop policies for independent removal and

education on technique for placement and
management of device and collecting bag
Thank you

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Urinary Tract Infections in

○ Symptomatic UTI (SUTI)- occurs with manifestation of

○ Catheter Associated UTI (CAUTI) – manifestation of signs symptoms

○ Cather Asymptomatic Bacteriuria (CA-ASB) – Presence of > or = 10(5)

Pyelonephritis – infection of the upper urinary tract

Asymptomatic Bacteriuria (ASB)– Isolation of a

 Incidence of symptomatic UTIs in elderly in

 Prevalence of asymptomatic bacteriuria in

 AND if catheter removed within last 2 calendar days

Common – perhaps 55% of women in LTC and 30% of men

○ No guidelines. Reasonable approach is TMP-SX

○ Topical, vaginally applied estrogens have been

 Develop policies for independent removal and

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