ReviewsinClinicalGerontology

http://journals.cambridge.org/RCG AdditionalservicesforReviewsinClinicalGerontology: Emailalerts:Clickhere Subscriptions:Clickhere Commercialreprints:Clickhere Termsofuse:Clickhere

Urinarytractinfectionsinolderpatients
WJMacLennon
ReviewsinClinicalGerontology/Volume13/Issue02/May2003,pp119127 DOI:10.1017/S0959259803013236,Publishedonline:15June2004

Linktothisarticle:http://journals.cambridge.org/abstract_S0959259803013236 Howtocitethisarticle: WJMacLennon(2003).Urinarytractinfectionsinolderpatients.ReviewsinClinicalGerontology, 13,pp119127doi:10.1017/S0959259803013236 RequestPermissions:Clickhere

Downloadedfromhttp://journals.cambridge.org/RCG,IPaddress:217.73.168.22on21Nov2012

Reviews in Clinical Gerontology 2003 13; 119-127 0 2003 Cambridge University Press Printed

in

the United Kingdom DOI:10.1017/S0959259803013236

Urinary tract infections in older patients

WJ MacLennon
Edinburgh

Introduction Factors increasing the risk of urinary tract infections in old age include reduced T lymphocyte regulation, decreased B lymphocyte antibody synthesis, impaired killer T cell function and slowed neutrophil chemotaxis.1,2 More practical causes for a high incidence of urinary infections are multiple pathology and poor nutrition. In women, a low oestrogen level increases the intravaginal pH, resulting in the lactobacillus being replaced by a pathogenic agent. Faecal stasis may also increase the risk of a urinary infection. The presentation and severity of a urinary infection are affected by intercurrent disorders such as diabetes mellitus, poor bladder control, concurrent medication and cognitive impairment. Other relevant but less common disorders are bladder calculi and tumours. Common signs of pyouria in old age are urinary incontinence, anorexia, lethargy and conf ~ s i o n The . ~ infection may even be asymptomatic and this is discussed later.

Aetiology
There is considerable diversity in reports as to which organisms are linked to urinary tract infections. A review of patients of all ages with urinary infections concluded that Escherichia coli was responsible for 80% of infections with staphylcocci responsible for a high proportion of the re~nainder.~ Less common sources were Klebsiella, Enterobacter and Proteus spp. Secondary contributory factors include increased age, diabetes mellitus, prostatic dysfunction, a neurogenic bladder and long-term catheterization. A more focused survey of urinary infections in hospitals across North America established that 49% were due to Escherichia coli, 14% to Ekterococcus spp, 12% to Klebsiella spp, 6% to Address for correspondence: WJ Mclennon, 26 Caiystone Avenue, Edinburgh EHlO 6SG, Scotland, UK.

Pseudomonas aeroginosa, 4% to Enterobacter s p p and 4% to Proteus rnirabili~.~ In the UK, 1 2 laboratories analyzed samples of infected urine from patients living in the community.6 These gave 65% of patients with E. coli, 23% with other coliforms, 5 % with Proteus spp, 2% with Pseudomonas spp, 2 % with enterococci, 1 % with group B Streptococci, 2 % with coagulase Staphylcocci and 1 % with Staphylcoccus aureus. One of many reviews of patients with urinary infections aged 65 years and over concentrated on those in a large community hospital in the USA.' The most common organisms in those infected were E. coli in 54%, Staphylcoccus in 13% and Enterococcus in 6%. There may be a genetic predisposition to urinary tract infections.R This is more likely in patients who have an ABH non-secretor blood group, and where there is a family history of an early age of onset of the condition. Recent investigations also have established that the risk of infection is accentuated where the genetic structure of an Escherichia promotes a pilus-mediated attachment or invasion of bladder epithelial c e k 9 This protects the organism against antibiotics and sets off a crescendo of epithelial cell death, with the release of inflammatory mediators. It has also been established in a separate study that that E coli strains most likely to cause pyelonephritis rather than cystitis are those producing either alpha-haemolysin or mannose resistant haemagglutinin type IV and exhibiting P fimbriae.'" Another example is that Klebsiella pneumonia bacteri, associated with recurrent urinary infections in patients with a spinal cord injury, are more likely to have a RD6 genotype." This may be because it exhibits a particularly high level of somatic cellular adherence. In due course, it may be possible to utilize material from such apparently arcane studies in devising a more effective way of attacking urinary bacteria.

120

W] MacLennon
urinary sepsis in old age and is reserved for the few who have a colicky loin pain or who have an infection that fails to respond to an appropriate antibiotic. l 7 Recurrent infection also may warrant investigation where there is n o obvious cause such as an indwelling catheter or neurogenic bladder. Prevention Given atrophy of the vaginal epithelium and an increase in its p H after the menopause, it might be expected that treatment with oestrogens and/or progestogens would reduce the risk of recurrent infections. Observation established that, in women aged 4 5 to 85 years, there was no difference in the incidence of infections in those taking or not taking oestrogen replacement therapy.I8 Another study comparing low dose oestriol with placebo in 72 women from aged over 60 years from two geriatric medicine units yielded similar inconclusive result^.'^ Even a large study of 2763 women aged 44 to 79 years taking conjugated oestrogens with medoxyprogesterone when compared to placebo did not demonstrate an effect on urinary infections.20 An alternative New Age approach to preventing recurrent infections is the long-term administration of cranberry-loganberry juice.21 Taken five days a week for one year, it produced a 2 0 % reduction in the incidence of recurrent infections. The mode of action is that it reduces the pH of the urine. Treatment The seductively simple instruction for treatment of a urinary tract infection is that the patient should be given a three-day course of an appropriate antibiotic.22 If there is a suspicion of pyelonephritis, the course should be continued for two weeks. The difficult part is selecting the antibiotic. Extensive use of antibiotics has produced a resistance to these that varies from country to country and region to region. An example of this is that the resistance of E. coli in the United States varies from 10% in the north east to 2 2 % in the west.23 Data from 20 hospitals from countries in Europe give a particularly detailed account of the susceptibility of urinary pathogens to antibiotics (Table 1).24 Although the table shows that most urinary

Diagnosis
The classical feature of a urinary infection is dysuria, though this also may result from trauma, bladder calculi, interstitial cystitis prostatic hyperplasia or psychogenic disorders.I2 The issue is resolved by sending a sample of urine off for culture. The presentation is more complex in frail older patients. One of the cluster of signs recently recognized is that of cough and breathlessness associated with c ~ n f u s i o n . ~ In this situation, pyuria causes bacteraemia, leading in turn to a respiratory infection. Given the prominence of the latter, the source of infection is often missed. If a sample of urine is to be of any value, it must be uncontaminated. This can be particularly difficult in elderly women with impaired mobility or with cognitive impairment. At one time, more aggressive investigation involved the collection of urine from a suprapubic stab. This is unsuccessful and more dangerous if an elderly patient is unable to maintain a full bladder. An alternative is to pass a narrow bore catheter attached to a drainage bag, but this has not found acceptance in busy acute geriatric and general medical wards. Failing this, reliance is placed on trying to maintain a clear catch by swabbing the vulva with soap and water. An antiseptic must be avoided since this may destroy bacteria in the specimen. The specimen should be plated almost immediately or stored overnight at a temperature of 40C. It should be examined for neutrophils and for bacteria. An infection is deemed present if the white cell count exceeds 8 per high-powered microscopic field and if the bacterial count exceeds 10/m1.4~If more than one type of bacterium is present, it is likely that the specimen has been contaminated. Routine blood culture for bacteraemia is not justified, but ideally should be undertaken in all patients with a pyrexia or other signs of a systemic infection. The diagnosis of bacteraemia is often missed in patients treated for a urinary infection. In one series of nursing home residents with bacteraemia, 51% had positive urine cultures.16 It remains to be seen whether more rigorous investigation and treatment of the condition over and above that of the pyuria would have a significant effect on morbidity or mortality. Imaging such as ultrasonography or scintigraphy has little part to play in the investigation o f

Urinary tract infections in older patients

Table 1. Sensitivities of antibiotics to organisms in the urinary tract.24 Organism Antibiotic
% susceptible to antibiotic

121

Escherichia coli
Penicillins Piperacillin/tazobactram parenteral Cephalosporins Amikacin parenteral Quinolones

<60 98 98 100 89

Klebsiella spp
Cephalosporins (New generation) Carbemepens parenteral Amikacin parenteral

82-95 100 94
100 80-90 100 100 100

Enterobacter spp
Carbamepens parenteral Amikacin parenteral

Proteus spp
Ceftriaxone parenteral Carbenepens parenteral Piperacillinltazobactam parenteral

Pseudomonas aeroginosa
Carbapenems parenteral Piperacillin/tazobactam Amikacin parenteral Ticarcillin parenteral

89 84 80 80 98 98 94

Enterococcus spp
Vancomycin parenteral Teicoplanin parenteral Ampicillin

bacteria are sensitive to a range of antibiotics, many of these have to be given parenterally and are extremely expensive. It would be impractical to use these in the large number of older people with urinary infections. A simpler approach is to avoid amoxicillin, since most organisms are resistant to it and to chose one of several simple alternatives such as trimethoprim, co-amoxiclav, cephalexin, ciprofloxacin and n o r f l o ~ a c i n Review .~~ of 199 pathogens indicated efficacy rates of 48% for ampicillin, 57% for cephalothin, 67% for trimethoprim, 74% for cefuroxime, 78% for nitrofurantoin, 85% for nalidixic acid and 99% for ciprofloxacin.2h Over the last decade there has been a change in the susceptibility of organisms to antibiotics. An example of this is shown in Table Since there is wide variation in patterns of resis-

tance, the advice of the local microbiology department should be sought in choosing a drug before the results of a culture are available. Newer and more expensive drugs should be reserved for a time when there is an inevitable increase in bacterial resistance to those in current use. There has recently been an attempt to determine whether some patients are at greater risk of developing resistant organisms than others.28 Important factors for resistance to co-amoxiclav included treatment of an organism resistant to the agent in the previous year and the use of a catheter over the previous six months. Patients with an organism resistant to a fluoroquinolone were more likely to be male and to be of advanced years. Main factors for resistance to co-trimoxazole were being male and receiving hospital care over the previous year. Such piecemeal information is of limited clinical value but further stud-

122
Table 2.

W ] MacLennon
Change in susceptibility
of

E coli to antibiotics between 1991, 1994 and 19972h

1994 1997 39% 39% o 23 y 15%

Antibiotic Ampicillin Carbenicillin Tetracycline Tridsulpf

1991 30% 29% 29% 15%

45 % 42 % 40% 32%

ies may lead to more useful guidelines for the prevention of antibiotic resistance.
Complications

Apart from the general effects of lethargy and confusion, urinary tract infections may have some more specific manifestations.

Diabetes mellitus
Given the effects of diabetes mellitus on immune function, it is not surprising that a high proportion of elderly patients with the condition is susceptible to recurrent urinary tract infection^.'^ Compared with non-diabetic patients, those with the condition are five to ten times more likely to have bacteruria.'" Complications include pyelonephritis and a renal abscess. Compared to controls, patients with diabetes were found to be 3.3 times more likely to have renal scars." Diabetic patients with urinary infections also are more likely to have less common organisms more resistant to antibiotic^.^^ Fungal infections also are more common and should be treated with a fluoroquinolone. Critically ill patients should be given parenteral imipenem, ticarcillin/clavulanate or piperacillidtacobactam. Many patients with diabetes have asymptomatic bacteruria but there is no evidence that long-term treatment with antibiotics is of any value in this group.i3

ultrasound, with renal pelvic obstruction in 48% of patients and a positive computerized tomogram with segments of renal pelvic necrosis in 68%. With all tests combined, it was possible to make an analysis of pyelonephritis in 61%. If the signs of infection are mild and there is no evidence of structural damage to the kidney or ureter, the condition usually responds to a two-week course of an oral antibiotic such as cotrimoxazol or a fluo r o q ~ i n o l e Patients .~~ in shock or with evidence of prior renal damage require parenteral treatment. The drug of choice is dependent upon the sensitivity of the infecting organism, but both gentamycin and ceftriaxone (a third generation cephalosporin) have the advantage of only requiring a once daily dose.l3 Patients allergic to these usually respond to vancomycin.

Urinary incontinence
Many patients with a urinary infection present with urinary incontinence. One series of 214 nursing home patients with chronic urinary incontinence established that 43% had bacteruria.3h Investigation of another group of 97 women aged 80 to 89 years revealed that 46% had urinary incontinence and that over the past two years, 33% of these had had a urinary tract infe~tion.~' In neither group was a comparison made between infected and non-infected patients or an assessment made of the efficacy of treatment with antibiotics.

Pyelonephritis
Infection of the kidney tends to be associated with a particularly virulent organism or an illness such as diabetes that compromises immune function.'" It usually presents with severe loin pain and pyrexia but these signs are less reliable in old people. Even urine and blood cultures are unreliable. In one series of 52 cases, only 23% had bacteruria and 12% b a ~ t e r a e m i a . ~ Delineation ~ of the infected kidney by imaging gave only a positive

Asymptomatic bacteriuria
Many elderly patients, particularly those with multiple pathology have bacteruria with no symptoms whatever? The condition is particularly common in nursing homes where it often occurs in between 25 to 50% of residents.39 The incidence of the condition also is increased in diabetes m e l l i t ~ s . Additional ~~ risk factors for asymptomatic bacteriuria in Type 2 diabetes are

Urinary tract infections in older patients

age, macroalbuminuria, a low body mass index and the history of a urinary infection over the previous year. There is no evidence that asymptomatic bacteriuria has any effect on physical function or survival. There are concerns, however, that the condition may contribute to a reservoir of infection, leading to an increased risk of bacterial resistance to antibiotics. About the most convincing evidence that the condition might have some effect on immunological function was a study that assessed patients for laboratory evidence of low grade inflammatory activity.41 This established that patients with asymptomatic bacteriuria had greater concentrations of neutrophils and higher levels of circulating tumour necrosis factor receptors, but their temperatures were normal and they had no clincal signs of infection. Many clinical trials have established that treatment with antibiotics is of no benefit in asymptomatic bacteriuria. In a recent study, the effects of an antibiotic in patients with asymptomatic bacteria were that, after one month, 20% of those on treatment were bacteriuric, compared with 78% of those on a placebo.42 Follow-up over two years, however revealed that the incidence of recurrent infection was 42% in the treatment group and 40% in the placebo group. Days of hospital admission for a urinary tract infection were 0.06 per 1000 total days for patients on treatment against 0.10 per 1000 days for those on placebo.

123

organisms in the urine. The fungus often merely presents as a comensal, in which case it should not be treated with an expensive agent. The prognosis often is excellent in uncomplicated cystitis. In one review, 30 of 36 patients with a urinary fungal infection were cured when given systemic antifungal agents.46

Nosocomial infection
Patients in hospitals or nursing homes run the risk of contracting urinary infections from other residents. In one review in an English hospital, 2.8% of patients developed a hospital-acquired urinary infe~tion.~ Factors increasing the risk of this were female sex, length of stay, surgery and urethral catheterization. The risk of the condition is particularly high in diabetes and in geriatric medicine units. A particularly large study reviewed 141 patients from 25 European countries.48 This yielded an incidence of 3.6% episodes of nosocomial urinary infections per 1000 patient days. The most commonly isolated organisms were E. coli, Enterococcus ssp, Candida ssp, Klebsiella ssp and Pseudomonas aeroginosa. Sixty-eight per cent of infected patients had indwelling urinary catheters. A urinary nosocomial infection often involves organisms resistant to a wide range of antibiotics and may lead to septicaemia or a severe renal infection.49 The incidence of the infection can be minimized by high standards of hygiene and reducing the use of urinary catheters to a minimum.

Candidiasis
A small proportion of urinary tract infections are fungal in origin. The most common organism is Candida spp, but others occasionally encountered are Gyptococcus neoformans, Aspergillus spp and endemic m y c ~ s e s . Recent ~~ developments increasing the incidence of fungal infection have been the greater use of antibacterial agents, corticosteroids, immunosuppressive agents and cytotoxic Other factors in old age are the presence of diabetes mellitus, chronic renal failure or the prolonged use of a urinary catheter. One drug particularly effective in the treatment of the condition is f l ~ c o n a z o l eWhere . ~ ~ there is pyelonephritis, a more powerful parenteral agent should be given. In deciding on treatment, close attention should be given to signs and symptoms and the concentrations of both white cells and

Neurogenic bladder
Many disabled old people suffer from bladder dysfunction due to disorders such as cerebrovascular disease, Parkinsons disease, Alzheimers disease or an autonomic disorder associated with diabetes mellitus.50 A hypertonic bladder becomes infected because it fails to empty completely. The pattern of trabecula and pouches also creates areas where there may be local areas of stasis. In an atonic bladder, the low general level of activity makes it more susceptible to infection. The organisms in a neurogenic bladder are often unusual and frequently resistant to standard antibiotics. It is difficult to eliminate the infection since treatment with new and expensive antibi-

124

WJ MacLennon
Symptoms are unusual and bacteraemia or shock even less common. In a recent review of 1497 catheterized patients, only 23% went on to develop an early urinary tract infection.54 The signs and symptoms in these were no different from those of the rest of the population, and only one patient developing a urinary infection went on to develop a bacteraemia. Given the ineffectiveness of treatment of asymptomatic bacteriuria, only the occasional complex case with prostatitis or neurogenic bladder should be treated. An alternative is to use a catheter coated with a bactericidal substance. Considerable attention has been given to the use of silver-coated latex. In one trial, the incidence of urinary tract infection using a silver impregnated catheter was 4.4 per 1000 catheter days, compared with 7.2 using an ordinary one.ss Given the expense of such catheters and the low rate of complications from catheterization, many clinicians prefer to adopt a watching brief. Urinary tuberculosis Because tuberculosis of the urinary tract is now rare in the UK, it often goes ~nrecognized.~ Symptoms when they are present are likely to be loin pain associated with dysuria and haematuria. There often is haematuria, while infection and stenosis of a ureter may lead to a hydronephrosis. The diagnosis is made by collecting an early morning specimen of urine. This usually contains a large number of white cells while culture establishes the presence of tubercle bacilli. There is an inevitable delay in obtaining a result. A much more rapid alternative is to perform an immunological assay such as a polymerase chain reaction and non-radioactive DNA hybridization. The exact nature of damage to a tuberculous kidney can be defined by ultrasonography or computerized tomography.* There is considerable scope for misdiagnosis, however, so that it is essential that a detailed clinical history is available. The lesion should be treated with triple antituberculous therapy with drugs to which the organism is sen~itive.~ These should be continued for at least 12 months. Even with this careful approach, however, there is about a 20% relapse rate. Tuberculosis often causes severe structural damage. Stenosis of a ureter may cause

otics is likely to lead to further resistance and the selection of an even more resistant organism.

Prostatitis
Infection of the urinary tract sometimes gives rise to prostatitis, a condition that presents as dysuria, lower abdominal pain and difficulty in voiding urine.5 The associated organism usually spills over into the bladder, so that a urine sample usually is sufficient to identify it and its sensitivity. Since the condition is often deep-seated, the antibiotic chosen should penetrate soft tissue. Examples are co-trimoxazole or a fluoroquine. Treatment should be continued for four weeks for an acute infection and for six to 12 weeks for chronic bacterial prostatitis.

Urinary catheters
Urinary catheters are frequently used in old people to relieve urinary obstruction or control urinary incontinence. Whether this is the most appropriate measure is another matter. The prevalence of long-term catheterization varies, but it has been estimated that between 5% and 10% of residents in long-stay units in Canada are treated in this way.2 In a recent study within four long-term care units and two residential homes, preferences for the management of urinary incontinence were explored in older patients, relatives and the staff.53 Eighty-five per cent of relatives preferred continence pads and 77% preferred prompted voiding to catheterization. A similar pattern was noted in the staff where prompted voiding was preferred to catheterization. Patients themselves recorded catheterization as the least favoured. In contrast to relatives and nursing staff however, they preferred medication to the use of incontinence pads. Clearly then, all classes saw catheterization as the least-favoured option, but patients also were unhappy about the indignity associated with the use of incontinence pads. An even more important contraindication to the long-term use of urinary catheters is that they introduce organisms to the urinary bladder and are responsible for a large proportion of infections bladder infections in this situation. Infection may result from organisms ascending urine in the catheter lumen or penetrating a film with organic material around it.

Urinary tract infections in older patients

hydronephrosis but can be successfully treated by placing a stent in it.60 Favourable prognostic factors evident on computerized tomography are a thick renal medulla, a minor level of renal involvement and the site of a lesion being distal to the kidney. Surgery also is useful in a poorly functioning kidney subject to foci of recurrent infection.6' An operation of particular benefit in frail elderly patients is a laparoscopic nephrectomy. References
1 Lord JM, Butcher S, Killampali V, Lascalles D, Sahnan M. Neutrophil ageing and immunosenescence. Mech Ageing Devel 2002; 108: 25-38. 2 Di Lorenzo G, Balistreni CR, Cardona G etul. Granulocyte and natural killer activity in the elderly. Mech Ageing Devel 1999; 108: 25-38. 3 Jolleys JV. The reported prevalence of urinary symptoms in women in one rural general practice. Br J Gen Pruct 1990; 40: 335-37. 4 Ronald A. The aetiology of urinary tract infection: traditional and emerging pathogens. A m J Med 2002; 113 (SUPPI 1A): 14s-19s. 5 Jones RN, Kugler KC, Pfaller M, Winokur P. Characteristics of pathogens causing urinary tract infections in hospitals in North America: results from the SENTRY Antimicrobial Surveillance Programme, 1997. Diugn Microbiol Infect Dis 1999; 35: 55-63. 6 Barrett SP, Savage M, Rebec M etal. Antibiotic sensitivity of bacteria associated with communityacquired urinary tract infection in Britain. J Antimicrob Chemother 1999; 44: 359-65. 7 Ackermann RJ, Monrow PW. Bacteremic urinary tract infection in older people. JAGS 1996; 44: 927-3 3. 8 Hooton TM. Pathogenesis of urinary tract infection: an update. J Antimicrob Chem 2000; 44 (SUPPI 1): 1-7. 9 Schilling JD, Mulvey MA, Hultgtren S. Dynamic interactions between host and pathogen during acute urinary tract infections. Urology 2001; 57 (SUPPI 6): 56-61. 10 Blanco M, Blanco JF, Alonso MJ, Blanco J. Virulence factors and 0 groups of Escherichia coli isolates from patients with acute pyelonephritis. Eur J Epidem 1996; 12: 191-98. 1 1 Kil DS, Daarouiche RC, Hull RA, Mansouri MI, Musher DM. Identification of a Klebsiella pneumonia strain associated with a nosocomial urinary tract infection. Clin Microb 1997; 35: 2370-04. 12 Bremnor JD, Sadovsky R. Evaluation of dysuria in

125

adults. A m Fam Phys 2002; 65: 1589-96. 13 Barkham TM, Martin FC, Eykyn SI. Delay in the diagnosis of bacteraemic urinary tract infection in elderly patients. Age Ageing 1996; 25: 130-32. 14 Young JL, Soper D1. Urinalysis and urinary tract infection update for clinicians. Infect Dis Obst Gyn 2001; 9: 249-55. 15 Anon. Managing urinary tract infection in women. Drug Ther Bull 1998; 36: 30-32. 16 Mylotte JM, Tayara A, Goodnough S. Epidemiology of bloodstream infection in nursing home residents; evaluation in a large cohort from multiple homes. Clin Infect Dis 2002; 35: 1484-90. 17 Webb JA. The role of imaging in adult urinary tract infection. Eur Radio1 1997; 7: 837-43. 18 Oliviera SA, Klein RA, Reed J, Cirillo P, Christos J, Walker AM. Oestrogen replacement therapy and urinary tract infections in postmenopausal women aged 45-89. Menopause 1998; 5: 1-3. 19 Cardozo 1, Benness C, Abbot D. Low-dose oestrogen prophylaxis for genitourinary tract infections in elderly women. Br J Obs Gyn 1998; 105: 403-07. 20 Brown JS, Vittinghoff E, Kanaya A M etal. Urinary tract infections in postmenopausal women: effect of hormone therapy and risk factors. Obs Gyn 2001; 98: 1045-52. 21 Kontiokari T, Sudqvist K, Nuutinen N, Pokka I, Uhari M. Randomised trial of cranberryloganberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women. BMJ 2001; 322: 1571. 22 Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated urinary tract infection. Infect D i s Clin N A m 1997; 11: 551-58. 23 Gupta K, Sahm DP, Mayfield I, Stamm WB. Antimicrobial resistance among uropathogens that cause community-acquired urinary tract infections in women: a nationwide analysis. Clin Infect Dis 2001; 33: 89-94. 24 Fluit AC, Jones MI, Schmitz F etul. Antimicrobial resistance among urinary tract infection (UTI) isolates in Europe: results froin the SENTRY Antimicrobial Surveillance Program 1997. Antonine van Leeuwenhoek 2000; 77: 147-52. 25 MacLennan WJ, Watt B, Elder AT. Infections in elderly patients. London: Edward Arnold, 1994: 21-22. 26 Cormican M, Morris D, Corbett-Feeney 0, Flynn I. Extended spectrum beta-lactamase production and fluoroquinolone resistance in pathogens associated with community acquired urinary tract infection. Diugn Microbiol Infect Di5 1998; 32: 3 17-1 9. 27 Dyer IE, Sankary TM, Dawson JM. Antibiotic resistance in bacterial urinary tract infections,

126

WJ MacLennon
43 Sobel JD, Vazquez JA. Fungal infections of the urinary tract. World ] Urol 1999; 17: 410-14. 44 Krcmery S, Dubrava N, Krcmery V. Fungal urinary tract infections in patients at risk. Int ] Antimicrob Agents 1999; 11: 289-91. 45 Lundstrom T, Sobel A. Nosocomial candiduria: a review. Clin Infect Dis 2001; 32: 1602-07. 46 Oravcova E, Lacka J, Drgona L etal. Funguria in cancer outcome in 50 patients. lnfection 1996; 24: 3 19-23. 47 Ngyen-van-Tam SE, Nguyen-van-Tam JS, Myint S, Pearson JC. Risk factors for hospital acquired urinary tract infection teaching hospital: a case control study. lnfectton 1999; 27: 192-97. 48 Wagenlehner EM, Naber K. Hospital acquired urinary tract infection. ] Hose Infect 2000; 46: 171-81. 49 Bouza E, San Juan R, Voss A etal. A European perspective o n outcome (ESGNI-004 study). European Study Group on nosocomial infection. Clin Microhiol lnfect 2001; 7: 532-42. 50 Sauerwein D. Urinary tract infection in patients with neurogenic bladder dysfunction. Int ] Antimicrob Agents 2002; 19: 592-97. 51 Lipsky BA. Prostatitis and urinary tract infection in men: whats true. A m J Med 1999; 106: 327-34. 52 Nicolle LE. The chronic indwelling catheter and urinary infection in long-term care facility residents. Control Hosp Epidem 2001; 22: 3 16-21. 53 Johnson TM, Ouslander JC, Uman GC, Schnelle JB. Urinary incontinence treatment preferences in long-term care. ]AGS 2001; 49: 710-08. 54 Tambyah PA, Maki D. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of catheterised patients. Arch Int Med 2000; 160: 678-82. 55 Newton I, Still JW, Law I. A comparison of the effect of early insertion of standard latex and silver impregnated latex foley catheters on urinary tract infections in burn patients. Infect Control Hosp Epidem 2002; 23: 217-18 56 Gokce G, Kilicarslan H, Azan S. Genitourinary tuberculosis: a review of 174 cases. Scand ] Infect Dis 2002; 34: 33840. 57 Moussa O M , Erakyl 1, El-Far MA etal. Rapid diagnosis of genitourinary tuberculosis by polymerase chain reaction and non-radioactive DNA hybridisation. J Urol 2000; 164: 584-89. 58 Zusin R, Gazer G, Chowen M etal. Computerised tomography findings of abdominal tuberculosis: report of 19 cases. Israel Med Ass J 2001; 3: 414-1 8. 59 Wechsler H. Update o n chemotherapy of renal tuberculosis. Urol 1988; 124: 319-20.

1991 to 1997. W e s t ] Med 1998; 169: 265-68. 28 Sotto A, De Boever CM, Fabbro-Peray E etal. Risk factors for antibiotic resistant Escherichia coli isolated from hospitalised patients with urinary tract infections: a prospective study. J Clin Microbiol 2001; 39: 438-44. 29 Patterson JE, Andriole VT. Bacterial urinary tract infections in diabetes. Infect Dis Clin N A m 1997; 11: 735-50. 30 Ronald A, Ludwig I. Urinary tract infections in adults with diabetes. Int J Antimicrob Agents 2001; 17: 287-92. 31 Goswami R, Bal CS, Tejaswi S, Punjabi G, Kochupillai N. Prevalence of urinary tract infection and renal scars in patients with diabetes. Diabetes Res Clin Pract 2001; 53: 181-86. 32 Stapleton A. Urinary tract infections in patients with diabetes. A m ] Med. 2002; 113 (suppl 1A): 80s-84s. 33 Mylotte JM, Tayara A, Goodenough S. Epidemiology of bloodstream infection in nursing home residents; evaluation in a large cohort from multiple homes. Clin Infect Dis 2002; 35: 1484-9 0. 34 Rollino C, Boero R, Ferro M etal. Acute pyelonephritis analysis of 52 cases. Renal Failure 2002; 24: 601-08. 35 Nickel JC. The management of acute pyelonephritis in adults. Can J Urol 2001; 8 : (SUPPI 1): 29-38. 36 Ouslander JG, Schapira M, Schnelle JI, Fingold S. Pyuria among chronically incontinent but otherwise asymptomatic nursing home residents. JAGS 1996; 44: 420-23. 37 Bjornsdottir, LT, Geirsson RT, Jonsson PV. Urinary incontinence and urinary tract infections in octogenarian women. Acta Obst Gyn Scand 1998; 77: 1988: 105-09. 38 Nicolle LE. Asymptomatic bacteriuria in the elderly. Infect Dis Clzn N Amer 1997; 11: 647-62. 39 Nicolle LE. Urinary infections in the elderly: symptomatic or asymptomatic. Int J Antibact Agents 1999; 11: 265-68. 40 Geerlings SE, Stolk RI, Camps M etal. Asymptomatic bacteruria may be considered a complication in women with diabetes. Adu Exp Med Biol 2000; 493: 255-62 41 Prio TK, Bruunsgaard I, Roge I, Pedersen BS. Asymptomatic bacteriuria associated with increasing levels of circulating T N F receptors and elevated numbers of neutrophils. Exp Ceront 2002; 37: 693-99. 42 Harding GK, Zhanel GC, Nicolle L, Cheang I. Antimicrobial treatment in diabetic women with asymptomatic bacteriuria. N Eng ] Med 2002; 347: 576-831

Urinary tract infections in older patients

60 Ramathan, Kuman A, Kapoor R, Bandari. Relief of urinary tract obstruction t o improve renal function Br 1 Urol 1998; 81: 199-209. 61 Lee KS, Kim HH, Byun SS. Laparoscopic

127

nephrectomy for tuberculous non-functioning kidney: comparison with laparoscopic simple nephrectomy for other diseases. Urol 2002 ; 60: 41 1-14.