Urinary Infections in the

Elderly

Christopher French
BMedSci MD FRCSC
Adult and Pediatric Urology
Clinical Assistant Professor of Surgery
May 2009
Objectives
• Rationale for Treating Positive Urinary
Cultures
• Simple vs Complicated Infections
• Rationale for Prophylactic Antibiotics
• Optimal Catheter Management
• Evaluate risk factors for urinary
infections in the elderly
Cystitis
• Localized symptoms with positive
urine culture (and inflammation)
• The only group that receive
abbreviated treatment (3 day) is
young healthy women
• “Uncomplicated”
• Complicated urinary infections
require upper tract investigations
Complicated Cystitis
• In the elderly assume there is
residual urine
• Bladder power decreases with age
• Men usually have a component of
BPH, women atrophy (low estrogen)
• Failure to eradicate is commonly
associated with a foreign body such
as stone or catheter
Febrile Urinary Infections
in the elderly
• Assume there is Pyelonephritis
• Obstruction is common
– Catheter, ureter, prostate
• High Morbidity
– Associated confusion, falls, CHF, poor
host response, mortality
Prostatitis
• Patterns in medicine
– Men in 40’s
– 90% culture negative
– Association with pelvic pain
– Chronic
– Failure to identify organism associated with
cyclical natural history leads to false belief
that long courses of antibiotics will be
effective
• Unusual in the elderly
Asymptomatic Bacteruria
• Urinalysis done for other reasons
• Limitations of obtaining samples
• Difficulty with reliable history
• If frail and poor mental status-treat
• If well, treat conservatively, repeat
culture and consider treatment if
symptoms appear
 When do you treat asymptomatic bacteriuria?

1) Pregnant
2) Debilitated, older patients
3) Severely diabetic
4) Child with VUR
5) Obstruction
6) Patients who feel better with sterile urine
7) Patients about to undergo a GU procedure (TURP, etc.)
Why are the elderly at increased risk of UTI?
Systemic Renal
1) Dehydrated 1) GFR and decreased urine flow rate
2) Malnourished 2) Renal failure - poor excretion of
3) Other intercurrent illness e.g., antibiotics
diabetes 3) Stones ( risk)
4) Decreased immunity to infection 4) Renal diseases – e.g., hypertension,
(decreased cell-mediated immunity) DM
5) Multiple medications - some may be
immune suppressing
6) Frequent antibiotic use - promote
resistant organisms

Organism Factors Bladder

1) More virulent pathogen
2) Hospital acquired infections more
common
1) Poor emptying due to BPH or
detrussor contractility
2) Epithelial cell receptivity to bacteria
3) Acquired outlet obstruction
4) Urethral instrumentation
5) Indwelling catheter
6) Stones
Urine
1) Decreased immunoglobulins
In men: Prostatic factors
In women: Vaginal factors
1) Atrophic vaginitis
2) Decreased lactobacillus
Case Study
• 73 year old Diabetic Female
• Develops suprapubic pain, low
grade fever
• No voided sample available.
• Foley inserted for 800cc cloudy
urine.
• Micro wbc’s many, rbc’s few
Case Study
• Cultures sent
• Started emperically on Cipro 250
bid
• US--small kidneys, no hydro or
stones

• Culture E. Coli resistant to septra

Case Study
• What next?
1) Look for cause of Urinary retention
Diabetic Autonomic Dysfunction
(weak bladder)
Constipation
Altered Mental Status (early
dementia)
Medical Comorbidities (recent
pneumonia)
Case Study
• What next?
2) How long should she be treated?
Upper tract vs Lower tract infection
10-14d vs 3-7d
When is her foley likely to be removed?
Case Study
• She has had a similar episode 10
years ago. Had a bladder
suspension 30 years ago. Her
daughter says she feels her mom
is depressed.
– Constipation
– Altered mental status
Case Study
• Cipro is given for 14 days.
• Reculture negative
• Foley removed days 2, 5, 10. Finally
voiding on her own.
• Culture drawn monthly for 3 months.
• 3rd culture is positive for Enterococcus
without symptoms.
Case Study
• Is this Asymptomatic Bacteriuria in the
elderly? Yes but,
• because of history of recent urinary retention
and complicated UTI we are suspect.
• U/S PVR 300 mls
• Why Enterococcus?
• Treated with culture specific antibiotic
(amoxil)
Case Study
• Over the past year she continues to get
monthly UTI’s, each time associated with
altered mental status.
• Referred to Urology
– Repeat US Normal
– Cysto atrophy, thin bladder, some debris, PVR 200

– Is she a good candidate for prophylaxis?

• Which one?
Catheter Associated UTI
• 24hrs 5%
• 48 15%
• 72 25%
• 5 days 95%
Case 2
• 90 year old veteran with severe
disabling arthritis. Indwelling foley.
• He had the foley out but was troubled
by nocturia times 4 and daytime urge
incontinence.
• Complains the foley is bothering him
– UA 2+ wbc’s
– Culture mixed organisms including E. Coli
Case 2
• 90 year old veteran
• Treated with a 7 day course of Cipro
• Reculture clear, micro less wbc’s

• Should he have routine cutures drawn?

• Is there a role for treating his nocturia and

trying to remove foley?
Case 2
• 90 year old veteran

Repeat Cultures grow various coliforms, for which he is treated

each for 7 days.

3 months later the Urine grows candida

He is having problems with blocked catheters.
Is there an accociation of blocked catheters and Candida?

Received 8 weeks of fluconazole in order to obtain a negative

culture.

What else can we do?

Case 2
• 90 year old veteran- Trial without Foley
– Bowel regime
– Urinal at bedside
– Push daytime fluids
– Trial of DDAVP for nocturia

• Success.
• Manage expectations- The catheter was convenient but Charlie, you
had so many infections.
• PVR 30cc
• Check Urine only is symptomatic
Colonisation vs Infection
Some estimates of 5% of elderly have
a positive urine culture without
symptoms
Patients on intermittent or indwelling
foley are all colonized
In the absence of symptoms catheter
associated positive cultures can be
managed conservatively
Conservative treatments
Increase fluid intake
mechanical flushing of bladder
Keep Bowels soft
Constipation leads to poor pelvic floor
relaxation
Timed voiding
Cranberry
juice is more effective than extract
(volume)
Antibiotics
Enterobacter common
E Coli
Enterococcus common in failure of first line
Strep Faecalis
Proteus (urea splitting think Struvite stone)
Candida in the urine is usually the result of
long term antibiotic use. If a foreign body is
present will not clear.
Antibiotics
Antibiotics Pearls
30 % of E Coli resistant to AMP
20% of E Coli resistant to Septra
10% of E Coli resistant to Cipro

The longer an antibiotic has been used

the higher the resistance
Antibiotics Pearls
All Proteus are resistant to Nitrofurantoin

Enterococcus require Amp or

nitrofurantoin and while are low
virulence are commonly associated with
treatment failure
B Lactam antibiotics are poor when used
as low dose suppressive therapy
Conclusions
Urinary infections in the elderly can be a source
of morbidity
Prevention by minimizing catheter use is most
effective
Assume all elderly have some degree of impaired
bladder emptying
Complicated UTI’s in the elderly warrant upper
tract investigations
Prophylaxis is required in few for recurrent
urinary infections