CLINICAL FOCUS
Recurrent urinary tract infection in older women: an evidence-based approach Linda Nazarko
Linda Nazarko is Nurse Consultant and Clinical Lead, Community IV Services, Ealing NHS Trust
W
omen are at greater risk of urinary tract infection (UTI) than men due to anatomical differences. The urethra provides a barrier to the ascent of bacteria, and in women it is only around 5 cm long, whereas in men it is around 15 cm long. One woman in three and one man in twenty will develop a UTI in their lifetime. Around 20% of all women with UTI will experience a recurrence, and most are due to re-infection (Chung et al, 2010). Age-related changes increase the risk of UTI (Raz and Stamm, 1993; Boyko et al, 2005; Nazarko, 2005). Women aged over 60 have 7–8% annual incidence of UTI, and those over 80 have 20% annual incidence (Willacy, 2012). This article aims to explore UTI in women aged 65 and over. It examines how UTI is diagnosed and treated and how age-related changes increase infection risks and the risks of misdiagnosis and inappropriate treatment. It also explores strategies for reducing the risk of recurrent UTI.
© 2013 MA Healthcare Ltd
What is UTI? Lower UTI is generally defined as ‘evidence of urinary tract infection with symptoms suggestive of cystitis’ (Scottish Intercollegiate Guidelines Network (SIGN), 2012: 2). The classical symptoms of a UTI are dysuria, frequency of urination, suprapubic tenderness, urgency, polyuria and haematuria (SIGN, 2012: 2). UTIs may be classified as simple or complex. Simple UTIs occur in a structurally and functionally normal urinary tract, while complex UTIs occur in an abnormal urinary tract. Most UTIs occur when normal bacterial flora resident in the bowel, vagina or perineum ascend the urethra and migrate into the bladder. Adherence to the bladder wall causes an inflammatory response and the person develops symptoms of UTI. Normally the perinual skin and vagina secretions are acidic. This acidic mantle inhibits the growth of enterobacteriaceae. Bladder filling and emptying protect the bladder from bacterial adherence. The acidity of urine provides a hostile environment for bacteria. Age-related changes increase the risk of infection. Falling hormone levels affect the pH level of the vagina and it becomes alkaline rather than acidic. This affects bacterial flora and
British Journal of Community Nursing Vol 18, No 8
Email: [email protected] leads to an increased colonisation of enterobacteriaceae, which can cause UTI (Raz and Stamm, 1993). The bladder becomes smaller and stiffer with age. This can lead to incomplete bladder emptying whereby the flushing mechanism becomes less effective. There is an increase in the amount of urine left in the bladder after voiding. This residual urine can then act as a reservoir for bacteria (Boyko et al, 2005; Nazarko, 2005). Recurrent UTI is defined as three episodes of UTI with three positive urine cultures in the previous 12 months, or two episodes in the last 6 months (Albert et al, 2004). There are three main causes of recurrent UTI in older women. These are diagnostic failure, treatment failure and re-infection. Figure 1 outlines how to identify and treat these.
Diagnostic failure Sometimes older people can be misdiagnosed as having one or more UTIs because clinicians do not understand how to diagnose UTI in older people. Misdiagnosis and inappropriate treatment with antibiotics is common in older people (Woodford and George, 2009; Beveridge et al, 2011).
Abstract Ageing increases the risk of a woman developing a urinary tract infection (UTI). It also increases the risk of misdiagnosis and inappropriate antibiotic therapy being prescribed. Antibiotic therapy has costs as well as benefits and can lead to changes in gut and vaginal flora that further predispose older women to UTI. Antibiotic resistance is growing and those who do have a UTI may experience treatment failure because of resistance to commonly used antibiotics. Accurate diagnosis and effective evidencebased treatment becomes even more crucial in the face of an ageing population and increasing antimicrobial resistance. Furthermore, the need for specific evidence-based guidelines for UTI in older people is increasing.
KEY WORDS Recurrent urinary tract infection w older women w diagnostic error w treatment failure w re-infection
407
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CLINICAL FOCUS
Diagnostic error?
Treatment failure
Reducing risks of re-infection
Recurrence
Symptoms suggest UTI?
Confirm diagnosis
Confirm diagnosis, sensitivities, concordance with previous treatment and treat
Dysuria, frequency of urination, suprapubic tenderness, urgency, polyuria and haematuria
Confirm sensitivities, willing and able to take prescribed medication
Check predisposing factors e.g. diabetes, bladder abnormalities, voiding difficulties
Identify and treat contributing factors
If no urinary symptoms consider asymptomatic bacteriuria or alternative diagnosis
Ensure right antibiotic prescribed in right dose for right duration
Check infection resolved
Optimise treatment of long-term conditions
Check infection resolved
Consider referral for further investigations and treatment
Consider bacteriostatic agents
Improve hygiene, optimise fluid intake
Figure 1. Identification, treatment and risk reduction in recurrent urinary tract infections.
‘our interpretation of these results is that dipstick testing is likely to add little if anything to clinical diagnosis’. In the past, UTI was diagnosed on the basis of urinary bacterial counts and clinicians referred to ‘symptomatic’ and ‘asymptomatic’ UTIs (Kontiokari et al, 2001; Bissett, 2004). These definitions are unhelpful and have contributed to the confusion that leads to overdiagnosis and overtreatment of UTI, which is especially problematic in older people. Woodford and George (2009) found that only 31% of those diagnosed and treated for UTI actually had any symptoms of this infection.
Box 1. HPA (2011a,b) guidance on suspected UTI in older people w Do not send urine for culture in asymptomatic elderly people with positive dipsticks w Only send urine for culture if two or more signs of infection are present, especially dysuria, fever of greater 38° or new incontinence. w Do not treat asymptomatic bacteriuria in the elderly, as it is very common w Treating does not reduce mortality or prevent symptomatic episodes, but increases side effects and antibiotic resistance
408
Diagnosing UTI in older women A UTI should not be diagnosed on the basis of a urine dipstick or nonspecific symptoms such as reported increased confusion:
‘A urinary tract infection is diagnosed on the basis of significant bacteriuria and characteristic symptoms and signs.’ (Clinical Knowledge Summaries (CKS), 2012) In older people, UTI should be diagnosed on the basis of a full clinical assessment, including checking temperature, pulse and blood pressure (McMurdo and Gillespie, 2000; CKS, 2012; SIGN, 2012). Health Protection Agency (HPA) (2011a,b) guidance on UTI in adult women under the age of 65 advises clinicians to consider alternative diagnosis in the presence of only two of the symptoms mentioned in their guidance. Box 1 summarises HPA (2011a,b) guidance.
Clinical features of UTI If an older woman has the clinical features of UTI and is presenting for the first time, a diagnosis can be made on the basis of clinical features and a prescribed antibiotic (Box 2). Confirmed lower UTI should be treated with oral antibiotics according to local prescribing guidelines. Trimethoprim and nitrofurantoin are recommended as first-line treatments for UTI (HPA, 2011). Resistance rates are growing, and a study carried out in London concluded that ‘levels of resistance to trimethoprim and ampicillin render them unsuitable for empirical use’ (Bean et al, 2008). There are low levels of resistance to nitrofurantoin; however, if a person has severe renal impairment then nitrofurantoin is contraindicated (Christiaens et al, 2002). The optimum duration of treatment is still not clear.
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A woman can sometimes be misdiagnosed as having a recurrent UTI when the real problem is misdiagnosis. UTI is too often diagnosed on the basis of urine testing (Nazarko, 2013). Sundvall and Gunnarsson (2009) evaluated the usefulness of combined nitrite and leukocyte esterase dipstick analysis in predicting the presence of pathogenic bacteria in nursing home residents. This study did not differentiate between the presence of bacteria in the bladder (bacteriuria) and the presence of clinical infection. Beveridge et al (2011) comment that
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CLINICAL FOCUS
w Unusually frequent urination w An intense urge to urinate w Dysuria: pain, discomfort or a burning sensation during urination w Pain, pressure or tenderness in the area of the bladder (midline, above or near the pubic area) w Urine that looks cloudy, or smells foul or unusually strong w Fever, with or without chills w Nausea and vomiting w Pain in the side or mid to upper back w Nocturia: awakening from sleep to pass urine w Onset of enuresis (bedwetting) in a person who has usually been dry at night Source: Nazarko (2009)
It appears that a 3-day course of treatment is effective in younger women (Christiaens et al, 2002). Older women benefit from 3 to 6 days of treatment (Lutters and Vogt, 2000; Vogel et al, 2004; Lutters and Vogt-Ferrier, 2008).
Interpreting urine cultures The quality of the urine sample affects the ability to detect bacteria and to provide accurate cultures. The risk of contamination varies according to how the specimen is obtained and stored prior to arrival at the laboratory. Urine is normally sterile. Bacteriuria is the term used when
Table 1. Key messages about bacteriuria Message Bacteriuria is not a disease
Comments Bacteriuria is rare in those under 65 It becomes increasingly common as people age It is more common in women than in men It is common in people with indwelling urinary catheters and those using intermittent urethral catheters Around 40% of women living in care homes have bacteriuria
Tests to identify bacteria or white cells in the urine are not diagnostic of UTI
The diagnosis of urinary tract infection (UTI) is based on clinical features. Tests to identify bacteria or white cells in urine can inform the management of UTI but are not diagnostic
Only urine obtained by needle aspiration of the bladder eliminates the risk of contamination and false positives
Obtaining midstream specimens and specimens from urethral catheters increases the risk of contamination and false diagnosis of UTI may result
Routine culture is not required to manage lower UTI in women
Patients who have not responded to treatment should have urine sent for culture and sensitivity
410
bacteria are present in the urine. However, the presence of bacteria in urine does not necessarily indicate that antibiotic therapy is required. There are differences between bacteriuria (bacteria in the urine) and infection. A diagnosis of infection is made on the basis of clinical symptoms. Studies indicate that certain groups of people (especially women, older people and those who are catheterised) may have asymptomatic bacteriuria (Brocklehurst et al, 1997). SIGN (2012: 4) guidelines on the management of suspected UTIs in adults indicate that 17% of women aged 75 and over have bacteriuria. Beyer et al (2001) suggest that up to 40% of women living in care homes or long-stay hospitals have asymptomatic bacteriuria. Older women who have bacteriuria in the absence of the clinical features of a UTI do not require antibiotic therapy (Brocklehurst et al, 1997; Beyer et al, 2001; Juthani-Mehta, 2007; SIGN, 2012). Treating bacteriuria in the absence of clinical symptoms can be harmful and exposes the person unnecessarily to the hazards of antibiotic therapy (Nicolle 2000; Walker et al, 2000).Table 1 illustrates key messages on asymptomatic bacteriuria based on SIGN (2012) guidance and the above authors. Culture and sensitivity tests can help clinicians to determine whether they have prescribed the correct antibiotic to a person who has symptoms of a UTI. A ‘mixed growth’ (i.e. a culture containing more than two strains of bacteria) is indicative of either contamination or of bacteriuria, not infection.
Treatment failure Around 20% of all women treated for UTI will require further treatment (Chung et al, 2010). Clinicians in all settings who encounter a person failing to respond to an initial course of antibiotic therapy should send a urine specimen for culture and sensitivity. Urine cultures enable the clinician to determine what the infecting bacteria are and what antibiotic therapy they are sensitive to. Worldwide, the most common infective organism is Escherichia coli (E. coli). E. coli is responsible for 80–90% of all UTIs (Kahlmeter, 2003). Around 5–10% of infections are caused by Staphylococcus saprophyticus. The remaining infections are caused by Proteus species and other Gram-negative rods (Zalmanovici Trestioreanu et al, 2010). Proteus species cause only 1–2% of community-acquired infections in healthy urinary tracts and account for just 5% of hospital-acquired UTIs. Proteus infections are most common in people who currently have or who have had an indwelling urinary catheter (Ruso and Johnson, 2010). Certain broad-spectrum antibiotics such as penicillins and cephalosporins contain a four-atom ring known as a beta-lactam. Certain species of bacteria such as E. coli have developed a way of combating antibiotics by breaking apart the molecular structure of the beta-lactam and inactivating the antibiotic. These bacteria are known as extendedspectrum beta-lactamase (ESBL) organisms. These bacteria (for example, ESBL E. coli) were once confined to acute hospitals but are now increasingly common in the community (Falagas et al, 2010; HPA, 2011b). Prescribing the appropriate antibiotic for the appropriate
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Box 2. Clinical features of urinary tract infection
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CLINICAL FOCUS duration should address treatment failure. It is important to emphasise that antibiotics are only effective when they are taken as prescribed. Many people of all ages do not comply with instructions to take antibiotics as prescribed. Older women may have problems with memory or have difficulty swallowing capsules or large tablets. Prescribers should take any issues that affect compliance into account when prescribing. For example, nitrofurantoin is available in a modified-release formula and this only needs to be taken twice daily instead of four times a day (Greener, 2011). Although modified-release formulations are more expensive, they can improve compliance and can therefore be cost-effective. SIGN (2012: 29) guidance recommends that clinicians investigate other potential causes in women who remain symptomatic after a single course of treatment. The level of investigation that clinicians can provide will be determined by their skill levels and access to diagnostic investigations.
Recurrence Re-infection may suggest that the case is not a simple UTI. The person may have a disease, such as diabetes, that increases infection risks or abnormalities of the upper or lower urinary tract. Clinicians working in the community can carry out certain investigations, such as checking for diabetes and checking post-void residual urine, and may refer to secondary care for further investigations. Clinicians should also be alert to the possibility that the person is not taking prescribed antibiotic therapy. This
might be because the person is forgetful, has memory impairment or does not complete a course of treatment because symptoms abate.
Reducing risks of recurrence Knowledge of how to prevent recurrent UTIs is limited. Risks can be reduced by treating contributing factors such as poorly controlled diabetes, and discontinuing medications such as anticholinergics that lead to bladder emptying problems. Improving hygiene by wiping front to back (anterior to posterior) following urination is thought to reduce the risk of contaminating the urethra with E. coli. There is some limited evidence gained from small studies that vaginal oestrogens may reduce infection risks (Perrotta et al, 2008). Encouraging women to drink around 2 litres of fluid a day is thought to reduce risks by flushing bacteria out of the bladder. Increasing fluid intake may be contraindicated in certain conditions such as chronic hyponatraemia or advanced renal or cardiac disease. Eating or applying probiotic yoghurt (containing lactobacillus) vaginally is thought to restore normal vaginal flora and to reduce enterobacteriaceae colonisation, which can cause infection. At present, there is insufficient evidence to recommend the use of probiotics (Barrons and Tassone, 2008). Using bacteriostatic agents such as hexamine (methanamine) hippurate (1 g orally twice daily) may be effective (Lee et al, 2007). The latest review on the use of cranberries indicates that few people continue to take cranberries long term and that the use of cranberries does not significantly reduce UTI (Jepson et al, 2012).
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Conclusion UTIs that occur in a normal urinary tract are normally selflimiting, and although antibiotic therapy leads to a more rapid resolution of symptoms, antibiotic therapy has costs as well as benefits. Treating simple UTIs with antibiotics adversely affects gut bacteria and vaginal flora and increases the risk of antibiotic resistance. As Foxman (2010) points out, as resistance rates grow, it may be time to explore alternative strategies to support people with UTIs. A review by Matthews and Lancaster (2011) reminds us that UTIs in older people encompass a spectrum from the ‘relatively benign cystitis to potentially life-threatening pyelonephritis’. They stress the need to treat the older person with a UTI holistically and to work out treatment based on the severity of illness, existing comorbidities and the ability of the patient to comply with therapy and call for improved guidelines for the diagnosis and management of UTIs in older people. BJCN Albert X, Huertas I, Pereiro I, Sanfelix J, Gosalbes V, Perrotta C. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev 2004(3): CD001209. http://tinyurl.com/nspe vup (accessed 12 May 2013) Barrons R, Tassone D (2008) Use of lactobacillus probiotics for bacterial genitourinary infections in women: a review. Clin Ther 30: 453–68 Bean DC, Krahe D, Wareham DW (2008) Antimicrobial resistance in community and nosocomial Escherichia coli urinary tract isolates, London 2005–2006. Ann Clin Microbiol Antimicrob 27: 13 Beveridge LA, Davey PG, Phillips G, McMurdo ME (2011). Optimal management of urinary tract infections in older people. Clin Interv Aging 6: 173–80 Beyer I, Mergam A, Benoit F, Theunissen C, Pepersack T (2001). Management of urinary tract infections in the elderly. Z Gerontol Geriatr 34(2): 153–7 Bissett L (2004) The control of urinary tract infection in hospitalised older people. Nurs Times 100(8): 54–6 Boyko EJ, Fihn SD, Scholes D, Abraham L, Monsey B (2005) Risk of urinary tract infection and asymptomatic bacteriuria among diabetic and nondiabetic postmenopausal women. Am J Epidemiol 161(6): 557–64 Brocklehurst JC, Bee P, Jones D, Palmer MK (1997) Bacteriuria in geriatric hospital patients: its correlates and management. Age Ageing 6(4): 240–5 Christiaens TC, De Meyere M, Verschraegen G, PeersmanW, Heytens S, De Maeseneer JM (2002). Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women. Br J Gen Pract 52(482): 729–34 Chung A, Arianayagam M, Rashid P (2010). Bacterial cystitis in women. Aust Fam Physician 39(5): 295–8 Clinical Knowledge Summaries (2012) Urinary tract infection (lower). Women: background information definition. NHS Evidence. http://tinyurl.com/nerzm44 (accessed 12 May 2013) Falagas ME, Kastoris AC, Kapaskelis AM, Karageorgopoulos DE (2010) Fosfomycin for the treatment of multidrug-resistant, including extendedspectrum beta-lactamase producing, Enterobacteriaceae infections: a systematic review. Lancet Infect Dis 10(1): 43–50
Learning points w Older women are at greater risk of developing urinary tract infections because of anatomical and age-related changes.
w Misdiagnosis and inappropriate prescribing of antibiotic therapy is common in older women.
w Urinary tract infection should be diagnosed on the basis of clinical symptoms.
w Antibiotic resistance has led to some once commonly used antibiotics becoming increasingly ineffective.
w Improved guidelines in treatment and management of older women with urinary tract infections are required.
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Foxman B (2010) The epidemiology of urinary tract infection. Nat Rev Urol 7(12): 653–60 Greener M (2011) Modified-release nitrofurantoin in uncomplicated urinary tract infection. Nurse Prescribing 9(1): 19–24 Health Protection Agency (2011a) UTI (Urinary Tract Infection) Quick Reference for Primary Care. HPA, Colindale, London. http://tinyurl.com/o6t7efh (accessed 12 May 2013) Health Protection Agency (2011b) Extended-Spectrum Beta-Lactamases (ESBLs). HPA, London. http://tinyurl.com/pvxotel (accessed 12 May 2013) Jepson RG, Williams G, Craig JC (2012) Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 2012(10): CD001321. Juthani-Mehta M (2007) Asymptomatic bacteriuria and urinary tract infection in older adults. Clin Geriatr Med 23(3): 585–94, viii Kahlmeter G (2003) An international survey of the antimicrobial susceptibility of pathogens from uncomplicated urinary tract infections: the ECO SENS Project. J Antimicrob Chemother 51: 69–76 Kontiokari T, Sundqvist K, Nuutinen M, Pokka T, Koskela M, Uhari M (2001) Randomised trial of cranberry–lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women. BMJ 322(7302): 1571 Lee BB, Simpson JM, Craig JC, Bhuta T (2007) Methenamine hippurate for preventing urinary tract infections. Cochrane Database Syst Rev 2007(4): CD003265 Lutters M, Vogt N (2000) What’s the basis for treating infections your way? Quality assessment of review articles on the treatment of urinary and respiratory tract infections in older people. J Am Geriatr Soc 48: 1454–61 Lutters M, Vogt-Ferrier NB (2008) Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women (Cochrane Review). Cochrane Database Syst Rev 2008(3) CD001535 Matthews SJ, Lancaster JW (2011) Urinary tract infections in the elderly population. Am J Geriatr Pharmacother 9(5): 286–309 McMurdo MET, Gillespie ND (2000) Urinary tract infection in old age: overdiagnosed and over-treated. Age Ageing 29(4): 297–8 Nazarko L (2005) Management of a patient with diabetes and hypotonic bladder. Nurs Times 101(47): 63–4 Nazarko L (2009) Urinary tract infection: diagnosis, treatment and prevention. Br J Nur 18(19): 1170–4 Nazarko L (2013) Solve the case: bothersome bladder symptoms. Nurse Prescribing 11(7): 338–43 Nicolle LE (2000) Asymptomatic bacteriuria in institutionalized elderly people: evidence and practice. CMAJ 163(3): 285–6 Perrotta C, Aznar M, Mejia R, Albert X, Ng CW (2008) Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev 2008(2): CD005131 Raz R, Stamm WE (1993) A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med 329: 753–6 Ruso TA, Johnson JR (2010) Diseases caused by Gram negative enteric bacilli. In: Kasper DL, Fauci AS eds. Harrison’s Infectious Diseases. McGraw-Hill Medical, New York Scottish Intercollegiate Guidelines Network (2012) Management of Suspected Bacterial Urinary Tract Infection in Adults: A National Clinical Guideline. Scottish Intercollegiate Guidelines Network, Edinburgh. http://www.sign. ac.uk/pdf/sign88.pdf (accessed 12 May 2013) Sundvall PD, Gunnarsson RK (2009) Evaluation of dipstick analysis among elderly residents to detect bacteriuria: a cross-sectional study in 32 nursing homes. BMC Geriatr 9(32): http://tinyurl.com/o52wygx (accessed 12 May 2013) Vogel T, Verreault R, Gourdeau M, Morin M, Grenier-Gosselin L, Rochette L (2004) Optimal duration of antibiotic therapy for uncomplicated urinary tract infection in older women: a double blind randomized controlled trial. CMAJ 170(4):469–73 Walker S, McGeer A, Simor AE, Armstrong-Evans M, Loeb M (2000) Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? A qualitative study of physicians’ and nurses’ perceptions. CMAJ 163(3): 273–7 Willacy H (2012) Recurrent urinary tract infection. Patient.co. uk. http://tinyurl.com/qcf5xxm (accessed 12 May 2013) Woodford HJ, George J (2009) Diagnosis and management of urinary tract infection in hospitalized older people. J Am Geriatr Soc 57: 107–14 Zalmanovici Trestioreanu A, Green H, Paul M, Yaphe J, Leibovici L (2010) Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database Syst Rev 2010(10): http://tinyurl.com/5rhglav (accessed 12 May 2013)
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CLINICAL FOCUS
British Journal of Community Nursing Vol 18, No 8
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on October 22, 2015. For personal use only. No other uses without permission. . All rights rese
Recurrent urinary tract infection in older women: an evidence-based approach Linda Nazarko
Linda Nazarko is Nurse Consultant and Clinical Lead, Community IV Services, Ealing NHS Trust
W
omen are at greater risk of urinary tract infection (UTI) than men due to anatomical differences. The urethra provides a barrier to the ascent of bacteria, and in women it is only around 5 cm long, whereas in men it is around 15 cm long. One woman in three and one man in twenty will develop a UTI in their lifetime. Around 20% of all women with UTI will experience a recurrence, and most are due to re-infection (Chung et al, 2010). Age-related changes increase the risk of UTI (Raz and Stamm, 1993; Boyko et al, 2005; Nazarko, 2005). Women aged over 60 have 7–8% annual incidence of UTI, and those over 80 have 20% annual incidence (Willacy, 2012). This article aims to explore UTI in women aged 65 and over. It examines how UTI is diagnosed and treated and how age-related changes increase infection risks and the risks of misdiagnosis and inappropriate treatment. It also explores strategies for reducing the risk of recurrent UTI.
© 2013 MA Healthcare Ltd
What is UTI? Lower UTI is generally defined as ‘evidence of urinary tract infection with symptoms suggestive of cystitis’ (Scottish Intercollegiate Guidelines Network (SIGN), 2012: 2). The classical symptoms of a UTI are dysuria, frequency of urination, suprapubic tenderness, urgency, polyuria and haematuria (SIGN, 2012: 2). UTIs may be classified as simple or complex. Simple UTIs occur in a structurally and functionally normal urinary tract, while complex UTIs occur in an abnormal urinary tract. Most UTIs occur when normal bacterial flora resident in the bowel, vagina or perineum ascend the urethra and migrate into the bladder. Adherence to the bladder wall causes an inflammatory response and the person develops symptoms of UTI. Normally the perinual skin and vagina secretions are acidic. This acidic mantle inhibits the growth of enterobacteriaceae. Bladder filling and emptying protect the bladder from bacterial adherence. The acidity of urine provides a hostile environment for bacteria. Age-related changes increase the risk of infection. Falling hormone levels affect the pH level of the vagina and it becomes alkaline rather than acidic. This affects bacterial flora and
British Journal of Community Nursing Vol 18, No 8
Email: [email protected] leads to an increased colonisation of enterobacteriaceae, which can cause UTI (Raz and Stamm, 1993). The bladder becomes smaller and stiffer with age. This can lead to incomplete bladder emptying whereby the flushing mechanism becomes less effective. There is an increase in the amount of urine left in the bladder after voiding. This residual urine can then act as a reservoir for bacteria (Boyko et al, 2005; Nazarko, 2005). Recurrent UTI is defined as three episodes of UTI with three positive urine cultures in the previous 12 months, or two episodes in the last 6 months (Albert et al, 2004). There are three main causes of recurrent UTI in older women. These are diagnostic failure, treatment failure and re-infection. Figure 1 outlines how to identify and treat these.
Diagnostic failure Sometimes older people can be misdiagnosed as having one or more UTIs because clinicians do not understand how to diagnose UTI in older people. Misdiagnosis and inappropriate treatment with antibiotics is common in older people (Woodford and George, 2009; Beveridge et al, 2011).
Abstract Ageing increases the risk of a woman developing a urinary tract infection (UTI). It also increases the risk of misdiagnosis and inappropriate antibiotic therapy being prescribed. Antibiotic therapy has costs as well as benefits and can lead to changes in gut and vaginal flora that further predispose older women to UTI. Antibiotic resistance is growing and those who do have a UTI may experience treatment failure because of resistance to commonly used antibiotics. Accurate diagnosis and effective evidencebased treatment becomes even more crucial in the face of an ageing population and increasing antimicrobial resistance. Furthermore, the need for specific evidence-based guidelines for UTI in older people is increasing.
KEY WORDS Recurrent urinary tract infection w older women w diagnostic error w treatment failure w re-infection
407
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CLINICAL FOCUS
Diagnostic error?
Treatment failure
Reducing risks of re-infection
Recurrence
Symptoms suggest UTI?
Confirm diagnosis
Confirm diagnosis, sensitivities, concordance with previous treatment and treat
Dysuria, frequency of urination, suprapubic tenderness, urgency, polyuria and haematuria
Confirm sensitivities, willing and able to take prescribed medication
Check predisposing factors e.g. diabetes, bladder abnormalities, voiding difficulties
Identify and treat contributing factors
If no urinary symptoms consider asymptomatic bacteriuria or alternative diagnosis
Ensure right antibiotic prescribed in right dose for right duration
Check infection resolved
Optimise treatment of long-term conditions
Check infection resolved
Consider referral for further investigations and treatment
Consider bacteriostatic agents
Improve hygiene, optimise fluid intake
Figure 1. Identification, treatment and risk reduction in recurrent urinary tract infections.
‘our interpretation of these results is that dipstick testing is likely to add little if anything to clinical diagnosis’. In the past, UTI was diagnosed on the basis of urinary bacterial counts and clinicians referred to ‘symptomatic’ and ‘asymptomatic’ UTIs (Kontiokari et al, 2001; Bissett, 2004). These definitions are unhelpful and have contributed to the confusion that leads to overdiagnosis and overtreatment of UTI, which is especially problematic in older people. Woodford and George (2009) found that only 31% of those diagnosed and treated for UTI actually had any symptoms of this infection.
Box 1. HPA (2011a,b) guidance on suspected UTI in older people w Do not send urine for culture in asymptomatic elderly people with positive dipsticks w Only send urine for culture if two or more signs of infection are present, especially dysuria, fever of greater 38° or new incontinence. w Do not treat asymptomatic bacteriuria in the elderly, as it is very common w Treating does not reduce mortality or prevent symptomatic episodes, but increases side effects and antibiotic resistance
408
Diagnosing UTI in older women A UTI should not be diagnosed on the basis of a urine dipstick or nonspecific symptoms such as reported increased confusion:
‘A urinary tract infection is diagnosed on the basis of significant bacteriuria and characteristic symptoms and signs.’ (Clinical Knowledge Summaries (CKS), 2012) In older people, UTI should be diagnosed on the basis of a full clinical assessment, including checking temperature, pulse and blood pressure (McMurdo and Gillespie, 2000; CKS, 2012; SIGN, 2012). Health Protection Agency (HPA) (2011a,b) guidance on UTI in adult women under the age of 65 advises clinicians to consider alternative diagnosis in the presence of only two of the symptoms mentioned in their guidance. Box 1 summarises HPA (2011a,b) guidance.
Clinical features of UTI If an older woman has the clinical features of UTI and is presenting for the first time, a diagnosis can be made on the basis of clinical features and a prescribed antibiotic (Box 2). Confirmed lower UTI should be treated with oral antibiotics according to local prescribing guidelines. Trimethoprim and nitrofurantoin are recommended as first-line treatments for UTI (HPA, 2011). Resistance rates are growing, and a study carried out in London concluded that ‘levels of resistance to trimethoprim and ampicillin render them unsuitable for empirical use’ (Bean et al, 2008). There are low levels of resistance to nitrofurantoin; however, if a person has severe renal impairment then nitrofurantoin is contraindicated (Christiaens et al, 2002). The optimum duration of treatment is still not clear.
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A woman can sometimes be misdiagnosed as having a recurrent UTI when the real problem is misdiagnosis. UTI is too often diagnosed on the basis of urine testing (Nazarko, 2013). Sundvall and Gunnarsson (2009) evaluated the usefulness of combined nitrite and leukocyte esterase dipstick analysis in predicting the presence of pathogenic bacteria in nursing home residents. This study did not differentiate between the presence of bacteria in the bladder (bacteriuria) and the presence of clinical infection. Beveridge et al (2011) comment that
British Journal of Community Nursing Vol 18, No 8
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CLINICAL FOCUS
w Unusually frequent urination w An intense urge to urinate w Dysuria: pain, discomfort or a burning sensation during urination w Pain, pressure or tenderness in the area of the bladder (midline, above or near the pubic area) w Urine that looks cloudy, or smells foul or unusually strong w Fever, with or without chills w Nausea and vomiting w Pain in the side or mid to upper back w Nocturia: awakening from sleep to pass urine w Onset of enuresis (bedwetting) in a person who has usually been dry at night Source: Nazarko (2009)
It appears that a 3-day course of treatment is effective in younger women (Christiaens et al, 2002). Older women benefit from 3 to 6 days of treatment (Lutters and Vogt, 2000; Vogel et al, 2004; Lutters and Vogt-Ferrier, 2008).
Interpreting urine cultures The quality of the urine sample affects the ability to detect bacteria and to provide accurate cultures. The risk of contamination varies according to how the specimen is obtained and stored prior to arrival at the laboratory. Urine is normally sterile. Bacteriuria is the term used when
Table 1. Key messages about bacteriuria Message Bacteriuria is not a disease
Comments Bacteriuria is rare in those under 65 It becomes increasingly common as people age It is more common in women than in men It is common in people with indwelling urinary catheters and those using intermittent urethral catheters Around 40% of women living in care homes have bacteriuria
Tests to identify bacteria or white cells in the urine are not diagnostic of UTI
The diagnosis of urinary tract infection (UTI) is based on clinical features. Tests to identify bacteria or white cells in urine can inform the management of UTI but are not diagnostic
Only urine obtained by needle aspiration of the bladder eliminates the risk of contamination and false positives
Obtaining midstream specimens and specimens from urethral catheters increases the risk of contamination and false diagnosis of UTI may result
Routine culture is not required to manage lower UTI in women
Patients who have not responded to treatment should have urine sent for culture and sensitivity
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bacteria are present in the urine. However, the presence of bacteria in urine does not necessarily indicate that antibiotic therapy is required. There are differences between bacteriuria (bacteria in the urine) and infection. A diagnosis of infection is made on the basis of clinical symptoms. Studies indicate that certain groups of people (especially women, older people and those who are catheterised) may have asymptomatic bacteriuria (Brocklehurst et al, 1997). SIGN (2012: 4) guidelines on the management of suspected UTIs in adults indicate that 17% of women aged 75 and over have bacteriuria. Beyer et al (2001) suggest that up to 40% of women living in care homes or long-stay hospitals have asymptomatic bacteriuria. Older women who have bacteriuria in the absence of the clinical features of a UTI do not require antibiotic therapy (Brocklehurst et al, 1997; Beyer et al, 2001; Juthani-Mehta, 2007; SIGN, 2012). Treating bacteriuria in the absence of clinical symptoms can be harmful and exposes the person unnecessarily to the hazards of antibiotic therapy (Nicolle 2000; Walker et al, 2000).Table 1 illustrates key messages on asymptomatic bacteriuria based on SIGN (2012) guidance and the above authors. Culture and sensitivity tests can help clinicians to determine whether they have prescribed the correct antibiotic to a person who has symptoms of a UTI. A ‘mixed growth’ (i.e. a culture containing more than two strains of bacteria) is indicative of either contamination or of bacteriuria, not infection.
Treatment failure Around 20% of all women treated for UTI will require further treatment (Chung et al, 2010). Clinicians in all settings who encounter a person failing to respond to an initial course of antibiotic therapy should send a urine specimen for culture and sensitivity. Urine cultures enable the clinician to determine what the infecting bacteria are and what antibiotic therapy they are sensitive to. Worldwide, the most common infective organism is Escherichia coli (E. coli). E. coli is responsible for 80–90% of all UTIs (Kahlmeter, 2003). Around 5–10% of infections are caused by Staphylococcus saprophyticus. The remaining infections are caused by Proteus species and other Gram-negative rods (Zalmanovici Trestioreanu et al, 2010). Proteus species cause only 1–2% of community-acquired infections in healthy urinary tracts and account for just 5% of hospital-acquired UTIs. Proteus infections are most common in people who currently have or who have had an indwelling urinary catheter (Ruso and Johnson, 2010). Certain broad-spectrum antibiotics such as penicillins and cephalosporins contain a four-atom ring known as a beta-lactam. Certain species of bacteria such as E. coli have developed a way of combating antibiotics by breaking apart the molecular structure of the beta-lactam and inactivating the antibiotic. These bacteria are known as extendedspectrum beta-lactamase (ESBL) organisms. These bacteria (for example, ESBL E. coli) were once confined to acute hospitals but are now increasingly common in the community (Falagas et al, 2010; HPA, 2011b). Prescribing the appropriate antibiotic for the appropriate
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Box 2. Clinical features of urinary tract infection
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CLINICAL FOCUS duration should address treatment failure. It is important to emphasise that antibiotics are only effective when they are taken as prescribed. Many people of all ages do not comply with instructions to take antibiotics as prescribed. Older women may have problems with memory or have difficulty swallowing capsules or large tablets. Prescribers should take any issues that affect compliance into account when prescribing. For example, nitrofurantoin is available in a modified-release formula and this only needs to be taken twice daily instead of four times a day (Greener, 2011). Although modified-release formulations are more expensive, they can improve compliance and can therefore be cost-effective. SIGN (2012: 29) guidance recommends that clinicians investigate other potential causes in women who remain symptomatic after a single course of treatment. The level of investigation that clinicians can provide will be determined by their skill levels and access to diagnostic investigations.
Recurrence Re-infection may suggest that the case is not a simple UTI. The person may have a disease, such as diabetes, that increases infection risks or abnormalities of the upper or lower urinary tract. Clinicians working in the community can carry out certain investigations, such as checking for diabetes and checking post-void residual urine, and may refer to secondary care for further investigations. Clinicians should also be alert to the possibility that the person is not taking prescribed antibiotic therapy. This
might be because the person is forgetful, has memory impairment or does not complete a course of treatment because symptoms abate.
Reducing risks of recurrence Knowledge of how to prevent recurrent UTIs is limited. Risks can be reduced by treating contributing factors such as poorly controlled diabetes, and discontinuing medications such as anticholinergics that lead to bladder emptying problems. Improving hygiene by wiping front to back (anterior to posterior) following urination is thought to reduce the risk of contaminating the urethra with E. coli. There is some limited evidence gained from small studies that vaginal oestrogens may reduce infection risks (Perrotta et al, 2008). Encouraging women to drink around 2 litres of fluid a day is thought to reduce risks by flushing bacteria out of the bladder. Increasing fluid intake may be contraindicated in certain conditions such as chronic hyponatraemia or advanced renal or cardiac disease. Eating or applying probiotic yoghurt (containing lactobacillus) vaginally is thought to restore normal vaginal flora and to reduce enterobacteriaceae colonisation, which can cause infection. At present, there is insufficient evidence to recommend the use of probiotics (Barrons and Tassone, 2008). Using bacteriostatic agents such as hexamine (methanamine) hippurate (1 g orally twice daily) may be effective (Lee et al, 2007). The latest review on the use of cranberries indicates that few people continue to take cranberries long term and that the use of cranberries does not significantly reduce UTI (Jepson et al, 2012).
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Conclusion UTIs that occur in a normal urinary tract are normally selflimiting, and although antibiotic therapy leads to a more rapid resolution of symptoms, antibiotic therapy has costs as well as benefits. Treating simple UTIs with antibiotics adversely affects gut bacteria and vaginal flora and increases the risk of antibiotic resistance. As Foxman (2010) points out, as resistance rates grow, it may be time to explore alternative strategies to support people with UTIs. A review by Matthews and Lancaster (2011) reminds us that UTIs in older people encompass a spectrum from the ‘relatively benign cystitis to potentially life-threatening pyelonephritis’. They stress the need to treat the older person with a UTI holistically and to work out treatment based on the severity of illness, existing comorbidities and the ability of the patient to comply with therapy and call for improved guidelines for the diagnosis and management of UTIs in older people. BJCN Albert X, Huertas I, Pereiro I, Sanfelix J, Gosalbes V, Perrotta C. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev 2004(3): CD001209. http://tinyurl.com/nspe vup (accessed 12 May 2013) Barrons R, Tassone D (2008) Use of lactobacillus probiotics for bacterial genitourinary infections in women: a review. Clin Ther 30: 453–68 Bean DC, Krahe D, Wareham DW (2008) Antimicrobial resistance in community and nosocomial Escherichia coli urinary tract isolates, London 2005–2006. Ann Clin Microbiol Antimicrob 27: 13 Beveridge LA, Davey PG, Phillips G, McMurdo ME (2011). Optimal management of urinary tract infections in older people. Clin Interv Aging 6: 173–80 Beyer I, Mergam A, Benoit F, Theunissen C, Pepersack T (2001). Management of urinary tract infections in the elderly. Z Gerontol Geriatr 34(2): 153–7 Bissett L (2004) The control of urinary tract infection in hospitalised older people. Nurs Times 100(8): 54–6 Boyko EJ, Fihn SD, Scholes D, Abraham L, Monsey B (2005) Risk of urinary tract infection and asymptomatic bacteriuria among diabetic and nondiabetic postmenopausal women. Am J Epidemiol 161(6): 557–64 Brocklehurst JC, Bee P, Jones D, Palmer MK (1997) Bacteriuria in geriatric hospital patients: its correlates and management. Age Ageing 6(4): 240–5 Christiaens TC, De Meyere M, Verschraegen G, PeersmanW, Heytens S, De Maeseneer JM (2002). Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women. Br J Gen Pract 52(482): 729–34 Chung A, Arianayagam M, Rashid P (2010). Bacterial cystitis in women. Aust Fam Physician 39(5): 295–8 Clinical Knowledge Summaries (2012) Urinary tract infection (lower). Women: background information definition. NHS Evidence. http://tinyurl.com/nerzm44 (accessed 12 May 2013) Falagas ME, Kastoris AC, Kapaskelis AM, Karageorgopoulos DE (2010) Fosfomycin for the treatment of multidrug-resistant, including extendedspectrum beta-lactamase producing, Enterobacteriaceae infections: a systematic review. Lancet Infect Dis 10(1): 43–50
Learning points w Older women are at greater risk of developing urinary tract infections because of anatomical and age-related changes.
w Misdiagnosis and inappropriate prescribing of antibiotic therapy is common in older women.
w Urinary tract infection should be diagnosed on the basis of clinical symptoms.
w Antibiotic resistance has led to some once commonly used antibiotics becoming increasingly ineffective.
w Improved guidelines in treatment and management of older women with urinary tract infections are required.
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Foxman B (2010) The epidemiology of urinary tract infection. Nat Rev Urol 7(12): 653–60 Greener M (2011) Modified-release nitrofurantoin in uncomplicated urinary tract infection. Nurse Prescribing 9(1): 19–24 Health Protection Agency (2011a) UTI (Urinary Tract Infection) Quick Reference for Primary Care. HPA, Colindale, London. http://tinyurl.com/o6t7efh (accessed 12 May 2013) Health Protection Agency (2011b) Extended-Spectrum Beta-Lactamases (ESBLs). HPA, London. http://tinyurl.com/pvxotel (accessed 12 May 2013) Jepson RG, Williams G, Craig JC (2012) Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 2012(10): CD001321. Juthani-Mehta M (2007) Asymptomatic bacteriuria and urinary tract infection in older adults. Clin Geriatr Med 23(3): 585–94, viii Kahlmeter G (2003) An international survey of the antimicrobial susceptibility of pathogens from uncomplicated urinary tract infections: the ECO SENS Project. J Antimicrob Chemother 51: 69–76 Kontiokari T, Sundqvist K, Nuutinen M, Pokka T, Koskela M, Uhari M (2001) Randomised trial of cranberry–lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women. BMJ 322(7302): 1571 Lee BB, Simpson JM, Craig JC, Bhuta T (2007) Methenamine hippurate for preventing urinary tract infections. Cochrane Database Syst Rev 2007(4): CD003265 Lutters M, Vogt N (2000) What’s the basis for treating infections your way? Quality assessment of review articles on the treatment of urinary and respiratory tract infections in older people. J Am Geriatr Soc 48: 1454–61 Lutters M, Vogt-Ferrier NB (2008) Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women (Cochrane Review). Cochrane Database Syst Rev 2008(3) CD001535 Matthews SJ, Lancaster JW (2011) Urinary tract infections in the elderly population. Am J Geriatr Pharmacother 9(5): 286–309 McMurdo MET, Gillespie ND (2000) Urinary tract infection in old age: overdiagnosed and over-treated. Age Ageing 29(4): 297–8 Nazarko L (2005) Management of a patient with diabetes and hypotonic bladder. Nurs Times 101(47): 63–4 Nazarko L (2009) Urinary tract infection: diagnosis, treatment and prevention. Br J Nur 18(19): 1170–4 Nazarko L (2013) Solve the case: bothersome bladder symptoms. Nurse Prescribing 11(7): 338–43 Nicolle LE (2000) Asymptomatic bacteriuria in institutionalized elderly people: evidence and practice. CMAJ 163(3): 285–6 Perrotta C, Aznar M, Mejia R, Albert X, Ng CW (2008) Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev 2008(2): CD005131 Raz R, Stamm WE (1993) A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med 329: 753–6 Ruso TA, Johnson JR (2010) Diseases caused by Gram negative enteric bacilli. In: Kasper DL, Fauci AS eds. Harrison’s Infectious Diseases. McGraw-Hill Medical, New York Scottish Intercollegiate Guidelines Network (2012) Management of Suspected Bacterial Urinary Tract Infection in Adults: A National Clinical Guideline. Scottish Intercollegiate Guidelines Network, Edinburgh. http://www.sign. ac.uk/pdf/sign88.pdf (accessed 12 May 2013) Sundvall PD, Gunnarsson RK (2009) Evaluation of dipstick analysis among elderly residents to detect bacteriuria: a cross-sectional study in 32 nursing homes. BMC Geriatr 9(32): http://tinyurl.com/o52wygx (accessed 12 May 2013) Vogel T, Verreault R, Gourdeau M, Morin M, Grenier-Gosselin L, Rochette L (2004) Optimal duration of antibiotic therapy for uncomplicated urinary tract infection in older women: a double blind randomized controlled trial. CMAJ 170(4):469–73 Walker S, McGeer A, Simor AE, Armstrong-Evans M, Loeb M (2000) Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? A qualitative study of physicians’ and nurses’ perceptions. CMAJ 163(3): 273–7 Willacy H (2012) Recurrent urinary tract infection. Patient.co. uk. http://tinyurl.com/qcf5xxm (accessed 12 May 2013) Woodford HJ, George J (2009) Diagnosis and management of urinary tract infection in hospitalized older people. J Am Geriatr Soc 57: 107–14 Zalmanovici Trestioreanu A, Green H, Paul M, Yaphe J, Leibovici L (2010) Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database Syst Rev 2010(10): http://tinyurl.com/5rhglav (accessed 12 May 2013)
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