Transcript Urinalysis in the Elderly

Urinalysis in the Elderly
The Good: The Bad: The Ugly
Can I Get a UA
● Mr. Smith is confused
● Mr. Jones fell
● Mr. Walker is not acting like his normal self
● Miss Foy is not eating well today
● Mrs. Weber’s urine is dark or cloudy
● etc
When to Order A Urine C&S
● Must have S/S of UTI
○ Increased frequency or urgency
○ Burning with urination
○ Fever
○ Flank Pain
○ Gross Hematuria
Urine C&S
● Should be ordered when it would affect Clinical Care
Interpretation of Analysis
Appearance cloudy
Leukocytes Esterace 1+
Blood 2+
UA Microscopic
WBC > 50
RBC 10-20
Occasional Bacteria
Microbiology Criteria
● At least 10 5th cfu/ml of no more than 2 organisms in
voided sample
● At least 10 2nd of any number of organisms in a specimen
collected by the in and out catheter
Minimal Inhibitory Concentration (MIC) Interpretation
● Susceptible
○ Strain can be treated with conventional antibiotics
● Intermediate
○ May work but the response may be reduced
● Resistant
○ Not work
Urine CX Results
Klebsiella Pneumoniae > 100,000
Antibiotic
MIC
Interpretation
Ampicillin
>= 32
R
Cefazolin
<=4
S
Cipro
<=0.25
S
Nitrofurantoin
32
S
UA
● Appearance
● Leukocyte Esterase
Cloudy
2+
● Nitrites
● Microscopic
○ WBC
> 50
○ Bacteria
Rare
C&S
● E Coli
● Antibiotic
Interpretation
MIC
● Ampicillin
S
<= 2
● Cefazolin
S
<= 4
● Cipro
<=0.25
UA
● Appearance
Turbid
● Leukocyte Esterase
3+
● Protein
+1
● Blood
+2
● Microscopic
○ WBC
○ RBC
> 50
5-10
Asymptomatic Bacteriuria
● Pt does not have SXS, but presence of bacteria in urine
micro or cx
● Confirm in 2 consecutive samples?
● Transient in older people
● Not associated with increased mortality or morbidity
● More common in cognitively impaired people
● Increased in patients with incontinence and impaired
bladder emptying
Do Not Screen
Do Not Treat
Urinary Tract Diagnosis
● Dx is made with both clinical features and lab evidence
● At least two sxs of the following
○ Acute Dysuria
○ Increased frequency or urgency
○ CVA tenderness
○ Suprapubic tenderness
● No more than 2 pathogens
● Pyuria
○ Leukocytes > 10 mm 3rd
○ Fever
Confusion is NOT a Urinary Tract sign or
symptom
Patients Not Meeting Criteria
● Perform a thorough systemic evaluation and assessment
● Differential Diagnosis
● Reassess
Current Guidelines
● The American Geriatric Society
○ Does not recommend antibiotics to treat bacteriuria
unless specific urinary tract sxs are present
McGeer Criteria Without a Catheter
● Must include criteria from both 1 and 2
○ 1). At least one of the following
■ Fever or Leukocytosis
○ 2). And at least 1 of the following
■ Acute CVA pain or tenderness
■ Suprapubic pain
● New or marked increase in urgency
● New or marked increase in frequency
● In the absence of fever or leukocytes: Then must have
2 from the above list
Loeb Criteria
Long Term Care Facilities
● Acute dysuria alone
● Fever 37.9 or .5 degrees above baseline and at least one
of the following
● New or worsening
● Urgency/Frequency/Incontinence
● Suprapubic Pain/ CVA tenderness
Complicated VS Uncomplicated
● Uncomplicated
○ Does not include the elderly
● Complicated
○ Elderly
○ Functional or structural abnormality in urinary tract
Antibiotic Stewardship
● Urine CX aids in narrowing the spectrum of antibiotics when you choose to treat
● Most common bacteria is ??
○ Know local resistance rates
● Risk VS Benefit
○ Side effects
○ Increased antibiotic resistance
Treatment Failure VS Reinfection
● Reinfection
● Treatment failure
Recurrent UTI Risk Factors
● Diabetes
● Functional Disability
● Sexual Intercourse
● HX of urological problems
● Urinary Retention or incontinence
● Postmenopausal Estrogen Deficiency
Prophylactic Antibiotic
● When to use
○ 2 or > UTI in 6 months
○ 3 or > UTI in 1 yr
● What to choose?
UTI Reduction
● Increase Fluids
● Routine Post Bathroom Care
● B/B training every 2 hrs during the day and every 4 hrs at
night
● Cranberry capsules still controversial
The Good
● UTI
○ Treat and patient feels better
● Prevent Urosepsis
The Bad
● Side effects
● Medication compliance
● Cost
The Ugly
● Clostridium Difficile
○ Antibiotics
○ Isolation
○ Diarrhea
○ Weakness etc
● Urosepsis
● Increased antibiotic resistance
Take Home Points
● UTI is commonly overdiagnosed and therefore
overtreated. Contributing to antibiotic resistance
● No sxs present do not test
● Educate staff and families
● Confusion is not a sxs of UTI
Questions?
Thank You