Transcript How to Manage UTI in the Elderley and Systemic Disease

UTI in
Elderly and
Systemic Disease
ewha univ. hosp.
shim, bongsuk
How to Manage UTI in the Elderly
Aging & Infection
UTI in the Elderly
Recurrent UTI
Asymptomatic Bacteriuria
CAUTI
Impact of Aging on Infections
Aging increase risks of infection
Immune changes
 drops with age
Organ changes
 skin ; decrease protection
 bladder ; changes to increase UTIs
Age-related diseases
 cancer, diabetes, dementia, voiding dysfunction, etc
Physiologic changes
 hospitalized, institutionalization, medical procedures
Department visits by Elderly
Drach GW. AUA Update Series Vol 24 Lesson 33 2005
Infectious Disease in Elderly
Yoshikawa TT. J Infect Dis 1997
UTI in the elderly
extremely common
most frequent infection among infectious
diseases in the elderly
risk factors for developing UTIs
 dementia, incontinence, decreased mobility
asymptomatic bacteriuria is common
 15-30% in men
 25-50% in women
Factors Associated with UTI
men
BPH
Prostate Ca
Prostate stone
Urethral stricture
Etc.
both
Coexisting diseases
Diabetes mellitus
Cerebrovascular accidents
Dementia
Increased hospitalizations
Instrumentation
Urinary catheters
Alterations of immunity
women
Changes in bladder
Introital G(-) bacteria
colonization ↑
Vaginal glycogen ↓
Vaginal pH ↑
Kunin CM. 1987
Underlying Dis. in complicated UTI
Causative Organisms of UTI
Escherichia coli
 most common, 60~70%, but relatively low rate
Proteus mirabilis
Klebsiella pneumoniae
enterococci
 more common than younger people
Pseudomonas aeruginosa
 leukemia, aplastic anemia, after GI tract manipulation
Staphylococcus
 rarely in elderly
Melani PN. Clin Geriatr 2005
Clinical Presentation
classic symptoms
 dysuria, frequency, urgency
 absent, masked or difficult to assess
 only 20% with new urinary symptoms
upper UTI
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confusion (delirium), lethargy, agitation, collapse
15%, no fever and no leukocytosis
deteriorate more rapidly from infection
bacteremic UTI in the elderly
often present respiratory symptoms, treated as ‘Pneumonia’
Barkham, et al. Age & Ageing 1996
Diagnosis
history
physical examination
laboratories
 urinalysis ; 5-10 WBC/HPF
 urine culture & sensitivities ; >105 CFU/mL
may diagnose acute uncomplicated cystitis
based on history, P/E, and U/A alone,
no need for culture to treat
Therapy with Antibiotics
3-day course for simple acute cystitis
7-day course
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complicated by hospitalization
instrumentation of the urinary tract
diabetes
immunosuppression
failure of previous therapy
more than three infections in the previous year
symptoms lasting over 7 days
Hooton TM. Med Clin North Am 1991
Stamm WE. N Engl J Med 1993
Antibiotics for UTI
Adverse Effects of Antibiotics
Melani PN. Clin Geriatr 2005
Acute Pyelonephritis (1)
atypical clinical presentation
 fever, confusion, lethargy, nausea and vomiting
 often of little help in the diagnosis
 15%, no fever or no leukocytosis
Laboratories
 three sets of blood cultures and one urine culture
Radiographic studies for urinary tract
 obstructive uropathy, calculous disease or abscess
 IVP, ultrasound or CT
Acute Pyelonephritis (2)
Treatments
hospitalization : bed rest, adequate hydration,
symptomatic care
aminoglycoside (amikacin, gentamicin, tobramycin)
+ cephalosporin IV for 5~7 days
oral antibiotics for more 2 weeks
no response after 2-3 days : re-evaluation
Follow-up
repeat UC at least 6 months after treatment
Preventing Recurrent UTI
Increased fluid intake
 no evidence, but it may be helpful
Antibiotic prophylaxis
 useful if >3 symptomatic UTIs/year
 risk of resistant organisms
Topical estrogen
 improves atrophic vaginitis
 encourages lactobacilli growth
Cranberry juice
Asymptomatic Bacteriuria
> 105 CFU/mL on 2 consecutive occasions
no UTI symptoms
more common
 in institutionalized or hospitalized patients
prevalence
40 ~ 60 y.o
ambulatory population
65~80
y.o
Men
Women
0.1%
5.0%
6%
18%
nursing homes
23%
hospitals
32%
over 80 y.o
21%
25~50%
Abrutyn E, et al. J Am Geriatr Soc 1988
Clinical Significance of
Asymptomatic Bacteriuria
in the past
 increased mortality
 routine treatment
Nordenstam GR, et al. N Engl J Med 1986
no direct causal association with mortality
rare proceeding to symptomatic UTI
not recommend routine screening and
treatment
Baldassarre JS. Med Clin North Am 1991
Kunin CM, et al. Am J Epidemiol 1992
No Screening for or Treatment of
Asymptomatic Bacteriuria
pre-menopausal, non-pregnant women
diabetic women
older persons living in community
elderly institutionalized subjects
persons with spinal cord injury
catheterized patients while the catheter
remains in situ
Boscia JA, et al. JAMA 1987
Nicolle LE, et al. Am J Med 1987
Abrutyn E, et al. J Am Geriatr Soc 1988
Screening for or Treatment of
Asymptomatic Bacteriuria
pregnant women
suspicious obstructive uropathy
before TURP
before urological interventions
before prosthetic device
 hip or cardiac valve
Nicolle LE, et al. Am J Med 1987
Abrutyn E, et al. Ann Intern Med 1994
Catheter associated UTI
incidence
 27% under 65, 52% over 65
 10-15% of hospitalized patients with indwelling
catheter develop bacteriuria
 3-5% per day of catheterization
 one-time catheterization ; 2% bacteriuria
gram(-) bacteremia
 most significant complication of CAUTI
greater antimicrobial resistance
absence of symptoms  no treatment
Garibaldi RA. N Engl J Med 1981, Gleckman R. J Urol 1982
4,50대
세상에서
바로남자들에게
호랑이
제일 무서운
마눌님
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여자는?
입니다.
.
How to Manage UTI in the Diabetes
DM and infection
Immune System in DM
UTI in the Diabetes
Emphysematous Pyelonephritis
Common UTIs in DM
Infection and DM
 higher
of incidence of infection
 complication & death - more frequent
 specific immunologic defects
 the risk factors of infection and resulting
complication
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duration of illness
severity of non-infectious complications
concurrent illnesses
level of glucose control
degree of medical supervision
Seymour A. Med J Aust 1963
Robbins SL. N Engl J Med 1994
Pathogenesis of Renal Failure in DM
Diabetes and the Immune System (1)
 function
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of PMN leukocytes
depressed chemotactic index – diminished response
diminished phagocytosis
diminished bactericidal activity
Mowat AG. N Engl J Med 1971
Molenaar DM. Diabetes 1976
 monocyte
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
function
decreased circulating monocytes
impaired monocyte chemotaxis
Geisler G. Acta Pathol Microbiol Immunol Scand 1982
Hill HR. Clin Immunol 1983
Diabetes and the Immune System (2)
 cell-mediated
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immunity
decreased the transformation of lymphocytes
decreased mitogenic response
diminished release of migration-inhibition factor by
T lymphocytes
MacCuish AC. Diabetes 1974
Casey JI. J Infect Dis 1987
 miscellaneous
factors
abnormalities in the microvascular circulation
 decrease tissue perfusion
 impair response to therapy
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McMillan DE. Mayo Clin Proc 1988
Infectious Diseases in DM
 Infections
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Mucormycosis
Malignant external otitis
Emphysematous Pyelonephritis
Emphysematous Cholecystitis
 Infections
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strongly associated with diabetes
possibly related to diabetes
Urinary tract infections
Fungal infections
Staphylococcus aureus infections
Soft-tissue infections
Tuberculosis
UTI in the Diabetes
 UTI
more common
 more serious infections
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increased risk of complicated pyelonephritis
 asymptomatic
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bacteriuria is common
cleared bacteriuria in short term
but did not decrease number of symptomatic
episodes or hospitalizations
does not reduce complications in diabetes
Harding, NEJM 2002
Common UTIs in DM
 Emphysematous
 Renal
pyelonephritis
or perirenal abscess
 Papillary
necrosis
 Xanthogranulomatous
 Fourniere’s
pyelonephritis
gangrene
 Staphylococcus
bacteremia
Emphysematous Pyelonephritis (1)
 85-100% of patients ; associated
Michaeli J, et al. J Urol 1984
Zebbo A, et al. Urology 1985
with DM
 10%
of patient ; bilateral involvement
 glucosuria providing a substrate for
production of gas by fermentation
 causative
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organisms
E. coli, Klebsiella pneumoniae, Proteus mirabilis,
Enterobacter aurogenes
Candida species
Emphysematous Pyelonephritis (2)
 Therapy
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potent antibiotics, for several weeks?
relieve any obstruction
undertake percutaneous drainage
consider nephrectomy if clinical improvement does
not occur
 mortality
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rate
medical : 75%, surgical : 23%
Lowe FC & Walther JM. Urology 1986
Renal Abscess
 twice frequency in DM
Saiki J, et al. West J Med 1982
Plevin SN, et al. J Urol 1979
 Pathogens
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E. coli, Klebsiella, Proteus
 Treatment
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antibiotic therapy alone ; resolve
prompt drainage ; no clinical improvement within a
few days, large collection, obstructive uropathy
open incision and drainage ; no response to closed
drainage
Perinephric Abscess
 DM
; major contributing factor in perinephric
abscess
 14-75% of perinephric abscess ; DM
Patterson JE. Infect Dis Clin North Am 1987
 no
symptoms resolving for pyelonephritis
within 4-5 days
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prompt radiologic evaluation – CT scan
 Treatment

drainage in combination with a prolonged course of
antibiotics
Renal Papillary Necrosis (1)
 Brauner
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DM increase risk of renal papillary necrosis
patients with proteinuria in DM ; more infected with
P-fimbrated strains of E.coli
 suspect
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A. Diabetes Res 1987
of renal papillary necrosis
frequent relapsing or difficult-to-eradicate
pyelonephritis
fulminant presentation of pyelonephritis,
accompanied by hematuria
more than 3 times UTI ; higher risk of papillary
necrosis
Renal Papillary Necrosis (2)
 30-50% of papillary necrosis
Mujais SK. Semin Nephrol 1984
; DM
 Treatment
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eradication of infection ; intensive antibiotics
catheter drainage or PCN for obstruction and
pyonephrosis
appropriate duration of antibiotics ; not clearly
established
nephrectomy
Fungal Urinary Tract Infection
 Candida albicans, Candida
Roy JB, et al. Urology 1984
 predisposing
glabrata
condition
 use of antibiotics, indwelling urinary catheter
 role of DM

not clear precisely
 Treatment

fluconazole orally
Fournier’s Gangrene
 subclassification
of necrotizing fasciitis
around the male genitalia
 often in combination with DM, 40%
 bacteria
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a mixture of gram-negative bacteria, anaerobes,
streptococci
 treatment
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wide surgical debridment of devitalized tissue
 mortality
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rate
40-50% even with aggressive management