Implications of UTI in Geriatric Patients

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Introduction   

A urinary tract infection (UTI) is broadly defined as an infection of the bladder, urethra, or kidneys (CDC). Urinary tract infections are prevalent in older adults and constitute 25% of all infections in the elderly (4). UTIs are more common in older female clients than older male clients because females have shorter urethras, which permit easier passage of bacteria from the perineal area to the bladder (1, 4, 9). UTIs are prevalent in 20% of women over aged 65 compared to 11% in the general population (3).  

T-cell function and cytokine-mediated inflammatory responses decline with age, thus contributing to UTIs in older adults. The risk of UTI increases substantially in persons over age 85, and the infection is a substantial cause of mortality in older adults (3). 

UTIs cause almost 16% of hospitalizations and 6.2% of deaths in clients over 65 years of age in the United States (4). UTI is the most common infection in hospitalized older women and those living in long-term care facilities, and it is the second-most common infection in older women living in the general population (9).  

Recurrent UTIs cost the U.S. healthcare system $2B to $3B per year (9). UTIs have a detrimental effect on the client’s quality of life. 

Causes and Risk Factors 

Escherichia coli (E. coli) is the pathogen most responsible for UTI, accounting for 70% to 95% of cases (3). Staphylococcus saprophyticus is responsible for 5% to 20% of cases (3). Other responsible pathogens include Proteus mirabilis, Klebsiella, Citrobacter, Pseudomonas aeruginosa, and Enterococcus (3, 7, 10). These pathogens are found in fecal flora and contaminate the periurethral area; they then ascend the urethra to the bladder and kidneys, resulting in UTI and pyelonephritis (CDC). Candida is another causative organism that is prevalent in long-term care residents, diabetics, and older adults who are immunocompromised and/or have an indwelling catheter (10). 

The presence of bacteria in the urine is bacteriuria, and asymptomatic bacteriuria (ASB) is when bacteria is present in the urine, but it doesn’t create any symptoms. ASB is often confused with UTI, especially in older adults, leading to an increase in unnecessary antibiotic treatment, one of the catalysts for multidrug resistant organisms (3, 4, 9). 

The risk factors for UTI are different for older adults than younger individuals, and the incidence of clinically diagnosed UTI increases with age (3, 9). However, history of UTI is a common risk factor in all age groups (9). Clients with a previous history of symptomatic UTIs have an increased risk for future UTIs by as much as seven times versus those with no prior history of symptomatic urinary tract infections (9).  

Risk factors for UTI in older adults include (2, 4, 7, 8, 9): 

• Hypertension 

• Renal stones 

• Liver disease 

• Diabetes, cancer, autoimmune disorders 

• Dementia, stroke, Parkinson’s disease, cognitive deficit 

• Estrogen deficiency (especially in postmenopausal women) 

• Prostatic hypertrophy 

• Indwelling urinary catheter 

• Increased body mass index 

• Gynecological disease in females 

• Nosocomial pathogens 

• Institutionalization (assisted-living, long-term care, rehabilitation facilities) 

• Inability to void completely 

• Anatomical abnormalities 

• Decreased pelvic floor muscle tone, prolapse (in women) 

• Sexual intercourse; anal intercourse 

Signs and Symptoms 

Older adults may not display the typical signs and symptoms of UTI, and contrary to previous belief, mental status changes alone do not accurately identify UTI in this population. However, mental status changes in conjunction with urinary symptoms can indicate UTI in older persons (4). In long-term care facilities, client falls are often considered a reason for urine testing, but the association of falls with UTI is controversial (4). 

Signs and symptoms of UTI in the geriatric population include (1, 2, 3, 4, 7, 9): 

• Dysuria 

• Nocturia 

• Hematuria 

• Urinary frequency 

• Urinary hesitation 

• Urinary urgency 

• Confusion, delirium 

• Increased lethargy 

• Anorexia, nausea, vomiting 

• Fever, chills 

• Suprapubic pain 

• Reduced mobility 

• New onset incontinence 

• Decreased activities of daily living 

• Urine that is cloudy to the naked eye and/or has a foul odor 

When the nurse assesses an older client’s urine sample, it is important to note that cloudy urine can be aseptic, and cloudiness can be due to the presence of protein not indicative of infection (1, 4).  

Assessment and Diagnosis  

Undiagnosed UTI can lead to sepsis and renal failure. UTI diagnosis in all clients over age 65 is based on a thorough client history, including previous UTI, symptoms, risk factors, medications, vital signs, diet history (including hydration), and abdominal examination (3). A urinary sample is used in conjunction with client history and clinician assessment in determining UTI. 

The diagnostic criteria for UTI are listed below (3, 4, 9). 

1. Clinical symptoms of urinary tract infection, such as urinary frequency, dysuria, flank pain, suprapubic pain, fever, and malaise, or acute onset of non-specific symptoms of infection are present. 
2. Laboratory findings of pyuria and bacteriuria based on urine culture. Urinary pathogen presence greater or equal to 105 colony-forming units/mL in a freshly voided midstream urine specimen confirms UTI. Additional criteria may include: 
   1. Two (no more) species of organisms identified on urine culture 
   2. Pyuria of greater than 10 white blood cells/mm3 per high-power field 
   3. Growth of greater than or equal to 103 colony forming units/mL of a urinary pathogen on urine culture in clients with a catheter-acquired UTI 
3. Fever, increased white blood cell count, or increased c-reactive protein count that indicates systemic inflammation are criteria. 
4. The absence of another infection or non-infectious process in the client can indicate urinary tract infection. 

A bacterial count of 105 CFU/mL is significant for bacteriuria, but lower counts can also indicate UTI in clients with symptoms. In older adults, bacteriuria is not always considered an abnormal finding, so UTI should not be diagnosed based on urine culture only (4). Urine culture should only be performed in older adults when the client has acute urinary symptoms that are synonymous with a UTI, or when the client is not able to provide an accurate history of acute urinary symptoms, but the client has symptoms of systemic inflammation that are not attributable to any other cause (4). 

It is also important to note that up to 50% of older adults and roughly 100% of clients who have an indwelling catheter for more than one month have tested positive for bacteria in the urine that has not caused infection (7). Treating asymptomatic bacteriuria in older adults can cause Clostridioides difficile and antimicrobial resistance (AMR). 

UTI can also be confirmed via positive blood culture when other sources of infection are not recognized. Positive blood culture is indicative of a high burden of infection, which can cause mortality in older adults. These cultures can confirm UTI in older adult clients who are at risk of contaminating urine samples, and the cultures can help clinicians decide whether to perform computerized tomography (CT) or other diagnostic tests (4, 10).  

If the client has not improved after 48-72 hours of antibiotic therapy, ultrasound and computed tomography of the renal tract is warranted. Clients with a history of obstruction due to renal or ureteric calculi and/or who have ureteric stents may also require image tests (4). If the client has chronic obstruction or chronic urinary incontinence, CT intravenous pyelography and urodynamic evaluation of the bladder may be necessary. 

Urine dipstick testing in not reliable in identifying Gram-positive bacteria, Enterococci, or Pseudomonas in older adults because these microorganisms do not reduce urinary nitrates to nitrites. The urine dipstick nitrite test will not test positive for these organisms, making them an unreliable diagnostic tool (4).https://onlinelibrary.wiley.com/doi/10.1002/jppr.1650 Using urine dipsticks in older adults is not recommended since a positive result can be triggered by asymptomatic bacteriuria (3, 7). 

Treatment 

UTI is the second most frequent reason for the prescription of antibiotics, with 50% of these prescriptions believed to be unnecessary (3). Over-prescription of antibiotics can lead to antimicrobial resistance (AMR), a global healthcare issue according to the World Health Organization (3, 11). The World Bank estimates that AMR could be the catalyst for a loss $3.4M trillion in gross domestic product by 2030, and $1 trillion in healthcare costs by the year 2050 (11). 

Broad-spectrum antibiotics can be initiated in geriatric clients with UTI, but these medications should be switched to narrow-spectrum antibiotics once the causative organism is identified (10).  

The following table details the medication treatments for urinary tract infection (4, 5, 7, 10). 

The second-line medications should only be used if the client has an allergy or resistance to the first-line treatments, or if the first-line medications are not available (5). Antimicrobial treatment is used for symptomatic UTIs, but it is not appropriate to treat asymptomatic UTIs. 

A decrease in estrogen is associated with several conditions that may promote recurrent UTIs in postmenopausal clients, such as urinary incontinence, vesical prolapse, cystocele, and post-void residue. Because of this, estrogen therapy has been used in postmenopausal women to prevent recurrent UTIs (9). 

Xyloglucan is a compound extracted from tamarind seeds that is used to restore the physiological function of mucosal epithelial cells. Xyloglucan provides a bio-protective film that prevents pathogens from making contact with mucosal cells and has been found to be effective in preventing UTI. Cranberry products prevent E. coli cells from adhering to the bladder wall due to proanthocyanidins contained in the cranberries, which also helps prevent UTIs (9). 

Complications and Prevention 

UTIs can cause serious complications, including urosepsis, which can be fatal (1, 10). Complicated UTIs are caused by a broader spectrum of bacteria than regular UTIs, and therefore have a higher risk of clinical complications (10). Recurrent infections, immunosuppression, dementia, and prostatectomies are the cause of complicated UTIs in older adults. 

To prevent UTIs, nurses should teach older adults to (1, 2, 6): 

• Shower instead of taking baths 

• Perform hand hygiene practices 

• Void completely when urinating 

• Void when the urge to urinate is felt 

• Void as soon as possible after sexual intercourse 

• Use a heating pad on the back or abdomen to ease pain 

• Implement a toileting schedule that includes frequent voiding 

• Report symptoms of fever, hematuria, flank pain, cognitive changes 

• Wear cotton underwear and loose-fitting clothing to reduce moisture 

• Drink plenty of fluids and eat high water content foods to stay hydrated 

• Take prescribed medications as indicated and do not share the medications with others 

Nurses should teach clients the side effects of antibiotics, including nausea, diarrhea, rash, dizziness, and yeast infections (2). Clostridioides difficile infection is a serious side effect of antibiotics that can lead to severe colon damage and death (2). 

Conclusion

Urinary tract infection in older adults can cause serious health complications, including sepsis and death. UTI is the second most frequent reason for antibiotic prescription, which has led to the global healthcare crisis of antimicrobial resistance that costs the world trillions of dollars in economic losses. It is important that nurses take a thorough client history and assess for signs and symptoms of UTI instead of relying on urinalysis alone when caring for older adults with urinary tract infection. 

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