Mohammad Eid Alshalat


Correspondence:
Dr: Mohammad Eid Alshalat
Clinical associate, Geriatric medicine
HHCS Qatar, Doha
Email: drmohammad531@yahoo.com

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Introduction
Urinary tract infection ( UTI) : By definition urinary tract infection, or UTI, means any infection that can affect any part of the urinary tract, which involves :
1- Kidneys:
2- Ureters -- the tubes that take urine from each kidney to the bladder.
3- Bladder.
4- Urethra -- the tube that empties urine from the bladder to outside.
Or can be defined: is the presence of pathogenic bacteria in the urine, urethra, bladder, kidneys or prostate. The Public Health Laboratory Service uses the criteria of 10 bacteria which are present in the urine for a diagnosis(1)


Figure 1: anatomical urinary tract system.

Urinary tract infection (U T I) , & lower respiratory tract infection (LRTI) are the most common problems in the elderly. Sometimes there is misdiagnosis between those two problems, and a lot of elderly patients are diagnosed as having LRTI or UTI or even both but these diagnoses are not confirmed.

The most important cause for this problem is that many elderly patients are unable to give a definite clinical history suggestive of LRTI or UTI, because they are often confused at the time of presentation. In such conditions the correct diagnoses are the corner stone in the management .This required a good clinical examination and investigation, to differentiate between these two problems.

Urinary tract infections are very common problems in general practice in all age groups, but it is more common in elderly people, with a prevalence of approximately 20% in women over 65 years old. Women have a greater prevalence than men, but the trend to increase prevalence with age in over 65 year olds is greater in men(2). This may be contributed to by many factors:

1. Immunosuppression.
2. Underlying chronic medical illnesses like DM,HTN.RF
3. Urinary and fecal incontinence.
4. Depressed mental state like dementia, delirium.
5. Associated use of devices such as urinary catheters and nasogastric tubes.
6. Medications that suppress the immune system or the central nervous system (polypharmacy).
7. Advanced age.
8. Factors that promote person-to-person transmission such as crowding and sharing of meals(3).
9. Mechanical changes involving the bladder and urethra, such as increased post void residual urine, or that allow bacterial attachment .
10. Prostatic enlargement in men .
11. Decreased estrogen in postmenopausal women.
12. Not drinking enough fluids(4).

The diagnosis of UTI in adult patients depends on the history and the physical examination. The most common signs and symptoms of UTI are fever and/or chill, dysuria (burning sensation of urine), pyuria, frequency, urgency, Hematuria Colicky pain and incontinence. Cloudy urine, foul or strong urine odor, pressure in the lower pelvis.

Diagnosis of UTI in confused elderly patients or those who cannot express themselves is usually very difficult , and sometimes may present in different ways; that is the signs or symptoms are not related, like a patient who presented with hallucination, disorientation, agitatation.

The most important challenge for physicians in long term care setting is that under what conditions can they give antibiotic as a treatment for possible UTI in case of acute behavioral changes of demented patients or those who cannot report classical symptoms of UTI , which can help in making possible diagnosis.

In practice some demented elderly patients present with acute behavioral changes like agitation; most of them febrile. Those patients showed a significant improvement when they were treated for UTI with antibiotic.

The perfect management of UTI in elderly patients is very important, because it considers a serious infection and carries a big chance for severe complications. UTI in elderly patients usually differs significantly from that which occurs in the general population, in its etiology, clinical signs & symptoms, and treatment.

Definitions
1. Urinary tract infection means presence of pathogenic bacteria in the urine, urethra, bladder, kidneys, or prostate.
2. Recurrent UTI - Repeated episodes of infection (three or more/year) by different causative microorganism.(5)
3. Relapse - Repeat UTI with the same strain of microorganism within two weeks. This can be called failure of the treatment.
4. Bacteriuria is presence of bacteria in urine revealed by microscopy or by quantitative culture. Significant Bacteriuria equal to or more than 105 cfu/ml of a single bacterial species in a freshly voided specimen of urine.
a-women with symptomatic UTI > 102 cfu/ml .
b- men > 103 cfu/ml (if 80% of the growth is due to a single organism).(6)
5. Asymptomatic bacteriuria means presence of bacteria in the urine with no signs or symptoms, discovered microscopically in sample taken from patient's urine or by urine culture.
6. Bacteraemia means presence of bacteria in the blood and it is diagnosed by blood culture.
7. Empirical treatment of UTI is a treatment based on clinical symptoms or signs unconfirmed by urine culture.
8. Haematuria: it is presence of blood in the urine either visible (macroscopic haematuria) or invisible (microscopic haematuria) .
9. Catheterization: an indwelling catheter is inserted through urethra or suprapubic temporarily or permanently.
10. Short term catheter is an indwelling catheter left in place for 1-7 days.(7)
11. Long term catheterization is an indwelling catheter left in place for more than 4 weeks.
12. Pyuria : means number of white blood cells (WBC)/ml equal or more than (104 cells ) per milliliter of urine freshly voided.
13. Asymptomatic, abacteriuric patients: that means Pyuria without bacteriuria and this is most likely due to a foreign body, like urinary catheter, stones or neoplasms of urinary tract, lower genital tract infection.
14. Dysuria : means painful urination, or burning or stinging sensation and it is sometimes described as difficulty of urination. This is the most common symptom of lower UTI(8).

Goals of the study
In this proposal we will try to focus / on urinary tract infection to old age patients who live in their houses under home care services.

1 To determine the prevalence of urinary tract infection of the geriatric patients .
2 To identify the possible underlying risk factors which may be related, to cause UTI.
3 To recognize the most common organism.
4 To determine the most appropriate antibiotic for these organisms.

Epidemiology
PLACE: QATAR / DOHA/ HOMECARE
PATIENTS NUMBER: 614
DATE: 1stseptember 2010- 1st september2011
METHOD OF COLLECTION DATA: PATIENT FILES AND/ OR MEDICOM.
DURATION: 6 MONTHS
Collection data started at October 2011 retrospectively
For last year (1st September - 1st September 2011).

Total patients under home care for this period was614 patients, most of them were old age.

The ages were between 14-107 years.
67 patients aged between 14 -59 = 12.24%
547 patients aged between 60-107 = 87.76%


Figure 2: Distribution of patients according to age

Third paragraph explains the distribution of patients according to their genders.
Total number of patients : ( 614)
Male patients : ( 212)
Female patients : (402 )


Figure 3: distributed patients according to gender

In this diagram we will try to show the distribution of patients according to their nationalities.

Figure 4: patients according to nationality

Methods
We traced electronic medical records and patients' files during last year to collect these data. We depended on result of urine culture and urine analysis.

Results and Statistical Analysis
During data collection we found a lot of valuable things.
Here we will mention the most important findings :
A : None of total number of patients suffered from UTI 131.
Two (2) patients were on intermittent catheter.
Three(3) patients were on condom catheter.
Five(5) patients were on suprapubic catheter.
Twenty nine(29) patients on Foley catheter.
Total catheterization patients had UTI ( 38 ).
This / means that 29% of total no. of UTI patients.

This means as we mentioned above, catheterization considered as an important risk factor for UTI, and increases the chance of infection.

All chronic catheter users have bacteriuria. Its treatment does not improve mortality or morbidity but does increase the risk of antibiotic-related side effects and the development of infection with resistant organisms .(9)

Figure 5: catheterization patients

B : Causative microorganism :
a- E coli , it was the most common microorganism
(57 patients ) i.e 42.5% of total patients who suffered from UTI .
b- 2nd common causative organisms :
They were
1- pseudomonas aeruginosa.
2- klebseilla ssp.
3- enterococcus feacalis.
These three organisms affected 36 patients.

About 27.27% of UTI patients. (12) had all of them.

These microorganisms form about 70% of total patients suffering from UTI in this study. This is supported by A retrospective analysis of urine culture results issued by the microbiology department, Teaching Hospital, Karapitiya(10)

The common etiological agents are Escherichia coli, Pseudomonas spp., Proteus spp., Klebsiella spp. and Enterococcus spp.

c- Mixed growth : 16 urine samples of patients showed mixed growth.
d- No growth : 7 urine samples showed no micro organism had been found .
e- fungal infection especially candida ssp plays a role in this problem
Candida ssp grows from 7 urine samples that had been taken from patients. All of them females
f- the rest of causative organisms varied (5 patients) acitinebacter buammanii,
Citrobacter koseri' & streptococcus feacalis , are affected (2 patients) for everyone of them.
g- others : (3 patients) other organism.


Figure 6: organism found in urine culture samples.

C : In the table below we choose more common causative organisms of UTI. and sensitivity and resistance.
(E COLI , KLEPS ssp , ENTEROCCOCUS feacalis, PSEUDO MONAS aeruginosa)

These organisms form around 70% of cases.

1st a- Ecoli (54 cases) 53 cases of them sensitive to nitrofurantion, only one case is resistant.
28 cases (50% of cases) sensitive to septrin, 22 of cases (40%) sensitive to Tazocin.

b- 32, 34, 38 cases, ie about (60% - 70% of cases) are resistant to (cephalothin augmentin, ampicillin) respectively.



2nd (12 cases) of pseudomonas aeruginosa , 100% of them are sensitive to Tazocin & ciprofloxacin .

3rd ( 12 cases) of enterococcus feacalis , (8, 9 of them) are sensitive to ciprofloxacin & ampicillin respectively .

4th (12 cases) of klepseilla ssp, (6, 7, 8) are sensitive to ciprofloxacin Nitrofurantion & augmentin respectively

F: 62 patients suffered from recurrent UTI (relapse 10 cases) .
G : -in 53 patients WBC in blood increased
(10.700- 31.000) 4 cases showed decrease in no. of WBC less than normal.
H : only 62 urine analyses had been done, 64.51 % of them support the diagnosis of UTI .

I : This slide will show us percentage distribution of males to females suffering from UTI:
1- 39 male patients suffered from UTI, this means that 18.39% of total No. of male patients,
2- 92 female patients suffered UTI , this means that 22,88 % of total No. of female patients.

*Women suffered with UTI more than men; this fact has been proved by a lot of studies, but the causes are still not clear

J : The most antibiotics used in the treatment of UTI were as following:

Summary
• The prevalence of resistant bacteria causing urinary tract infection (UTI) from antimicrobials has increased in the last decades especially in elderly patients in the community.
• Patients in long-term care facilities, are more liable to develop this problem than others .
• Resistant bacteria isolates include common uropathogens, such as Escherichia coli and organisms with higher levels of intrinsic resistance, such as Pseudomonas aeruginosa(13).
• It is essential to send urine specimens for culture and susceptibility before starting antimicrobial therapy. This gives the clinician a chance to select specific antimicrobials for causative organisms and avoids empirical therapy which is usually broad-spectrum antimicrobial.
• Antimicrobial therapy should be avoided unless there is a clear clinical indication.
• Generally speaking asymptomatic bacteriuria should not be treated with antimicrobials.
• In case empirical therapy is essential, before isolated organisms recent antimicrobial therapy is the drug of choice until result of culture is availiable .
• Within ( 48- 72 hours) empiric therapy must be reassessed.
• UTI is commonly over diagnosed and over treated on the basis of nonspecific clinical signs and symptoms .(14)
• Urinary tract infections are a very common presentation in general practice in all age groups, with or without catheters(15),
• The risk of infection will be increased if there is any urological problem like abnormal structure of the urinary tract
• Incomplete bladder emptying and urinary stasis increases the incidence of bacteriuria especially with increasing age and disability.(16)
• A high percentage of patients with indwelling catheters (IDC) acquire bacteriuria each day even with the application of best practice for insertion and care of the catheter.
• In general, acute uncomplicated lower UTI is usually due to one organism like Ecoli, or streptococcus ssp ( 90-95%)(17)
• In patients with repeated infection, instrumentation or recent hospitalization, MDRO must be suspected.(18)
• All patients with long-term catheters are bacteriuric with urine samples and usually positive for two or more organisms.
• Urinary tract infections (UTI) are the most common infections acquired in hospitals and long-term care facilities. Early studies estimate the incidence of healthcare associated UTIs at around 2-3 patients per 100 admissions and this is supported by the more recently published Plowman Report. (Plowman et al, 1999)(19)
• Recently a number of risk factors for healthcare associated UTI have been established. The most important predisposing factor for healthcare associated UTI is the presence of an indwelling urethral catheter, and chronic medical problem like DM (70 patients of 131) as shownin our research .
• In elderly women (over 65 years of age), treatment of asymptomatic bacteriuria does not reduce mortality or significantly reduce symptomatic episodes. so no need to treat these cases.

Prevention
1- Drink plenty of water is an important prevention strategy.
2- Wipe from front to back.
3- Keep genital area clean and dry.
4- Do NOT drink fluids that irritate the bladder, like alcohol and caffeine.
5- Drink cranberry juice or use cranberry tablets, but NOT if you have a personal or family history of kidney stones(20).
6- Use of low-dose antibiotics like Nitrofurantoin 100mg once daily on a daily basis may be recommended to prevent UTIs if patient gets frequent infections.
7- A good control of DM and treatment of other chronic problems may play a role in decreased chance of getting UTI .
8- Frequent emptying of the bladder and prevention of congestion of urine is important to prevent growth.
9- Care giver must be able to pick up any changes in patient behavior.
10- Early treatment of symptomatic patients with UTI as soon as possible can be prevent more complications .

References
PHLS (2001) Management of infection: Guidance for primary care.
SCREENING FOR BACTERIURIA IN the elderly: A.Abyad, MD, MPH, AGSF Director, Abyad Medical Center &
Middle-East Longevity Institute Abyad Medical Center Tripoli-Lebanon
Uptodate subject UTI in elderly patients.
WEYTH.COM Urinary tract infection .
Scottish Intercollegiate Guidelines Network July 2006.
PHLS (2001) Management of infection: Guidance for primary care.
Scottish Intercollegiate Guidelines Network July 2006.
Scottish Intercollegiate Guidelines Network July 2006.
Diagnosis and Management of Urinary Tract Infection in Hospitalized Older People
Henry J. Woodford, MBBS, and James George, MBBS
Galle Medical Journal, Vol 13: No. 1, September 2008 .
Kidney infection in DM mahandeva santhakumar
Resistant Pathogens in Urinary Tract Infections) Lindsay E. Nicolle, MD JULY 2002-VOL. 50, NO. 7, SUPPLEMENT
Resistant Pathogens in Urinary Tract Infections) Lindsay E. Nicolle, MD JULY 2002-VOL. 50, NO. 7, SUPPLEMENT
Optimal management of urinary tract infections in older people Clin Interv Aging. 2011; 6: 173-180.
Published online 2011 June 22. doi: 10.2147/CIA.S13423
Scottish Intercollegiate Guidelines Network July 2006.
Uptodate subject UTI in elderly patients .
Harison edition 16 2005 page 1718 .
Harison edition 16 2005 page1718 .
(Plowman et al, 1999) .
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