Professional Documents
Culture Documents
older people
Urinary Tract Infection FREE
Janet M. Torpy, MD; Laura A. Schwartz, MS; Robert M. Diagnosis
Golub, MD
Clinical findings
JAMA. 2012;307(17):1877. doi:10.1001/jama.2012.3885.
In addition to a medical history and a physical complicated by the lack of typical symptoms and a clear
examination, your doctor may order a urinalysis, which
history. Up to one-third of elderly patients do not present
examines a urine sample for the presence of white blood
cells and bacteria. Urine may be sent for culture to see pyrexia in response to infection.12 The presence of
what kind of bacteria is present. If bacteria grow in the
specimen, those bacteria are then tested to see which kind cognitive impairment and communication difficulties can
of antibiotics will be most effective. A blood count and
blood chemistries may be ordered, especially if fever is make it difficult to obtain an accurate history. Many
present or there are signs of a serious infection, such as older patients have chronic genitourinary symptoms and
when UTI affects the kidneys (pyelonephritis).
it is important to recognize that this is not synonymous
PREVENTION AND TREATMENT
with infection.8
A 3-day course of antibiotics is sufficient to treat
most UTIs.
Many clinicians incorrectly attribute factors such as
For individuals who have recurrent UTIs (3 or functional decline, increased confusion, and nonspecific
more per year), drinking lots of fluid is important
to maintain good urine flow. signs and symptoms to urinary tract infections and start
Urinating after sexual intercourse may reduce the treatment on this basis.2,13,14 In the absence of clear
risk of UTIs, especially when the UTIs often occur
urinary tract localizing symptoms and signs, older
after sexual activity.
patients should be systematically assessed with a full
The use of spermicide foams for birth control can
increase the risk of UTIs, so women who have clinical evaluation performed to arrive at a differential
recurrent UTIs may want to use a different form of
contraception. diagnosis.2
In postmenopausal women, the use of low-dose Juthani-Mehta et al conducted a prospective cohort study
vaginal estrogen replacement may reduce the risk
of UTIs. However, not all women can safely take of nursing home residents in Connecticut to ascertain
estrogen, so this should be discussed with the
physician. which clinical features are associated with bacteriuria
Published online 2011 June 22. and given the high prevalence of bacteriuria in patients
with cognitive impairment, altered mental status may not
function, malaise, falls, and change in voiding pattern review was not specific to older people so the
were not significantly associated with bacteriura plus conclusions may not be transferable.
pyuria.
Sundvall and Gunnarsson evaluated the NPV of
Recognizing the diagnostic challenges in this population, combined nitrite and leucocyte esterase dipstick analysis
Loeb et al attempted to develop criteria for initiating in predicting the presence of pathogenic bacteria in
antibiotics in patients with bacteriuria in a long-term care elderly nursing home patients.20 They addressed
setting.16 This consensus paper suggested that antibiotics shortcomings in previous studies by including both visual
should be initiated for residents without a urinary and analyzer reading of dipsticks as well as providing
catheter with acute dysuria alone or fever (defined as data about the separate performance of tests for nitrites
temperature above 37.9°C or rise of 1.5°C above and leukocytes in the identification of specific bacteria in
baseline) and one of the following symptoms: new or addition to any bacteria. However, an important
worsening urgency, frequency, suprapubic pain, frank weakness of the study is its failure to provide separate
hematuria, costovertebral angle tenderness, or urinary data for symptomatic versus asymptomatic patients, and
urinary symptoms and these patients cannot always be According to their statistical analysis, ruling in or ruling
identified. The approach suggested by Nicolle is simply out bacteriuria was considered possible where the point
to closely monitor such patients and regularly reassess estimate of PPV/NPV was ≥85% with a lower confidence
clinical features.14 interval (CI) of ≥80%. The authors concluded that the
Catheter-associated UTIs account for a high proportion infection and underlying comorbidities should be taken
of health care associated infection and are common into consideration prior to prescribing antibiotics.
importance of obtaining cultures in the elderly prior to resistance, a group reviewed the recommendations for
commencing antibiotics.31 Local guidelines are now empiric treatment of UTI.34 They agreed that
local resistance patterns and available agents. used as first-line treatment in uncomplicated UTI if the
lower UTIs in females should be managed with results are relevant to older women, especially in care
trimethoprim for 3 days and males should receive 14 homes where they can be observed closely.37
is used as an alternative in penicillin allergic patients in Cranberries have long been considered to have a role in
conjunction with gentamicin. reducing UTIs. The exact mechanism has been disputed.
bacteriuria and also to identify ways of reducing A Cochrane review examined the evidence for the use of
antimicrobial prescribing in the older cranberry in the prevention of UTI in susceptible
population.13,36 Loeb et al conducted a cluster populations.39 This identified ten randomized controlled
randomized controlled trial to assess whether the use of trials using cranberry for the prevention of UTI. Four
an algorithm to aid diagnosis and management of urinary studies were included in the meta-analysis and
tract infections could reduce antimicrobial prescribing in demonstrated that cranberry significantly reduced the
nursing home residents in Canada.36 This used incidence of UTI at 1 year compared to placebo. Studies
educational material aimed at nurses and physicians included a variety of populations examined and cranberry
working in nursing homes and set out a diagnostic was more effective in younger adult females with
algorithm based on previous consensus criteria for recurrent UTI than in older people.
diagnosing UTIs in catheterized and noncatheterized
McMurdo et al conducted a randomized, placebo-
long-term care patients.16 The study was underpowered
controlled double-blind trial examining whether
to assess significant differences in hospital admission and
cranberry juice reduced UTI in elderly hospitalized
death between the group randomized to intervention and
patients in Scotland.40 The primary outcome was time to
the usual care group. It did however demonstrate that
onset of first symptomatic UTI. 376 patients were
using an algorithmic approach reduced antimicrobial
randomized making this one of the largest available
prescribing for suspected UTI.36
randomized controls examining the effect of cranberry
If patients do not have systemic signs there is no need to juice. This study had a lower symptomatic infection rate
start antibiotics immediately. In a randomized trial of than that observed during the pilot phase and so was
five management strategies for uncomplicated UTI in underpowered to demonstrate a significant difference
nonpregnant women delaying antibiotics to see if between cranberry and placebo. The number of E.
symptoms resolved spontaneously did not increase coli UTI was significantly lower in the cranberry group
duration or severity of symptoms and significantly compared to placebo.
reduced antibiotic use. Symptom score was 2.11 for
SIGN guidelines recommended that females with
delayed antibiotics vs 2.15 for immediate antibiotics but
recurrent UTI should take cranberry products to decrease
there was a 20% reduction in antibiotic use. This trial
frequency of recurrence.10 Capsules were advocated as
easier to take than juice. Cranberry products are not incidence of asymptomatic bacteriuria in catheterized
recommended for patients taking warfarin as cranberry is patients, it increases the risk of antimicrobial resistance.
Prevention of catheter associated UTI diagnosis and management. Several studies have
trained on indications for catheterization and written A strategy of observing patients for possible symptoms
protocols should be put in place.26,27 Catheters should before initiating antibiotics have been advocated,
also be removed the moment that they are no longer although recognizing this may not always be practical in
lower incidence of bacteriuria, however their use is With emerging knowledge on antibiotic resistance and
sometimes difficult in confused patients.27 A Cochrane health care-associated infection, guidelines need to be
review on short-term urinary catheterization in adults updated to reflect the need to prescribe narrow spectrum
found that suprapubic catheterization was associated with agents when available and avoid empirical use of broad
abdominal wall. Intermittent catheterization was also Can Fam Physician. 2012 April;
effectiveness of cranberry juice or cranberry-lingonberry Randomized trials of cranberry products for the treatment
juice in children. of UTI have not been performed yet. However, in one
its concentration might have been too low to affect them. Conclusion
Two randomized studies on prophylaxis against bacterial Further studies with robust methodology are needed.
UTI in a pediatric neuropathic bladder population were However, palatability of cranberry juice is a challenge in
conducted. In 40 patients, drinking 15 mL/kg of children, and the optimal dose has yet to be determined.
cranberry cocktail daily for 6 months did not have any Highlights for Management of a Child with a Urinary
effect compared with water on preventing UTI.19 In Tract Infection
another study, 3-month consumption of cranberry Int J Pediatr. 2012; 2012: 943653.
concentrate in 15 children had no effect on bacteriuria in Published online 2012 July 19.
this population.20In a study from Italy, 84 girls divided
Sabeen Habib *
into 3 groups were randomized to receive 50 mL of
. Clinical Presentation
cranberry juice, Lactobacillus GG drink, or placebo;
there were 5 of 27 (18.5%), 11 of 26 (42.3%), and 18 of 5.1. History and Physical Examination
27 (48.1%) episodes of symptomatic UTI, respectively
Signs and symptoms vary greatly by age of the patient
(P < .05). Withdrawal was minimal in all groups.3
becoming more specific as the child grows older. Even in
In a recent double-blind randomized placebo-controlled the absence of specific signs, a UTI should be included in
trial in 7 Finnish hospitals, 255 children treated for UTI the differential diagnosis of high-grade fever.
were given cranberry juice or placebo for 6 months. The Asymptomatic bacteriuria is present in about 3% of
investigators found no differences in timing between first preschool age children, as mentioned in the previous
recurrences of UTI (P = .32), but UTI incidence per section. About a third of these patients will have some
person-year at risk was 0.16 episodes lower in the symptoms of urinary tract eventually.
cranberry group (P = .035). The number of days on
In young infants, symptoms are usually nonspecific and
antibiotic therapy was much lower in children receiving
may include lethargy, decreased feeding, increased sleep,
cranberry (−6 days per patient-year; P < .001). This
vomiting, and decreased urinary output [16, 17]. Occult
suggests a potential for cranberry juice to reduce
UTI in neonates can be presented with late-onset
recurrent UTIs in children.16
jaundice especially if conjugated fraction is elevated too stated that urine cultures with fewer than 103 colony-
a positive urine culture 10.1% of the time, whereas those Unfortunately, oftentimes the culture will grow a
that tested positive for RSV had a positive urine culture bacterium that is obviously a contaminant, either from
5.4% of the time [21]. Even the presence of varicella, the skin or from other parts of the genital tract. Such
herpangina, croup has been found to decrease the risk of culture often has multiple organisms and colony count
UTI by 2.6% [5, 21]. In this age group, recurrent less than 105. Thus, most investigators define a UTI as
abdominal pain could be a symptom of recurrent UTI and the presence of single organism in the urine combined
should be evaluated promptly. with signs or symptoms of UTI in the patient [3, 23, 24].
In older children, fever is usually the presenting The traditional cutoff for urine obtained by noninvasive
symptom of UTI. A fever of greater than 38°C without a collection methods (bag or clean catch) has been 105
source has a positive likelihood ratio of 3.6 and with CFU/mL [5]. For suprapubic aspiration, 102 CFU/mL is
temperatures greater than 39°C have a positive likelihood regarded as the cut off [5, 25]. Some people have used
ratio of 4 [11]. Besides fever, children may have 50,000 CFU/mL from catheterized sample [26–28].
and fever. Sometimes, however, younger children may Culture of the urine remains the gold standard for
have short periods of urgency not associated with UTI. diagnosing UTIs [3,15]. The significance of bacterial
contamination increases by three folds [32]. Again, the In infants younger than 8 weeks, lumbar puncture is still
value of this method is in ruling out rather than recommended as there is lack of evidence to omit this
5.2.3. Urine Dipstick meningitis and UTIs are rare together [42].
5.2.6. Imaging
Urine dipstick is helpful for rapid screening till the
culture result comes back. The dipstick gives information All males and females with well-documented UTIs
about nitrites and leukocyte esterase (LE). Nitrites are should be imaged for the presence of urological
generated from the breakdown of dietary nitrate by anomalies associated with UTI. The extent of evaluation
bacteria [34] and leukocyte esterase is the breakdown varies depending on the age of presentation with the first
product of white cells. UTI and severity of the episode. The younger the child,
conversion requires 3-4 hours and these children urinate Renal ultrasound is helpful in delineating anatomic
much more frequently [36, 37]. abnormalities [43]. It can also be helpful in detecting
5.2.4. Urine Microscopy renal abscesses and stones [44]. For infants younger than
6 months with first-time UTI that responds to treatment,
Definition of pyuria is not clear in the literature. Multiple
ultrasound should be carried out within 6 weeks of the
studies and a few meta-analyses [36–38] found the cutoff
UTI. A normal ultrasound does rule out hydronephrosis
of 5 WBC per HPF being used, the sensitivity being 74%
which when present can suggest either vesicoureteral
and specificity being 86%.
reflux or obstruction of the urinary tract.
5.2.5. Blood Tests
5.2.8. DMSA (Dimercaptosuccinic Acid) Renal Scan
represent focal area of infection that eventually resolve. not be treated with antibiotics [47]. Studies have shown
DMSA scan may be needed in 6 months to confirm that it disappears over time [12].
scarring [46].
6.2. Long-Term Management
5.2.9. Voiding Cystourethrogram (VCUG)
6.2.1. Bowel and Voiding Habits
shorter than 7 days [48]. VUR often undergoes spontaneous resolution. The time
al. [51] reported decreased febrile UTIs as the only Healthcare professionals should ensure that when a child
benefit of surgical management. There was no difference or young person has been identified as having a
in renal scars or UTIs in general [51]. Surgical treatment suspected UTI, they and their parents are given
for vesicoureteric reflux is reserved for patients with high information about the need for treatment, the importance
grade and unilateral reflux, recurrent UTIs despite of completing any course of treatment and advice about
antibiotic prophylaxis, and noncompliance with prevention and possible long-term management [47].
antibiotics persistence beyond 9 yrs of age [44].
Parents should be made aware of the possibility of a UTI
Endoscopic management involves subureteral or
recurring and understand the need to be vigilant and to
intraureteral injection of bulking agent with
seek prompt treatment from a healthcare professional for
dextranomer/hyaluronic acid is suggested as first line
any suspected reinfection.
treatment [52].
up by a subspecialist. Infants and children who have 7. Summary: The Disease from a GP Perspective
Infants and children who have bilateral renal acceptable. Once diagnosed, prompt and appropriate
abnormalities, impaired kidney function, raised blood antibiotic treatment can prevent long-term complications
pressure, and/or proteinuria should receive monitoring and scarring. All younger infants with UTI and older
and appropriate management by a pediatric nephrologist children with complicated UTI should get a renal
to slow the progression of chronic kidney disease. ultrasound. This should be followed by VCUG only if
dysfunction.