Beruflich Dokumente
Kultur Dokumente
Elderly
Christopher French
BMedSci MD FRCSC
Adult and Pediatric Urology
Clinical Assistant Professor of Surgery
May 2009
Objectives
• Rationale for Treating Positive Urinary
Cultures
• Simple vs Complicated Infections
• Rationale for Prophylactic Antibiotics
• Optimal Catheter Management
• Evaluate risk factors for urinary
infections in the elderly
Cystitis
• Localized symptoms with positive
urine culture (and inflammation)
• The only group that receive
abbreviated treatment (3 day) is
young healthy women
• “Uncomplicated”
• Complicated urinary infections
require upper tract investigations
Complicated Cystitis
• In the elderly assume there is
residual urine
• Bladder power decreases with age
• Men usually have a component of
BPH, women atrophy (low estrogen)
• Failure to eradicate is commonly
associated with a foreign body such
as stone or catheter
Febrile Urinary Infections
in the elderly
• Assume there is Pyelonephritis
• Obstruction is common
– Catheter, ureter, prostate
• High Morbidity
– Associated confusion, falls, CHF, poor
host response, mortality
Prostatitis
• Patterns in medicine
– Men in 40’s
– 90% culture negative
– Association with pelvic pain
– Chronic
– Failure to identify organism associated with
cyclical natural history leads to false belief
that long courses of antibiotics will be
effective
• Unusual in the elderly
Asymptomatic Bacteruria
• Urinalysis done for other reasons
• Limitations of obtaining samples
• Difficulty with reliable history
• If frail and poor mental status-treat
• If well, treat conservatively, repeat
culture and consider treatment if
symptoms appear
When do you treat asymptomatic bacteriuria?
1) Pregnant
2) Debilitated, older patients
3) Severely diabetic
4) Child with VUR
5) Obstruction
6) Patients who feel better with sterile urine
7) Patients about to undergo a GU procedure (TURP, etc.)
Why are the elderly at increased risk of UTI?
Systemic Renal
1) Dehydrated 1) GFR and decreased urine flow rate
2) Malnourished 2) Renal failure - poor excretion of
3) Other intercurrent illness e.g., antibiotics
diabetes 3) Stones ( risk)
4) Decreased immunity to infection 4) Renal diseases – e.g., hypertension,
(decreased cell-mediated immunity) DM
5) Multiple medications - some may be
immune suppressing
6) Frequent antibiotic use - promote
resistant organisms
• Success.
• Manage expectations- The catheter was convenient but Charlie, you
had so many infections.
• PVR 30cc
• Check Urine only is symptomatic
Colonisation vs Infection
Some estimates of 5% of elderly have
a positive urine culture without
symptoms
Patients on intermittent or indwelling
foley are all colonized
In the absence of symptoms catheter
associated positive cultures can be
managed conservatively
Conservative treatments
Increase fluid intake
mechanical flushing of bladder
Keep Bowels soft
Constipation leads to poor pelvic floor
relaxation
Timed voiding
Cranberry
juice is more effective than extract
(volume)
Antibiotics
Enterobacter common
E Coli
Enterococcus common in failure of first line
Strep Faecalis
Proteus (urea splitting think Struvite stone)
Candida in the urine is usually the result of
long term antibiotic use. If a foreign body is
present will not clear.
Antibiotics
Antibiotics Pearls
30 % of E Coli resistant to AMP
20% of E Coli resistant to Septra
10% of E Coli resistant to Cipro