Urinary Tract Infections
This clinical information sheet has been developed to assist RACF staff, medical practitioners and relevant professionals (pharmacists, allied health clinicians) involved in the management of residential aged care patients with urinary tract infections.
It covers:
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Urinary Tract Infections
Lower urinary tract infection and pyelonephritis
Urinary tract infection (UTI) is the presence of pathogenic micro-organisms in the urine, urethra, bladder, kidney, or prostate [1, 4].
Urinary tract infections represent one of the most common bacterial infections accounting for 1- 3% of all GP visits [1]. UTI is also the most common infection seen in older adults within the community, with 5-10% of elderly men and 10-20% elderly women affected at any given time [2] . Within RACFs the prevalence is 20% in females aged 65-75yrs, 20-50% in females aged over 80, 3% in men aged 65-70yrs, and 20% in men aged over 80 years [1, 3-6]; 4% of the RACF population has recurrent UTI [6].
Females have higher rates of urinary tract infection, related to the shorter length of the urethra. In elderly women, oestrogen reduction leads to atrophy of the genitourinary tract resulting in poor bladder tone, urinary dysfunction and depletion in normal vaginal flora, all of which increase the risk of UTI [6]. In men, there is often associated infection of the posterior urethra, prostate or epididymis [8].
UTI is a significant burden on health care resources; 20-60% of systemic antimicrobial therapy in RACFs is for treatment of UTI. Lower UTI and pyelonephritis (kidney infection) are common causes of acute hospital admission [2]. As well as being costly, inappropriate use of antimicrobial therapy (only 30-60% are prescribed appropriately for UTI) contributes to the emergence of antimicrobial resistant bacteria [2].
Lower urinary tract infection is infection of the urethra (urethritis) and bladder (cystitis) [1, 4]. Pyelonephritis usually develops as a complication of lower UTI when bacteria travel up the urine tract. Some kidney infections develop due to abnormalities within the kidney. Other factors that contribute to high rates of pyelonephritis in residents of RACFs include presence of a foreign body (esp. indwelling urinary catheter), incomplete bladder emptying, and comorbidities such as diabetes [2]. The condition is more common in females, and there is a 25% chance of recurrence. Although permanent damage is unlikely, unless the patient has repeated kidney infections, pyelonephritis can develop rapidly into septicemia if not managed correctly and promptly [1, 4, 9].
Uncomplicated UTI is infection by a usual pathogen in a patient with a normal urinary tract and normal renal function. Complicated urinary tract infection is diagnosed when the infection is caused by a virulent organism, in immuno-compromised patients, and in those with abnormal urinary tract or impaired renal function [1, 4].
UTI usually develops due to cross-infection with bacteria from the gastrointestinal tract [2, 4]. E Coli is the most common causative organism [2]. Gram negatives such as Proteus, Klebsiella Enterobacter, Serratia, and Pseudomonas account for most other cases [1-3].
Related urinary tract conditions
Asymptomatic Bacteriuria
Asymptomatic bacteriuria exists when significant bacteria levels are cultured in the urine; however, the patient exhibits no signs or symptoms of UTI. No evidence has established a correlation between asymptomatic bacteriuria and UTI [3-5, 7]. Prevalence of asymptomatic bacteriuria increases with age. Older adults are more susceptible due to age-related changes such as decline in natural immunity, changes to pH and hormonal levels, reduction in vaginal and prostatic antibacterial factors, and comorbidities, e.g. dementia, diabetes [7]. Institutionalisation also increases risk of asymptomatic bacteriuria [3-5, 7], with an incidence of 50% in RACF populations compared to 10% older adults in the community [7]. Treatment has not been shown to decrease febrile illness, urinary bacterial levels or recurrent episodes [3-5, 7].
Urethral Syndrome
Urethral syndrome is commonly seen in women. Symptoms are similar to those in lower UTI, however, urine cultures show no pathogenic bacteria. Treatment consists of pain relief and reassurance, however, if symptoms do not resolve within 3 days or if they frequently recur, consider further investigations [1].
Assessment
Initial assessment
The most common presenting signs and symptoms of UTI are [3, 4, 10]:
Patients with pyelonephritis (kidney infection) present with the following signs and symptoms [9]:
Older adults may also present with [3, 4]:
Falls; Immobility; Increased confusion; Shock; Anorexia; or Poor general health.
Pyelonephritis is defined as mild if the patient has a low-grade fever, normal or slightly elevated white cell count, and no nausea or vomiting [10]. Pyelonephritis is severe where the patient has a high fever, high white blood cell count, vomiting, dehydration, or other evidence of sepsis [10].
Differential diagnosis
For males the following diagnoses should be excluded [4]: prostatitis, prostatic enlargement, calculi
Investigations
Diagnosis of lower UTI or pyelonephritis (kidney infection) is dependent on presence of bacteriuria and pyuria [3]. The following investigations should be conducted to confirm the diagnosis and severity of illness, and to determine antimicrobial therapy.
Urine dipstick
Urine dipstick tests are frequently used to detect white blood cells (pyuria) and nitrates [3, 4]. However, urine dipstick cannot be relied on to exclude or confirm a diagnosis of UTI, due to low sensitivity of the test, and the high rate of asymptomatic bacteriuria among residents [10, 11]. Urine culture provides the definitive diagnosis, and guides antimicrobial therapy [4].
Urine Culture
Urine microscopy, culture and sensitivity is traditionally used to confirm diagnosis, and inform choice of antibiotic [3, 11]. An MSU should be collected prior to commencement of antimicrobial therapy. Success in bacteria isolation depends on specimen collection technique. Fifty percent of MSUs fail to detect specific pathogens in symptomatic patients due to incorrect specimen collection technique [3].
Urine culture is indicated in the following circumstances [1-3]:
Doubt about the diagnosis; History of recent urinary infection (within the last 3 weeks) suggesting relapse of the previous infection and a degree of antibiotic resistance; History of recent urinary tract instrumentation, e.g. catheterisation; Presence of diabetes; Populations with high risk of infection with resistant organisms, e.g. RACF residents, and; Elderly patients presenting with atypically signs and symptoms.
Bacteria levels greater than 102 microorganisms/ml in a symptomatic female and greater than 103 microorganisms/ml in a symptomatic male have a sensitivity of 95% and a specificity of 85% in identifying UTI [3]. However, in most instances significant infection is defined as greater than 105 microorganisms/ml to allow for collection technique errors [1, 4].
Urine for microscopy and culture should be refrigerated at 4°C whilst awaiting processing, which should be performed as soon as possible after MSU collection. Urine that has been stored at 4°C for up to 48 hours is suitable for culture, but not for microscopy [1, 4].
Blood Cultures
Blood cultures should be conducted on older adults with pyelonephritis due to the high rates of bacteraemia and higher rates of infection with resistant bacteria strains seen in RACFs.
Imaging
Referral for urinary tract imaging to exclude structural abnormalities or obstruction should be considered in [1, 4]:
Men diagnosed with pyelonephritis; Patients with recurrent pyelonephritis; Patients with a history of genitourinary surgery or calculi; and Those with a poor response to therapy (after 72 hours) as assessed by pain and fever.
Imaging should also be considered for [1, 4]:
Patients over the age of 50 years with microscopic haematuria; Macroscopic haematuria; Men who have experienced more than 2 UTIs per year; and Women who have experienced more than 3 UTIs per year.
Ongoing Assessment
Residents with UTI should be assessed every shift by trained nursing staff for signs and symptoms suggesting progression of infection and/or worsening of overall condition[13]:
Rigours (indicate ongoing bacterial sepsis); Pain; Ongoing dysuria, frequency or haematuria; Fever; and Dehydration e.g. dry tongue, tissue turgour, urine colour.
The patient should be reviewed by his or her GP within 48hrs to determine progress and check urine culture results [4]. Consider hospital admission if there is persistent high fever and/or rigors, vomiting, or significant pain for longer than 48 hours [13].
Management
Management of UTI is guided by the resident’s clinical condition and pathology results, and may include antibiotics, fluids, analgesia and cranberry juice. Urine culture should be repeated 10-14 days after treatment to ensure clearance of infection [13, 14].
There is evidence that casts doubt on the effectiveness of urine alkalinizing agents, such as potassium citrate, sodium citrate, and sodium bicarbonate, in relieving the signs and symptoms of UTI [4].
Fluids
Patients with dehydration or severe vomiting may require intravenous or subcutaneous re-hydration (see Clinical Information Sheet on Subcutaneous Hydration). Increasing fluid intake is common advice for women suffering from lower UTI, however the effectiveness of increasing fluids to 'wash out' the bladder has not been clearly established and may cause distress to residents with dysuria [4, 10, 11].
Analgesia
Paracetamol relieves pain and high temperature and may be considered when there are no contra-indications [4].
Cranberry juice
Cranberry juice has been used widely for the prevention and treatment of urinary tract infections [15]. Cranberries have been shown to be ineffective in managing acute urinary tract infection and they have no effect in changing urinary pH, reducing bacterial counts or reducing urinary WBC counts [16]. There is some evidence of effectiveness in preventing recurrent cystitis in women, however, this requires further research [4, 17, 18]. It should also be noted that there have been reports of serious side effects and death in older patients taking cranberry concurrently with warfarin, however, at this stage there is no reliable evidence documenting this effect [17].
Antibiotics
It is important to perform urine cultures and sensitivities to guide treatment, as pathogens in residents are difficult to predict empirically and therapy may to be prolonged, high-dose and parenteral [7]. Antimicrobial agents can cause vulvovaginal candidiasis, hypersensitivity reactions, rashes and gastrointestinal disturbances, all of which can increase morbidity in elderly patients.
Asymptomatic Bacteriuria
Generally, no treatment is required for asymptomatic bacteriuria or asymptomatic pyuria [7], including those with a urinary indwelling catheter [3, 4, 8]. All patients with an indwelling catheter (IDC) will have bacteriuria at some stage. Soon after insertion the IDC surface becomes covered with a biofilm of microbes. Routine care and removal of the IDC as soon as possible is recommended in the prevention of catheter associated UTI. Intermittent catheterisation rarely results in UTI; therefore, where possible it should be used instead of IDC. Increased fluid intake, where there is no contraindication, promotes urine flow and decreases the risk of symptomatic infection. Routine prophylactic antibiotics are not recommended [4, 8] (See Urinary Indwelling Catheter Management Clinical Information Sheet). Unless the patient is symptomatic, urine culture and treatment is not required [2, 4, 8].
Uncomplicated Lower UTI
Resistance to Trimethoprim in uncomplicated UTI is less than 5% [4]. Amoxycillin is only recommended if susceptibility of the organism is proven [7]. Fluoroquinolones, e.g. ciprofloxacin and norfloxacin, should not be used as first-line drugs as they are the only oral medication effective in the treatment of Pseudomonas and other multi-resistant bacteria. Their use should be reserved for second-line treatment, e.g. for trimethoprim resistance [12].
The recommended antibitoic regimes for management of uncomplicated lower UTI are [4, 7, 12]:
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Trimethoprim 300mg orally daily (3 days for women, 14 days for men)
OR
Cephalexin 500mg orally 12 hourly (5 days for women, 14 days for men)
OR
Amoxycillin/clavulanate 500mg/125mg orally 12 hourly (5 days for women, 14 days for men)
OR
Nitrofurantoin 50 mg orally, 6-hourly
If there is proven microbial resistance to other medications use:
Norfloxacin 400 mg orally 12-hourly hourly (3 days for women, 14 days for men)
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Optimal duration of therapy for lower cystitis in older patients is still unknown.
For women, regimes vary from 1, 3 and 7-days. Single dose therapy is less effective than longer courses, and is not recommended for management in older adults [12]. In one study of elderly women with UTI, 3-day antibiotic courses were as effective as 7-days of treatment, with patients experiencing significantly less adverse effects [14]. Limiting treatment to a minimum reduces adverse effects and cost, therefore where possible a 3-day course should be prescribed [12].<.p>
For men, antibiotic treatment is recommended for 14 days as there is often associated infection of the posterior urethra, prostate or epididymis. Investigations should be done to exclude an underlying urinary tract abnormality [7].
In immunocompromised patients, a 7-day course may be considered more appropriate [1].
If relapse occurs, pyelonephritis should be considered, and treatment given for 10 to 15 days [7].
Complicated lower UTI / Mild-moderate pyelonephritis
Treat complicated lower UTI and mild-moderate kidney infection for 10 days [7]:
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Cephalexin 500mg orally 6 hourly for 10 days
OR
Amoxycillin/clavulanic acid 875mg/125mg 12 hourly for 10 days
OR
Trimethoprim 300mg orally daily for 10 days
If the patient has had a previous UTI due to resistant organism, use:
Ciprofloxacin 500mg orally 12 hourly.
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Severe pyelonephritis
For severe kidney infection with suspected sepsis or vomiting, parenteral treatment should be given initially and changed to oral therapy as soon as clinical improvement is evident, e.g. improvement in pain, loss of fever, usually within 48-72 hours. The choice of oral agent is directed by urine culture results. The standard duration of therapy is 10-14 days, however, most of this can be administered orally.
Gentamicin should not be used in patients with renal or hearing impairment. The standard regime for severe pyelonephritis is [7]:
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Amoxy/Ampicillin 1g IV 6-hourly,
AND
Gentamicin 4-6 mg/kg IV daily
(adjust dose according to Gentamicin levels and renal function at the 2nd dose and 2-3 days thereafter)
For patients hypersensitive to penicillin (excluding immediate hypersensitivity) use:
Gentamicin alone
For patients with impaired renal function/hearing/vestibular problems use:
Ceftriaxone 1g IV daily
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Some residents may receive IV antibiotic treatment for pyelonephritis at the RACF, through Hospital in the Home. Most patients over 60 with pyelonephritis will be treated in hospital initially, but may be suitable for early transfer back to the RACF with HITH management if medically stable and blood cultures are negative. See : Hospital in the Home IV Antibiotic Therapy - Kidney Infection and : Management of Kidney Infection.
Recurrent UTI
Recurrent symptomatic UTIs can be relapse or reinfection. In men, chronic prostatitis is the most common cause of recurrent UTI [7], whilst changes related to decrease in oestrogen levels is thought to contribute to recurrent UTI in older women [6]. Management depends on frequency of recurrence. Infrequent episodes should be treated as separate cases with antibiotics for ten days. In some cases long-term prophylactic therapy with Trimethoprim 150mg at night may be indicated for 3-6 months or longer [7]. Intra-vaginal oestrogen can reduce recurrent infections in postmenopausal women [7]. For patients with frequent UTIs or incapacitating symptoms, referral for imaging and further investigation is appropriate [3].
Sources of Information
Where to go for more information
Therapeutic Guidelines
Therapeutic Guidelines have been prepared by writing groups of experienced clinicians, and represent independent consensus opinion based on the evidence available at the time of publication. The guidelines are available as pocket-sized book, CD-ROMs for installation on personal computers, and electronic versions for use on Health Department intranets, integration with commercial prescribing software, and hand-held computers. See Antibiotic Guidelines, version 12, 2003.
Website: http://www.tg.com.au
References
(PRODGY) Practical Support for Clinical Governance, Urinary Tract Infection (lower) in women. 1994, UK: Department of Health. L Nicholle, Resistent pathogens in urinary tract infections. JAGS, 2002. 50: p. S230-S235. R Gray,J Malone-Lee, Review: urinary tract infection in elderly people - time to review management? - health management. Age and Ageing, 1995. July. (PRODGY) Practical Support for Clinical Governance, Urinary Tract Infection (lower) in men. 2002, UK: Department of Health. L Nicholle, Screening for asymptomatic bacteriuria in the elderly, in Canadian Guide to Clinical Preventative Health Care, Canadian Task Force on the Periodic Health Examination, Editor. 1994, Health Canada: Otawa. p. 966-973. C Maloney, Estrogen and Recurrent UTI in postmenopausal women. American Journal of Nursing, 2002. 102(8): p. 44-53. eTG (editors), Therapeutic Guidelines: urinary tract infections, in http://www.tg.com.au (accessed August 2006), eTG, Editor. 2004 (PRODGY) Practical Support for Clinical Governance, Kidney Infection (pyelonephritis). 2002, UK: Department of Health. Giannattasio FC, Saconato H, Soars BOG, Atallah AN., Antibiotics for asymptomatic urinary tract infection in the elderly. (Systematic Review Protocol). The Cochrane Database of Systematic Reviews, 2002(4). Aged Care GP Panels Initiative, Residents of Aged Care Homes & Urine Testing Draft Protocol: Aged Care Home Guide. 2006, North East Valley Division of General Practice: Melbourne. p. 2. Aged Care GP Panels Initiative, Residents of Aged Care Homes & Urine Testing Draft Protocol: General Practitioner Guide. 2006, North East Valley Division of General Practice: Melbourne. p. 2. J Warren, E Abrutyn, J Hebel, J Johnson, A Schaeffer, Stamm W, Guidelines from the Infectious Disease Society of America: Guidelines for Antimicrobial Treatment of Uncomplicated Acute Bacterial Cystitis and Acute Pyelonephritis in Women. Clinical Infectious Diseases, 1999. 29: p. 745–58. A Dent, G Phillips, J Daffy, P Stanley, A Beswick, O'Sullivan E, Hospital in the Home Pyelonephritis Treatment. 2004 T Vogel, R Verreault, M Gourdeau, M Morin, L Grenier-Gosselin, L Rochette, Optimal duration of antibiotic therapy for uncomplicated urinary tract infection in older women: a double-blind randomized controlled trial. Canadian Medical Association Journal, 2004. 170(4): p. 479-473. The Cochrane Collaboration, Cranberries for treating urinary tract infections. The Cochrane Library, 2004. T Linsenmeyer, B Harrison, A Oakley, S Kirshblum, J Stock, S Millis, Evaluation of cranberry supplement for reduction of urinary tract infections in individuals with neurogenic bladders secondary to spinal cord injury. A prospective, double-blinded, placebo-controlled, crossover study. Journal of Spinal Cord Medicine, 2004. 27(1): p. 29-44. New Zealand Health Technology Assessment (NZHTA) Unit, Cranberry for the prevention of urinary tract infection, in http://www.cam.org.nz/record_general.asp?recordid=48 accessed November 2004, Department of Public Health and General Practice New Zealand Health Technology Assessment Unit (NZHTA), Christchurch, School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand. 2004 P Griffiths, The role of cranberry juice in the treatment of urinary tract infections. British Journal of Community Nursing, 2003. 8(12): p. 557-61. National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
The information presented is developed from summaries of previously published systematic reviews. Among other resources, information published by Practical Support for Clinical Governance for the UK Department of Health was used to provide background information. The following table outlines the level of evidence of each reference:
The following table outlines the level of evidence of each reference:
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Reference |
Year |
Level of Evidence |
1. |
(PRODGY) Practical Support for Clinical Governance, Urinary Tract Infection (lower) in women. 1994, UK: Department of Health. |
1994 |
Level IV B evidence |
2. |
L Nicholle, Resistent pathogens in urinary tract infections. JAGS, 2002. 50: p. S230-S235. |
2002 |
Level IV C evidence |
3. |
R Gray,J Malone-Lee, Review: urinary tract infection in elderly people - time to review management? - health management. Age and Ageing, 1995. July. |
1995 |
Level IV B evidence |
4. |
(PRODGY) Practical Support for Clinical Governance, Urinary Tract Infection (lower) in men. 2002, UK: Department of Health. |
2002 |
Level IV B evidence |
5. |
L Nicholle, Screening for asymptomatic bacteriuria in the elderly, in Canadian Guide to Clinical Preventative Health Care, Canadian Task Force on the Periodic Health Examination, Editor. 1994, Health Canada: Otawa. p. 966-973. |
1994 |
Level II evidence |
6. |
C Maloney, Estrogen and Recurrent UTI in postmenopausal women. American Journal of Nursing, 2002. 102(8): p. 44-53. |
2002 |
Level IV C evidence |
7. |
eTG (editors), Therapeutic Guidelines: urinary tract infections, in http://www.tg.com.au (accessed August 2006), eTG, Editor. 2004 |
2006 |
Level IV C evidence |
8. |
(PRODGY) Practical Support for Clinical Governance, Kidney Infection (pyelonephritis). 2002, UK: Department of Health. |
2002 |
Level IV B evidence |
9. |
Giannattasio FC, Saconato H, Soars BOG, Atallah AN., Antibiotics for asymptomatic urinary tract infection in the elderly. (Systematic Review Protocol). The Cochrane Database of Systematic Reviews, 2002(4). |
2002 |
Level IV C evidence |
10. |
Aged Care GP Panels Initiative, Residents of Aged Care Homes & Urine Testing Draft Protocol: Aged Care Home Guide. 2006, North East Valley Division of General Practice: Melbourne. p. 2. |
2006 |
Level IV C evidence |
11. |
Aged Care GP Panels Initiative, Residents of Aged Care Homes & Urine Testing Draft Protocol: General Practitioner Guide. 2006, North East Valley Division of General Practice: Melbourne. p. 2. |
2006 |
Level IV C evidence |
12. |
J Warren, E Abrutyn, J Hebel, J Johnson, A Schaeffer, Stamm W, Guidelines from the Infectious Disease Society of America: Guidelines for Antimicrobial Treatment of Uncomplicated Acute Bacterial Cystitis and Acute Pyelonephritis in Women. Clinical Infectious Diseases, 1999. 29: p. 745–58. |
1999 |
Level I evidence |
13. |
A Dent, G Phillips, J Daffy, P Stanley, A Beswick, O'Sullivan E, Hospital in the Home Pyelonephritis Treatment. 2004 |
2004 |
Level V evidence |
14. |
T Vogel, R Verreault, M Gourdeau, M Morin, L Grenier-Gosselin, L Rochette, Optimal duration of antibiotic therapy for uncomplicated urinary tract infection in older women: a double-blind randomized controlled trial. Canadian Medical Association Journal, 2004. 170(4): p. 479-473. |
2004 |
Level II evidence |
15. |
The Cochrane Collaboration, Cranberries for treating urinary tract infections. The Cochrane Library, 2004. |
2004 |
Level I evidence |
16. |
T Linsenmeyer, B Harrison, A Oakley, S Kirshblum, J Stock, S Millis, Evaluation of cranberry supplement for reduction of urinary tract infections in individuals with neurogenic bladders secondary to spinal cord injury. A prospective, double-blinded, placebo-controlled, crossover study. Journal of Spinal Cord Medicine, 2004. 27(1): p. 29-44. |
2004 |
Level II evidence |
17. |
New Zealand Health Technology Assessment (NZHTA) Unit, Cranberry for the prevention of urinary tract infection, in http://www.cam.org.nz/record_general.asp?recordid=48 accessed November 2004, Department of Public Health and General Practice New Zealand Health Technology Assessment Unit (NZHTA), Christchurch, School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand. 2004 |
2004 |
Level I evidence |
18. |
P Griffiths, The role of cranberry juice in the treatment of urinary tract infections. British Journal of Community Nursing, 2003. 8(12): p. 557-61. |
2003 |
Level IV C evidence |
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Urinary Tract Infections
The following reference cards are designed to be used in conjunction with the Urinary Tract Infections Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
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Reference Cards:
Management of Kidney Infection
Hospital in the Home IV Antibiotic Therapy
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