Urinary tract infections
Urinary tract infections are a significant problem for residents in RACFs. The prevalence among women is 20% between 65-75 years of age; 20-50% over 80 years of age; and among males over 80 years of age, 3%. Four percent of the RACF population has recurrent urinary tract infections.245 Asymptomatic bacteriuria has an incidence of 50% in the RACF population compared to 10% in older people living in the community.
Contributing factors are related to ageing and disease and include decreased urinary concentrating ability, failure to completely empty the bladder, incontinence, diabetes, kidney stones, urinary catheters, medications with anticholinergic effects, and microbial resistance. Additional factors in women are a short urethra and atrophic changes due to reduced oestrogen levels, while men may have prostatic hypertrophy, urethral stricture, or prostatitis.246,247 Inadequately treated lower urinary tract infections can ascend to cause pyelonephritis.
Common symptoms of a lower urinary tract infection are dysuria, frequency, urgency, nocturia, haematuria, and suprapubic discomfort. Patients with pyelonephritis may have loin pain, fever, nausea, vomiting, diarrhoea and general malaise. Older people may also present with delirium, confusion, falls, immobility or anorexia.248
Diagnosis of an urinary tract infection depends on the presence of pyuria and bacteriuria in a carefully collected specimen of urine, preferably midstream. Microscopy, culture and sensitivity will confirm diagnosis and severity and guide antibiotic treatment. Blood cultures should be done for patients with pyelonephritis due to high rates of bacteremia and higher rates of infection with resistant strains. Patients may require further investigation if they have a high risk of obstruction or structural abnormalities.
Treatment is not recommended for asymptomatic bacteriuria or asymptomatic pyuria. Treatment has not been shown to decrease bacteria levels in the urine, prevent recurrent episodes or decrease the risk of febrile illness developing, and may lead to resistant organisms.249,250
Antibiotic treatment of lower urinary tract infections can be commenced on clinical diagnosis, and reviewed with results of urine culture. Most cases are caused by E. coli and gram negatives such as proteus, klebsiella enterobacter, serratia, and pseudomona due to cross infection from the gastrointestinal tract. Recommended first line oral regimens are trimethoprim 300 mg at night (to maximise urinary concentration) or cephalexin 500 mg 12 hourly, or amoxycillin/clavulanate 500 mg/125 mg 12 hourly. If there is proven microbial resistance, use norflaxacin 400 mg 12 hourly (but do not combine with an alkaliniser as it can cause crystallisation).251,252 Optimal duration of treatment is not known, and current recommendations are to treat women for 3-7 days and men for 14 days.253,254 Monitor clinical progress daily and do a follow up urine culture at least 1 week after the conclusion of therapy. Paracetamol can relieve pain and fever. Dehydration should be corrected, however additional benefits of increasing fluid intake, urinary alkalinisers and cranberry juice have not been established.255
Pyelonephritis requires treatment for 10 days, and may need intravenous therapy for the first 2-3 days in hospital or at the facility using hospital in the home. Refer to Therapeutic guidelines: antibiotic for recommended regimens.256 Measures to prevent recurrent urinary tract infections include investigating the underlying causes, addressing identified risk factors, perineal hygiene, adequate fluid intake, intravaginal oestrogen and prophylactic antibiotics with cephalexin 250 mg or trimethoprim 150 mg at night. There is not enough evidence to support the use of hexamine hippurate, however it may have some efficacy in patients without upper renal tract abnormality.257