Urinary Infections and Catheters in Older Adults

liq goldUTIs, UICs, and CAUTIs in older adults! In this episode, Mary Mulcare, EM and geriatric-EM-trained physician in NYC and I discuss how to diagnose UTIs in older adults, and the confounding factors of asymptomatic bacteriuria, sterile pyuria, and colonization. We discuss how to diagnose a UTI, how to pick medications, dos and don’ts of when to place a urinary catheter, and how to create a protocol at your institution to reduce IUCs and CAUTIs. You may think this topic is simple, cut, and dry, but it is not. Treating a non-existent UTI can do harm, because of all the side effects of medications. But not treating a true UTI can also do harm, as it can lead to sepsis. Placing urinary catheters sometimes is absolutely required, and other times is less clear. It too has risks and benefits. Particularly in frail elderly patients, UTIs and also IUCs can lead to delirium and deconditioning.

You can listen by clicking play or by finding GEMCAST on itunes. See below for lots and lots of show notes and references. Dr. Mulcare’s protocol for reducing IUCs and CAUTIs is at the bottom of the notes.

Definitions

UTI: Urinary Tract Infection

IUC: Indwelling Urinary Catheter

CAUTI: Catheter-Associated UTI

Pyuria: white blood cells in urine

Asymptomatic bacteriuria: presence of bacteria in urine without clinical signs suggestive of UTI -> really difficult in older adults as they may not present with symptoms the same way younger folks do.

Symptomatic UTI: symptom + pyuria + urine culture identifying pathogen

Demographics of UTI

In the older adult population at large, the incidence of UTIs in population is about 10% of women over 65 and 30% of women over 85 by self report in preceding 12 months. It is the second most common diagnosed infection in acute hospital setting (pneumonia first, bacteremia third). 5% of all ED visits in adults over 65 are due to UTIs. The numbers jump extraordinarily when discussing long term care facilities. Beyond the risk factor of having had a previous UTI, these patients are more commonly cognitively impaired, have issues with regular voiding, suboptimal self hygiene, and are at risk for needing catheterization.

Diagnosis

There is often confusion regarding urinalysis in diagnosing UTIs. Sterile pyuria is frequent in older adults, as well as colonization. Urine cultures are the most important, but should not be sent unless there is clinical concern for a UTI.

A high percentage of older adults have colonized urine (ASB)

  • Starts low (lower in men) and increases with age.
  • Men over 80 = 10%
  • Women over 80 = 20%. This number doubles in SNFs.
  • After antibiotics, 25% of these patients have persistent bacteriuria, hence the term colonization.
  • Indwelling catheters: 3-10%/day risk, up to 100% with chronic indwelling IUCs…which we’ll discuss more coming up

Pyuria with bacteriuria also increases with age and is close to 90% in men and women over 80

Criteria for Treatment

There are criteria out there for treating UTIs in older adults (by McGeer and Loeb and colleagues), however those criteria are rarely followed. Either acute dysuria or fever with worsening urological symptoms (incontinence, smell, frequency, urgency, pain, CVA tenderness, hematuria).  Some people include mental status changes. Ultimately the urine culture is the most important piece.

Risks of Treating Without a Definite UTI

Overuse of antibiotics is leading to more virulent strains of multidrug resistant pathogens. Hence the importance of making educated decisions about when to treat. Also many of the medications have drug-drug interactions with other medications such as fluorquinolones and warfarin. Or they may cause acute renal failure, such as with Bactrim (TMP/SMX) or other adverse drug reactions.

Antibiotic Choices

The most common pathogen is E.coli. If a prior culture exists with sensitivities, use that to guide your choice while the current urine culture is pending. Each institution will have specific sensitivities and treatment should be guided by the local antibiogram. Cephalexin, nitrofurantoin, and fosfomycin (in women) are common choices for simple, uncomplicated UTI (ie. not pyelonephritis, sepsis, or catheter-associated UTIs).

CAUTIs

Catheter-associated urinary tract infections, or C-A-U-T-Is, are common, especially in our older adult patients. Catheter-associated UTIs account for 11-40% of hospital-acquired bacteremic episodes. The risk of developing a catheter-associated UTI is directly related to the amount of time the IUC is in place, with the risk of infection increasing by approximately 5% per 24-hour period that the catheter is in place. As of October 1, 2008, CMS no longer reimburses hospitals for CAUTIs. This is one of eleven hospital acquired conditions for which this applies.

Placement of IUCs

Placement of an indwelling urinary catheter, or I-U-C, is one of the most frequently performed procedures in the hospital, and often initiated in the emergency department. This is a decision that is infrequently reversed once the patient is transferred to the floor. In fact, per a study done in 2000, 28% of the time the inpatient provider does not know that a patient under their care has an IUC. Much of the conundrum around whether or not to place an IUC is related to the anticipated risk/benefit ratio when considering the individual patient scenario.

Risks of IUC placement include infection, delirium, falls, discomfort to the patient, traumatic removal, and immobility. Nearly half of all hospitalizations originate in the ED, and 8-23% of ED patients who are admitted receive urinary catheters with the highest rates in older adults. In one study, 91% of IUCs placed in the first 24 hours of admission were placed in the ED. Recent literature suggests that as many as 64% of these IUCs placed in the ED are done so inappropriately. Thus, an intervention focused on geriatric patients in the ED, the “front door” or “point of entry” of a hospital stay, may have a significant impact on IUC placement practices and CAUTI rates.

Protocolized Reduction of IUC Placement to Reduce CAUTIs

Dr. Mulcare and team developed a protocol focused on the different stages of decision making when considering an IUC in older adults in the Emergency Department. These include:

  • diagnosis-based recommendations for placement,
  • critical actions when placing the IUC,
  • alternative modes for urine collection,
  • assuring agreement within the team for IUC placement,
  • reassessment of the IUC for removal.

Diagnoses for which an IUC is indicated:

  • critical illness requiring hourly I&O monitoring
  • acutely ventilated patients
  • acute pulmonary edema or a CHF exacerbation requiring non-invasive positive-pressure ventilation
  • burns greater than 20% total body surface area
  • major trauma as per the ATLS protocol
  • orthopedic injuries requiring immobilization such as pelvis and spine fractures, hip fracture
  • spinal cord injury or compression
  • acute urinary retention

IUCs should NOT routinely be placed solely for:

  • delirium
  • dementia
  • incontinence
  • being bed-bound
  • measuring post-void residual (for which we should be using ultrasound, a bladder scanner, or if necessary a straight cath)
  • obtaining a urine sample
  • presence of a urinary tract infection
  • alcohol intoxication
  • morbid obesity
  • IUCs should not be placed for convenience of care by staff or simply by request of the family
  • IUCs should not be placed if refused by the patient or health-care proxy

Some cases are not clear cut and may require an IUC if other options fail:

  • lower extremity injuries requiring immobilization in the acute period
  • maceration of perineal or sacral skin in the setting of incontinence
  • palliative care or comfort measures in certain scenarios
  • accurate ins and outs monitoring at greater than one hour intervals, where a commode with a measurement hat, urinal, or condom catheter, for example might be tried first
  • CHF patients who do not require non-invasive positive-pressure ventilation, alternative methods should be adequate to track clinical status and avoids the risks of IUC placement. This does represent a change to existing practice for many providers, and evidence shows that the patients do as well if not better clinically without the IUC due to increased mobility with decreased rates of catheter-associated UTIs.
  • Finally, avoiding placement of IUCs in the pre-operative period unless transport to the operating room is imminent or as otherwise indicated by the patient’s condition.

Recommendations for Creating an IUC Protocol

Find a nursing champion. Remind the group about the alternate modes of urine collection present in your ED and likewise make sure that your ED is stocked with commodes and bedpans and supplies prior to insisting on fewer IUCs. Advocate for reassessment at shift change and on transfer to the floor for whether an IUC still needs to be present. Include parameters for removal in signouts. Ultimately, mold the protocol to something that will work at your institution and based on your culture. The question of how to best treat older adults with UTIs in general is ripe for research if anyone has interest!

Other Preventative Possibilities for Recurrent UTIs

Overall a Cochrane review from 2012 found no statistically significant benefit to cranberry juice. For older women who have recurrent UTIs, who may have vaginal atrophy topical estrogen to the perineum may help reduce UTIs. Improving mobility may help prevent future infections

IUC and CAUTI Reduction Protocol from NY Presbyterian

IUC Protocol final.jpg

References

  1. Saint S, Wiese J, Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109(6):476-480. http://www.ncbi.nlm.nih.gov/pubmed/11042237. Accessed February 2, 2018.
  2. Mulcare MR, Rosen T, Clark S, et al. A Novel Clinical Protocol for Placement and Management of Indwelling Urinary Catheters in Older Adults in the Emergency Department. Heard K, ed. Acad Emerg Med. 2015;22(9):1056-1066. doi:10.1111/acem.12748.
  3. Nicolle LE. Urinary Tract Infections in the Elderly. Clin Geriatr Med. 2009;25(3):423-436. doi:10.1016/j.cger.2009.04.005.
  4. Rowe TA, Juthani-Mehta M. Diagnosis and Management of Urinary Tract Infection in Older Adults. Infect Dis Clin North Am. 2014;28(1):75-89. doi:10.1016/j.idc.2013.10.004.
  5. Christina Shenvi. Fosfomycin (Monurol) – Emergency Physicians Monthly. EP Monthly . http://epmonthly.com/article/fosfomycin-monurol/. Published 2014. Accessed February 2, 2018.
  6. Christina Shenvi. Uncomplicated Urinary Tract Infections in Older Adults: Diagnosis and Treatment (Part 2). Academic Life in EM. https://www.aliem.com/2014/04/uncomplicated-urinary-tract-infections-older-adults-diagnosis-treatment-part-2/. Published 2014. Accessed February 2, 2018.
  7. Christina Shenvi. Uncomplicated Urinary Tract Infection in Older Adults: Diagnosis and Treatment (Part 1). Academic Life in EM. https://www.aliem.com/2014/03/uncomplicated-urinary-tract-infection-older-adults-diagnosis-treatment-1/. Published 2014. Accessed February 2, 2018.
  8. Ouslander JG, Schapira M, Schnelle JF, Fingold S. Pyuria among chronically incontinent but otherwise asymptomatic nursing home residents. J Am Geriatr Soc. 1996;44(4):420-423. http://www.ncbi.nlm.nih.gov/pubmed/8636589. Accessed February 2, 2018.
  9. Sanchez G V, Master RN, Karlowsky JA, Bordon JM. In vitro antimicrobial resistance of urinary Escherichia coli isolates among U.S. outpatients from 2000 to 2010. Antimicrob Agents Chemother. 2012;56(4):2181-2183. doi:10.1128/AAC.06060-11 [doi].
  10. Hooton TM, Gupta K. Acute uncomplicated cystitis and pyelonephritis in women. http://uptodate.com. Published 2014.
  11. Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures. J Am Geriatr Soc. October 2015. doi:10.1111/jgs.13807 [doi].
  12. Oplinger M, Andrews CO. Nitrofurantoin contraindication in patients with a creatinine clearance below 60 mL/min: looking for the evidence. Ann Pharmacother. 2013;47(1):106-111. doi:10.1345/aph.1R352 [doi].
  13. Panel B the AGS 2015 BCUE. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. October 2015. doi:10.1111/jgs.13702 [doi].
  14. Loeb M, Bentley DW, Bradley S, et al. Development of Minimum Criteria for the Initiation of Antibiotics in Residents of Long-Term–Care Facilities: Results of a Consensus Conference. Infect Control Hosp Epidemiol. 2001;22(2):120-124. doi:10.1086/501875.

This podcast uses sounds by Jobro and HerbertBoland

Image credit [1]

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