Riesa Gusewelle, MNSc, RN, APRN, GNP-BC OBJECTIVES Identify early warning signs of urinary tract infections (UTIs) in older adults Describe actions to take for early management of UTIs in older adults List factors that prevent or minimize UTI s in older adults 1
FIRST: WHAT ARE UTI S? Caused by germs, usually bacteria, that enter the urethra and then the bladder Once in the bladder, they can lead to infection that can then spread to the kidneys and then lead to infection throughout the body, sepsis RISK FACTORS FOR GETTING UTI S Women more so than men Users of pessaries or urethral medications Menopausal women Sexual activity: in women vaginal intercourse or masturbation; in men rectal intercourse Spinal cord injuries or multiple sclerosis Many women suffer from recurrent UTI s. Nearly 20% of women who have a UTI will have another, and 30% of those will have yet another. Of this last group.80% will continue to have recurrence Each infection will have a strain or type of bacteria that is different from the previous infection 2
THE COMORBITIES THAT INCREASE THE CHANCES FOR UTI S Diabetes Advancing age Problems empting the bladder, such as urinary retention Having a urinary foley catheter Bowel incontinence &/or improper perineal hygiene Enlarged prostate, or anything that blocks the flow of urine Kidney stones Laying still or immobility for long periods, such as with flu or recovering from hip fracture Any surgery or procedure involving the urethra, like an in and out catheter Chronic urinary tract problem leading to stasis Low urinary ph Decreased fluid intake Decreased thirst mechanism 3
UTI s are serious health problems Affecting millions of people each year 1 woman in 5 develop a UTI in her lifetime Symptomatic UTI s are the most common infectious problem among older adults both in the community and institutional settings Important issues The diagnosis of symptomatic UTI among older adults is complicated by the high prevalence of asymptomatic bacteriuria, which does not require any treatment, and the difficulty in interpreting the signs and symptoms of UTI in a population in which significant comorbidities can cause problems in the communication between the patient and the medical team. The constant increase in antimicrobial resistance, especially in long-term care facilities, where antimicrobial use is greater than in the community. Financial implications The financial implications for the health care system are staggering: more than $2 billion annually for the total cost of both community- and hospital acquired infections in the U.S. alone Account for about 8.3 million provider visits each year 4
PREVALENCE In the community setting, the rate of UTI accounts for 24% of all diagnosed infections, followed by respiratory tract infections UTIs are prevalent in 33 50% of older women with incontinence In patients without an indwelling catheter is between 25% and 50% for women and 15% and 40% for men UTIS ARE THE MOST COMMON INFECTION REPORTED IN LONG TERM CARE FACILITIES They account for 25 30% of all bacterial infections 5 10% of the institutionalized population use chronic indwelling catheters There is a presence of significant comorbidities Increase of residents with incontinence of both urine and bowel The risk of transmission of uropathogens from resident to resident have been associated with both asymptomatic and symptomatic infections **The more impaired or frail the individual, the higher the risk for a symptomatic or asymptomatic UTI** 5
DETECTION OF UTIS IN OLDER ADULTS Classic symptoms and signs for UTI include: Painful urination Incontinence, either new onset or a worsening of incontinence Increased frequency &/or urgency, with a strong need to go even right after empting the bladder Cloudy, milky, bloody or odorous urine (unless had asparagus lately) Pressure, cramping or pain in the lower abdomen or back Confusion, or change in cognitive status Fever, although older adults may not spike a fever until very ill OR their fever may be only 1-2 degree above their normal. Their normal may be 96 or 97 degree F A general feeling bad all over Some men may feel a fullness in the rectum IF THE INFECTION SPREAD TO THE KIDNEYS. Chills and shaking or night sweats Fatigue and general ill feeling Fever over 101 Side, back or groin pain Flushed, warm, or reddened skin Confusion, or change in cognitive status Falls Nausea or vomiting General abdominal pain 6
EARLY MANAGEMENT OF UTI S IN OLDER ADULTS Early detection of UTIs in older adults is the key to minimize illness Obtain urinalysis and culture (either clean catch or in & out catheterization) prior to any antibiotic treatment Sometimes CBC or blood cultures obtained Starting therapy AS SOON AS POSSIBLE, generally Ciprofloxacin or Levofloxacin are started. As they have broad spectrum capabilities and low resistance so far KEY THINGS TO REMEMBER Antibiotics MUST be started ASAP, taken daily as ordered AND taken to full number of doses and days ordered to prevent resistance or risk incomplete eradication of infection Follow up on urine culture results as organism may be resistant to antibiotic started and will need to identify AS SOON AS POSSIBLE and start the correct medication HAVE PATIENTS DRINK PLENTY OF WATER, IN ANY FORM!! Avoid carbonated beverages, and if possible caffeine and citrus juices Do not douche or use feminine hygiene sprays, powders, or any product containing perfumes in the perineal area Do NOT use catheters unless ABSULUTELY necessary, and then use VERY sterile technique 7
PREVENTION OF UTI S IN OLDER ADULTS Change peri-pads every time the person goes to the bathroom If in adult diapers, check patients that have mobility or memory issues with changing their own attends every 2-4 hours and change them every when they are soiled do not wait until they are soaked or over flowing to change the briefs. Or better yet, take them to the toilet every 2-4 hours for bowel and bladder training. Do not douche or use feminine hygiene sprays, powders, or any product containing perfumes in the perineal area Do NOT use catheters unless ABSULUTELY necessary, and then use VERY sterile technique Avoid tight fitting underwear and britches Wear cotton cloth or at least cotton panel crotch in underwear and pantyhose. Change the underwear/pantyhose AT LEAST once a day Drink or assist persons in drinking 64 oz water, and water based fluids daily Take showers instead of baths. Avoid bath oils Keep the perineal area clean, including cleaning genital and anal areas before and after sexual activity, including masturbation in women Urinate before and after sexual activity For women, wipe front to back AT ALL TIMES after using the toilet, or when cleaning persons up after incontinence 8
Drink cranberry juice or cranberry tablets, but NOT if there is a personal or family history of kidney stones. It is thought to help inhibit the ability of bacteria to adhere to the surface membrane of cells in the urinary tract. Cranberry also has anti-inflammatory properties and antioxidant activity The American College of ObGyns released evidenced based clinical practice guidelines in 2008 on uncomplicated UTIs in non-pregnant women that included drinking cranberry juice had shown to decrease recurrence. Although the length of time to drink it and amount that was beneficial was not determined DO NOT drink fluids/foods that irritate the bladder, such as alcohol, caffeine and carbonated beverages. Many times citrus foods and drinks can irritate the bladder also. Do not hold or resist urinating when you have the urge to go NURSES this is especially for you!! REFERENCES Urinary Tract Infection-Adults. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/000521.ht m Urinary Tract Infections. http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult Urinary Tract Conditions:Examining The Evidence on Cranberry And Saw Palmetto. NIH:National Center For Complimentary And Alternative Medicine. Hhtp://nccam.nih.gov/news/newsletter/2009_novem ber/urinarytractcond.htm 9