Pyuria among chronically incontinent but otherwise asymptomatic nursing home residents

Urinary and Double Incontinence in Cognitively Impaired Patients: Impacts on Those Affected and Their Professional Caregivers

Urinary or double incontinence in frail elderly people is common and leads to a reduction in quality of life and an increased burden on the patients' caregivers. Up to now, no special instrument has been available to assess the impact of incontinence on cognitively impaired patients and their professional caregivers. Thus, the outcomes of incontinence-specific medical and nursing interventions for cognitively impaired individuals are not measurable. Our aim was to investigate the impacts of urinary and double incontinence on both the affected patients and their caregivers using the newly developed "International Consultation on Incontinence Questionnaire Cognitively Impaired Elderly" (ICIQ-Cog) tool. The severity of incontinence was measured by incontinence episodes per night/per 24 h, the type of incontinence, the type of incontinence devices used, and the proportion of incontinence care out of total care; all these measures were correlated to the ICIQ-Cog. Incontinence episodes per night and the proportion of incontinence care out of total care showed significant correlations with the patient- and caregiver-related ICIQ-Cog scores. Both items have negative effects on patient quality of life and caregiver burden. Improving nocturnal incontinence and reducing the need for incontinence care overall can decrease the incontinence-specific bother of affected patients and their professional caregivers. The ICIQ-Cog can be used to verify the impacts of medical and nursing interventions.

Prevalence, impact, and management strategies for asymptomatic bacteriuria in the acute care elderly patient: a review of the current literature

Introduction: It is unclear how to prevent the negative impact of inappropriate urine cultures in older acute care patients who have a high rate of asymptomatic bacteriuria.Areas covered: A nonsystematic literature review of the definition, impact, and management of elderly acute care patients with asymptomatic bacteriuria (ASB).Expert opinion: In the elderly, patients with ASB include those with extra-urinary tract diseases (e.g. pneumonia) and those with symptoms/signs that resolve without antibiotic therapy, but the diagnosis of ASB is unclear in febrile patients responding to antibiotics. We consider four management strategies that could decrease the negative impact of culturing the urine including unnecessary antibiotic therapy in those with ASB: (1) Prevent urine testing in patients with extra-urinary tract reasons for their acute care (2) Cancel urine cultures if the urine dipstick is negative. (3) Avoid catheterization in stable patients who cannot provide a urine specimen on demand and (4) Withhold antibiotics in stable non-febrile elderly patients who do not have new local urinary tract symptoms or decompensation on follow-up, and pursue further investigations for another etiology/diagnosis.

Urine cultures in a long-term care facility (LTCF): time for improvement

Background

Urinary tract infections (UTIs) are the most prevalent infections in long-term care facilities (LTCFs). Numerous studies have described the problem of inadequate UTI diagnosis and treatment. We assessed the role of urine cultures in the diagnosis and treatment of UTIs in a LTCF.

Methods

In a 370-bed non-academic LTCF a retrospective assessment of antibiotic (AB) prescriptions for UTIs and urine cultures was performed from July 2014 to January 2016. The reasons why physicians, including 11 nursing home physicians and 2 junior doctors, ordered urine cultures were recorded using questionnaires.

Results

During the study period, 378 residents were prescribed 1672 AB courses; 803 were for UTIs. One hundred and fifty-five urine cultures were obtained from 135 residents; 66 of these cultures were performed on the same day as ABs were prescribed (8% of all prescriptions for UTI), while 89 were not. There was a discrepancy between the actions that seemed logical based on the culture results and the actions that were actually taken in 75% of the cases. In these cases, initial AB treatment was not adjusted when the isolated microorganism was resistant to the AB prescribed, the urine culture was positive and no ABs had previously been administered, or ABs were prescribed and no microorganism was isolated.

The most frequent reason for ordering a urine culture was to confirm the diagnosis of a UTI.

Conclusion

In the majority of patients, AB therapy was not adjusted when the urine culture results suggested it may be appropriate. The physicians were erroneously convinced that UTIs could be diagnosed by a positive urine culture.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0909-x) contains supplementary material, which is available to authorized users.

Diagnosis and treatment of urinary tract infections across age groups

Urinary tract infections are the most common outpatient infections, but predicting the probability of urinary tract infections through symptoms and test results can be complex. The most diagnostic symptoms of urinary tract infections include change in frequency, dysuria, urgency, and presence or absence of vaginal discharge, but urinary tract infections may present differently in older women. Dipstick urinalysis is popular for its availability and usefulness, but results must be interpreted in context of the patient's pretest probability based on symptoms and characteristics. In patients with a high probability of urinary tract infection based on symptoms, negative dipstick urinalysis does not rule out urinary tract infection. Nitrites are likely more sensitive and specific than other dipstick components for urinary tract infection, particularly in the elderly. Positive dipstick testing is likely specific for asymptomatic bacteriuria in pregnancy, but urine culture is still the test of choice. Microscopic urinalysis is likely comparable to dipstick urinalysis as a screening test. Bacteriuria is more specific and sensitive than pyuria for detecting urinary tract infection, even in older women and during pregnancy. Pyuria is commonly found in the absence of infection, particularly in older adults with lower urinary tract symptoms such as incontinence. Positive testing may increase the probability of urinary tract infection, but initiation of treatment should take into account risk of urinary tract infection based on symptoms as well. In cases in which the probability of urinary tract infection is moderate or unclear, urine culture should be performed. Urine culture is the gold standard for detection of urinary tract infection. However, asymptomatic bacteriuria is common, particularly in older women, and should not be treated with antibiotics. Conversely, in symptomatic women, even growth as low as 10² colony-forming unit/mL could reflect infection. Resistance is increasing to fluoroquinolones, beta-lactams, and trimethoprim-sulfamethoxazole. Most uropathogens still display good sensitivity to nitrofurantoin. First-line treatments for urinary tract infection include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when resistance levels are <20%). These antibiotics have minimal collateral damage and resistance. In pregnancy, beta-lactams, nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole can be appropriate treatments. Interpreting the probability of urinary tract infection based on symptoms and testing allows for greater accuracy in diagnosis of urinary tract infection, decreasing overtreatment and encouraging antimicrobial stewardship.

Sensitivity of the dipstick in detecting bacteremic urinary tract infections in elderly hospitalized patients

BACKGROUND

The sensitivity of the dipstick in elderly patients with a suspected urinary tract infection (UTI) is unclear because of the inclusion of patients with urine contamination or asymptomatic bacteriuria in previous studies.

METHODS

We selected consecutive patients aged 65 years or older hospitalized in internal medicine departments with bacteremic UTI (same organism in blood and urine cultures) minimizing misclassifications. The false positive rate was determined in consecutive patients with negative culture results. A positive dipstick was a test result with a trace leukocyte esterase and/or nitrite positivity. Bacteriuria was the growth of at least 105 colony-forming units per milliliter of urine.

RESULTS

Of 20,555 consecutive patients, 228 had a bacteremic UTI, and 4069 a negative culture result. The sensitivity of the dipstick was 96.9% (95% CI-93.7-98.6) with a false positive rate of 42.4% (95% CI, 41.0-43.8) in those with a negative culture result.

CONCLUSIONS

In elderly hospitalized patients with a bacteremic UTI, the dipstick urinalysis is highly sensitive, much higher than reported previously in studies of UTIs in the elderly. It is unclear whether the observed high sensitivity of the dipstick was due to the exclusion of patients with asymptomatic bacteriuria or to spectrum bias. Studies of the clinical utility/disutility of using a negative dipstick to rule out a urinary tract infection are warranted.

Management of Asymptomatic Bacteriuria, Urinary Catheters and Symptomatic Urinary Tract Infections in Patients Undergoing Surgery for Joint Replacement: A Position Paper of the Expert Group 'Infection' of swissorthopaedics

In this position paper, we review definitions related to this subject and the corresponding literature. Our recommendations include the following statements. Asymptomatic bacteriuria, asymptomatic leukocyturia, urine discolouration, odd smell or positive nitrite sediments are not an indication for antimicrobial treatment. Antimicrobial treatment of asymptomatic bacteriuria does not prevent periprosthetic joint infection, but is associated with adverse events, costs and antibiotic resistance development. Urine analyses or urine cultures in asymptomatic patients undergoing orthopaedic implants should be avoided. Indwelling urinary catheters are the most frequent reason for healthcare-associated urinary tract infections and should be avoided or removed as soon as possible.

Asymptomatic Bacteriuria and Bacterial Interference

Asymptomatic bacteriuria is very common. In healthy women, asymptomatic bacteriuria increases with age, from <1% in newborns to 10% to 20% of women age 80 years, but is uncommon in men until after age 50 years. Individuals with underlying genitourinary abnormalities, including indwelling devices, may also have a high frequency of asymptomatic bacteriuria, irrespective of age or gender. The prevalence is very high in residents of long-term-care facilities, from 25% to 50% of women and 15% to 40% of men. Escherichia coli is the most frequent organism isolated, but a wide variety of other organisms may occur. Bacteriuria may be transient or persist for a prolonged period. Pregnant women with asymptomatic bacteriuria identified in early pregnancy and who are untreated have a risk of pyelonephritis later in pregnancy of 20% to 30%. Bacteremia is frequent in bacteriuric subjects following mucosal trauma with bleeding, with 5% to 10% of patients developing severe sepsis or septic shock. These two groups with clear evidence of negative outcomes should be screened for bacteriuria and appropriately treated. Asymptomatic bacteriuria in other populations is benign and screening and treatment are not indicated. Antimicrobial treatment has no benefits but is associated with negative outcomes including reinfection with antimicrobial resistant organisms and a short-term increased frequency of symptomatic infection post-treatment. The observation of increased symptomatic infection post-treatment, however, has led to active investigation of bacterial interference as a strategy to prevent symptomatic episodes in selected high risk patients.

Febrile urinary tract infection in the emergency room. Curr Opin Infect Dis. 2015;28:106-111. [PMID: 25402776 DOI: 10.1097/qco.0000000000000121]

PURPOSE OF REVIEW

To review the recent advances in the diagnostic and therapeutic approach to adults presenting with febrile urinary tract infection (UTI) in the emergency department (ED).

RECENT FINDINGS

Recent research suggests overdiagnosis and therefore overtreatment of UTI in the ED, especially in the elderly. Antimicrobial pretreatment, an indwelling catheter, and malignancy are independent risk factors for bacteremia with uropathogens that cannot be cultured from urine. A simple clinical prediction rule can predict clinically relevant radiologic findings in patients with invasive UTI. Procalcitonin is a marker for bacteremia; pro-adrenomedullin predicts a complicated course and 30-day mortality in complicated UTI. Several reports have identified the risk factors for resistant uropathogens in community-acquired febrile UTI. Adherence to the guidelines and early culture-guided intravenous-to-oral switch reduces the length of hospitalization.

SUMMARY

An effective strategy is needed to improve the diagnosis of UTIs in acute care. Further research regarding biomarker-guided triage might improve the management of patients with febrile UTI. Future efforts should be directed toward the improvement of adherence to UTI treatment guidelines.

Bacteruria and Urinary Tract Infections in the Elderly

Both urinary tract infection (UTI) and asymptomatic bacteriuria (ASB) are common problems among elderly adults and represent a significant health care burden. Despite their frequency, differentiating between ASB and true UTI remains controversial among health care providers. Several challenges exist in the evaluation of urinary symptoms in the elderly patient. Symptoms of UTI are variable; problems are encountered in the collection, testing, and interpretation of urine specimens; and results of urinalysis are often misinterpreted and mishandled. Multiple studies have shown no morbidity or mortality benefit to antibiotic therapy in either community or long-term care facility residents with ASB.

Urinary tract infections in older women: a clinical review

IMPORTANCE

Asymptomatic bacteriuria and symptomatic urinary tract infections (UTIs) in older women are commonly encountered in outpatient practice.

OBJECTIVE

To review management of asymptomatic bacteriuria and symptomatic UTI and review prevention of recurrent UTIs in older community-dwelling women.

EVIDENCE REVIEW

A search of Ovid (Medline, PsycINFO, Embase) for English-language human studies conducted among adults aged 65 years and older and published in peer-reviewed journals from 1946 to November 20, 2013.

RESULTS

The clinical spectrum of UTIs ranges from asymptomatic bacteriuria, to symptomatic and recurrent UTIs, to sepsis associated with UTI requiring hospitalization. Recent evidence helps differentiate asymptomatic bacteriuria from symptomatic UTI. Asymptomatic bacteriuria is transient in older women, often resolves without any treatment, and is not associated with morbidity or mortality. The diagnosis of symptomatic UTI is made when a patient has both clinical features and laboratory evidence of a urinary infection. Absent other causes, patients presenting with any 2 of the following meet the clinical diagnostic criteria for symptomatic UTI: fever, worsened urinary urgency or frequency, acute dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness. A positive urine culture (≥105 CFU/mL) with no more than 2 uropathogens and pyuria confirms the diagnosis of UTI. Risk factors for recurrent symptomatic UTI include diabetes, functional disability, recent sexual intercourse, prior history of urogynecologic surgery, urinary retention, and urinary incontinence. Testing for UTI is easily performed in the clinic using dipstick tests. When there is a low pretest probability of UTI, a negative dipstick result for leukocyte esterase and nitrites excludes infection. Antibiotics are selected by identifying the uropathogen, knowing local resistance rates, and considering adverse effect profiles. Chronic suppressive antibiotics for 6 to 12 months and vaginal estrogen therapy effectively reduce symptomatic UTI episodes and should be considered in patients with recurrent UTIs.

CONCLUSIONS AND RELEVANCE

Establishing a diagnosis of symptomatic UTI in older women requires careful clinical evaluation with possible laboratory assessment using urinalysis and urine culture. Asymptomatic bacteriuria should be differentiated from symptomatic UTI. Asymptomatic bacteriuria in older women should not be treated.

Clinical features to identify urinary tract infection in nursing home residents: a cohort study

OBJECTIVES

To identify clinical features associated with bacteriuria plus pyuria in noncatheterized nursing home residents with clinically suspected urinary tract infection (UTI).

DESIGN

Prospective, observational cohort study from 2005 to 2007.

SETTING

Five New Haven, Connecticut area nursing homes.

PARTICIPANTS

Five hundred fifty-one nursing home residents each followed for 1 year for the development of clinically suspected UTI.

MEASUREMENTS

The combined outcome of bacteriuria (>100,000 colony forming units from urine culture) plus pyuria (>10 white blood cells from urinalysis).

RESULTS

After 178,914 person-days of follow-up, 228 participants had 399 episodes of clinically suspected UTI with a urinalysis and urine culture performed; 147 episodes (36.8%) had bacteriuria plus pyuria. The clinical features associated with bacteriuria plus pyuria were dysuria (relative risk (RR)=1.58, 95% confidence interval (CI)=1.10-2.03), change in character of urine (RR=1.42, 95% CI=1.07-1.79), and change in mental status (RR=1.38, 95% CI=1.03-1.74).

CONCLUSION

Dysuria, change in character of urine, and change in mental status were significantly associated with the combined outcome of bacteriuria plus pyuria. Absence of these clinical features identified residents at low risk of having bacteriuria plus pyuria (25.5%), whereas presence of dysuria plus one or both of the other clinical features identified residents at high risk of having bacteriuria plus pyuria (63.2%). Diagnostic uncertainty still remains for the vast majority of residents who meet only one clinical feature. If validated in future cohorts, these clinical features with bacteriuria plus pyuria may serve as an evidence-based clinical definition of UTI to assist in management decisions.

Evidence rocks in long-term care, but does it roll?

This article reviews the problems with the implementation of evidence-based care in long-term care. It highlights the fact that many common practices are incompatible with evidence and that available evidence, including evidence about inadvisable and ineffective treatments, is often not followed. Often, there is a tendency to follow recommendations for younger persons (for example, the management of hypertension and elevated cholesterol), or to use questionable interventions (for example, choices for treating constipation). In many cases, the treatments used have only marginal efficacy and increased potential for side effects. This article makes recommendations for improving the approach to evidence-based care in long-term care and strongly urges the FDA to require drug studies in nursing homes.

Diagnostic accuracy of criteria for urinary tract infection in a cohort of nursing home residents

OBJECTIVES

To prospectively evaluate nursing home residents with suspected urinary tract infection (UTI) to determine whether they met the McGeer, Loeb, or revised Loeb consensus-based criteria and whether any set of criteria was associated with laboratory evidence of UTI, namely bacteriuria (>100,000 colony forming units) plus pyuria (>10 white blood cells).

DESIGN

Prospective cohort study.

SETTING

Three New Haven-area nursing homes.

PARTICIPANTS

Of 611 residents screened, 457 were eligible, 362 consented, and 340 enrolled.

MEASUREMENTS

Participants underwent prospective surveillance from May 2005 to April 2006 for the development of suspected UTI (defined as a participant's physician or nurse clinically suspecting UTI). One hundred participants with suspected UTI and a urinalysis and urine culture performed were included in the analyses.

RESULTS

Participants were identified who met the criteria of McGeer, Loeb, revised Loeb, and laboratory evidence of UTI. Using laboratory evidence of UTI as the outcome, the McGeer criteria demonstrated 30% sensitivity, 82% specificity, 57% positive predictive value (PPV), and 61% negative predictive value (NPV); the Loeb criteria showed 19% sensitivity, 89% specificity, 57% PPV, and 59% NPV; and the revised Loeb criteria demonstrated 30% sensitivity, 79% specificity, 52% PPV, and 60% NPV.

CONCLUSION

All of the consensus-based criteria have similar test characteristics. The diagnostic accuracy of UTI criteria in nursing home residents could be improved, and the data suggest that evidence-based clinical criteria associated with laboratory evidence of UTI need to be identified and validated.

Role of dipstick testing in the evaluation of urinary tract infection in nursing home residents

Among 101 nursing home residents with suspected urinary tract infection (UTI), we determined the negative predictive value of dipstick testing for leukocyte esterase and nitrite to be 100% (95% confidence interval, 74%-100%), compared with laboratory evidence of UTI (greater than 10 white blood cells/mm(3) on urinalysis and greater than 100,000 colony forming units/mL on urine culture). Nursing home dipstick testing effectively excluded the possibility of UTI.

A survey regarding the use of the dipstick/pad method with elderly, incontinent patients

OBJECTIVE

To determine if nurses and physicians would use the dipstick/pad method to test urine in elderly, incontinent patients with suspected urinary tract infection.

DESIGN

A cross-sectional survey was sent to 1900 physicians and nurses.

SETTING AND SUBJECTS

A convenience sample of nurses and geriatricians, family practice, and internal medicine physicians was obtained from lists on the Internet, a geriatric care conference, and a geriatric nursing journal mailing list.

INSTRUMENTS

A 3-part questionnaire queried: (1) whether respondents would use the dipstick/pad method; (2) would they use results to initiate or monitor nonantibiotic interventions, antibiotic interventions, or determine further laboratory analysis; (3) would a particular combination of nitrite and leukocyte esterase results determine the need for further laboratory testing. Nurses were also asked if they had used results of dipstick urinalysis in their management of urinary tract infections.

METHODS

The questionnaire was mailed to 300 geriatric physicians, 1000 internal medicine and family practice physicians, and 600 nurses.

RESULTS

A total of 373 individuals (20%) responded to the survey. Sixty-five percent of the nurses responding had not used dipstick results; 90% of these nurses would consider using dipstick/pad results. Ninety-five percent of both the physician groups and the nurses who had previously used dipstick results indicated that they would consider using the dipstick/pad method. Determining the need for further laboratory analyses was the most accepted application by all groups. No combination of nitrite and leukocyte esterase dipstick results elicited greater than a 76% agreement by either physician group with regard to outcomes for further analyses.

CONCLUSIONS

Although the response rate was low, the results of this survey suggest that healthcare workers would consider using the dipstick/pad method with incontinent elderly patients in the assessment of a urinary tract infection, primarily to determine further laboratory tests.

A protocol for the urine dipstick/pad method

The urinary tract accounts for nearly one third of all infections in the long-term care setting. This article reviews factors that influence nitrite and leukocyte esterase results obtained from traditional urine dipstick analysis for assessment of urinary tract infections in elderly long-term care residents. This article also proposes a protocol for a urine dipstick pressed into an incontinence pad as an alternative to dipstick analysis of a clean-catch or catheterized urine specimen.

Nursing home practitioner survey of diagnostic criteria for urinary tract infections

OBJECTIVES

To identify clinical and laboratory criteria used by nursing home practitioners for diagnosis and treatment of urinary tract infections (UTIs) in nursing home residents. To determine practitioner knowledge of the most commonly used consensus criteria (i.e., McGeer criteria) for UTIs.

DESIGN

Self-administered survey.

SETTING

Three New Haven-area nursing homes.

PARTICIPANTS

Physicians (n=25), physician assistants (PAs, n=3), directors/assistant directors of nursing (n=8), charge nurses (n=37), and infection control practitioners (n=3).

MEASUREMENTS

Open- and closed-ended questions.

RESULTS

Nineteen physicians, three PAs, and 41 nurses completed 63 of 76 (83%) surveys. The five most commonly reported triggers for suspecting UTI in noncatheterized residents were change in mental status (57/63, 90%), fever (48/63, 76%), change in voiding pattern (44/63, 70%), dysuria (41/63, 65%), and change in character of urine (37/63, 59%). Asked to identify their first diagnostic step in the evaluation of UTIs, 48% (30/63) said urinary dipstick analysis, and 40% (25/63) said urinalysis and urine culture. Fourteen of 22 (64%) physicians and PAs versus 40 of 40 (100%) nurses were aware of the McGeer criteria for noncatheterized patients (P<.001); 12 of 22 (55%) physicians and PAs versus 38 of 39 (97%) nurses used them in clinical practice (P<.001).

CONCLUSION

Although surveillance and treatment consensus criteria have been developed, there are no universally accepted diagnostic criteria. This survey demonstrated a distinction between surveillance criteria and criteria practitioners used in clinical practice. Prospective data are needed to develop evidence-based clinical and laboratory criteria of UTIs in nursing home residents that can be used to identify prospectively tested treatment and prevention strategies.

Urinary tract infections in the frail elderly: Issues for diagnosis, treatment and prevention

Urinary tract infections (UTIs) are among the most common infections in frail elderly adults, whether they are community dwelling, live in long term care facilities (LTCFs) or are hospitalized. UTIs cause substantial morbidity and mortality in frail elderly men and women. While many major risk factors in these individuals may not be modifiable, improved attention to incontinence management, judicious use of antimicrobials and urinary catheters, and, in women, appropriate use of topical estrogen may be useful in reducing UTIs. Future strategies may also include the appropriate use of new urinary catheter technology and emerging vaccines.

Antimicrobial susceptibilities of urinary pathogens in a multidisciplinary long-term care facility

In order to determine bacterial distribution and antimicrobial susceptibility of urinary pathogens in a long-term-care-facility (LTCF), urine cultures were examined when clinically indicated. The LTCF consists of 286 beds, housing 931 residents during 32 months, in various wings; independent and frail residents (wing-A), nursing and demented patients (wing-B), and skilled-nursing patients (wing-C). A total of 1,401 positive urine cultures were obtained: E. coli was isolated significantly less often in wing-C than in wing-A (p = 0.02) and wing-B (p = 0.009). There was no significant difference in frequency of other organisms. Susceptibility of organisms decreased significantly from wing-C to wing-B (p < 0.05-0.001), and from wing-B to wing-A (p < 0.05-0.001). Susceptibility rates' decreased significantly over time in wing-B, less in wing-C and not at all in wing-A.

IN CONCLUSION

When selecting empiric antibiotic therapy for serious urinary tract infection in a long-term-care resident, one should take into account the microbial environment of the individual patient's department.

Urinary tract infection at the age extremes: pediatrics and geriatrics

Urinary tract infections (UTIs) are common and generally benign conditions among healthy, sexually active young women without long-term medical sequelae. In contrast, UTIs are more complicated among those individuals at either end of the age spectrum: infants/young children and geriatrics. UTI in children younger than 2 years has been associated with significant morbidity and long-term medical consequences, necessitating an extensive and somewhat invasive imaging evaluation to identify possible underlying functional or anatomic abnormalities. Pediatric UTI should be considered complicated until proved otherwise, and treatment should reflect the severity of signs and symptoms. Management in the acutely ill child frequently involves parenteral broad-spectrum antimicrobial agents, and less ill children can be treated with trimethoprim- sulfamethoxazole (TMP-SMX), beta-lactams, and cephalosporins.UTI among older patients (>65 years) may be complicated by comorbidities, the baseline presence of asymptomatic bacteriuria, and benign urinary symptoms that can complicate diagnosis. The etiology of UTI encompasses a broader spectrum of infecting organisms than is seen among younger patients and includes more gram-positive organisms. Symptomatic UTI is generally more difficult to treat than among younger populations. Management should be conservative, of longer treatment durations, and cover a broad spectrum of possible uropathogens. Oral or parenteral treatment with a fluoroquinolone for 7 days is the preferred empiric approach. TMP-SMX can also be considered a first-line agent in women only, but only if the pathogen is known to be TMP-SMX sensitive.

Systematic review of nursing management of urinary tract infections in the cognitively impaired elderly client in residential care: is there a hole in holistic care?

A systematic review of the current literature available exposed the deficit in nursing research as a resource for planning strategies and procedures in the care of a urinary tract infection. The cognitively impaired older client living in residential care is at particular risk because of their inability to articulate their problems, the subtle presentation of symptoms and the overuse of antibiotic therapy that has led to an increase in resistant organisms. The fiscal responsibility now required by health authorities highlights the need for a more enlightened approach to this distressing condition from those registered nurses in the front line of care.

Diagnosis and management of urinary incontinence in the older patient

OBJECTIVES

To review the various causes of urinary incontinence (UI) in elderly patients and to outline a therapeutic approach to the clinical management of UI.

DATA SOURCES

Online search of MEDLINE and additional references selected from the articles found during the search.

STUDY SELECTION

All peer-reviewed articles and review articles listed on MEDLINE published between 1966 and 1999. Key search terms included urinary incontinence, geriatric, aging, pelvic floor rehabilitation, and indwelling catheter.

DATA EXTRACTION

Articles with clinical relevance to the geriatric population were selected based on the robustness of the studies and reviews. If applicable, data from studies of healthier or younger populations was extrapolated to the elderly population examined in this review.

DATA SYNTHESIS

UI is a common occurrence among older adults treated in rehabilitation settings. The causes of UI in the elderly vary, including transient causes, established pathologic states of the urinary tract, and systemic multifactorial influences. Both behavioral and pharmacologic management strategies can successfully be implemented for UI, even in the frail elderly.

CONCLUSION

UI can be effectively investigated and treated by rehabilitation practitioners by following a simple, stepwise approach.

Hospital-acquired infection in elderly patients

Increasing numbers of elderly people are being treated in hospitals and are at particular risk of acquiring infections. The incidence, risk factors and types of hospital-acquired infection (HAI) in the elderly are reviewed. Special reference is made to urinary tract infections, respiratory tract infections, gastrointestinal infections including Clostridium difficile, bacteraemia, skin and soft tissue infections and infections with antibiotic-resistant organisms.

Aging and the lower urinary tract

Lower urinary tract symptoms and disorders are prevalent and bothersome in the rapidly growing aging population. Common symptoms include urinary frequency, nocturia, urgency, and incontinence. Among older men, symptoms of voiding difficulty, such as hesitancy, slow stream, and straining, are also common. A variety of aging changes, as well as age-associated disease, predispose older people to the development of lower urinary tract symptoms. Medications used to treat conditions outside the lower urinary tract also can contribute to these symptoms. Physicians and other health professionals should routinely ask specific questions about lower urinary tract symptoms in their older patients and evaluate them thoroughly when they are present.

Diagnostic assessment of geriatric urinary incontinence

Urinary incontinence affects 15% to 30% of the population and 50% of those living in nursing homes. Care for incontinence is difficult because this condition is underreported by patients and underdiagnosed by physicians. This article describes the medical and nursing diagnostic assessment of urinary incontinence of geriatric populations, and the criteria for referral. Comprehensive review of urinary incontinence, including treatment, is available elsewhere. Although this article focuses on the assessment of urinary incontinence, the type of treatment being considered guides the scope of the evaluation, and therefore, treatment of incontinence is discussed.