UTI in Elderly and Systemic Disease ewha univ. hosp. shim, bongsuk.
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Transcript of UTI in Elderly and Systemic Disease ewha univ. hosp. shim, bongsuk.
UTI inElderly and
Systemic Disease
ewha univ. hosp.
shim, bongsuk
1How to Manage UTI in the Elderly
Aging & Infection
UTI in the Elderly
Recurrent UTI
Asymptomatic Bacteriuria
CAUTI
Impact of Aging on Infections Impact of Aging on Infections
Aging increase risks of infection
Immune changes drops with age
Organ changes skin ; decrease protection bladder ; changes to increase UTIs
Age-related diseases cancer, diabetes, dementia, voiding dysfunction, etc
Physiologic changes hospitalized, institutionalization, medical procedures
Department visits by ElderlyDepartment visits by Elderly
Drach GW. AUA Update Series Vol 24 Lesson 33 2005
Infectious Disease in ElderlyInfectious Disease in Elderly
Yoshikawa TT. J Infect Dis 1997
UTI in the elderlyUTI in the elderly
extremely commonmost frequent infection among infectious
diseases in the elderlyrisk factors for developing UTIs
dementia, incontinence, decreased mobility
asymptomatic bacteriuria is common 15-30% in men 25-50% in women
Factors Associated with UTIFactors Associated with UTI
bothmen women
BPHProstate CaProstate stoneUrethral strictureEtc.
Coexisting diseasesDiabetes mellitusCerebrovascular accidentsDementiaIncreased hospitalizationsInstrumentationUrinary cathetersAlterations of immunity
Changes in bladderIntroital G(-) bacteria
colonization ↑Vaginal glycogen ↓
Vaginal pH ↑
Kunin CM. 1987
Underlying Dis. in complicated UTIUnderlying Dis. in complicated UTI
Causative Organisms of UTICausative Organisms of UTI
Escherichia coli most common, 60~70%, but relatively low rate
Proteus mirabilisKlebsiella pneumoniaeenterococci
more common than younger people
Pseudomonas aeruginosa leukemia, aplastic anemia, after GI tract manipulation
Staphylococcus rarely in elderly
Melani PN. Clin Geriatr 2005
classic symptoms dysuria, frequency, urgency absent, masked or difficult to assess only 20% with new urinary symptoms
upper UTI confusion (delirium), lethargy, agitation, collapse 15%, no fever and no leukocytosis deteriorate more rapidly from infection bacteremic UTI in the elderly
often present respiratory symptoms, treated as ‘Pneumonia’
Clinical PresentationClinical Presentation
Barkham, et al. Age & Ageing 1996
DiagnosisDiagnosis
historyphysical examinationlaboratories
urinalysis ; 5-10 WBC/HPF
urine culture & sensitivities ; >105 CFU/mL
may diagnose acute uncomplicated cystitis based on history, P/E, and U/A alone, no need for culture to treat
Therapy with AntibioticsTherapy with Antibiotics
3-day course for simple acute cystitis
7-day course complicated by hospitalization instrumentation of the urinary tract diabetes immunosuppression failure of previous therapy more than three infections in the previous year symptoms lasting over 7 days
Hooton TM. Med Clin North Am 1991Stamm WE. N Engl J Med 1993
Antibiotics for UTIAntibiotics for UTI
Adverse Effects of AntibioticsAdverse Effects of Antibiotics
Melani PN. Clin Geriatr 2005
Acute Pyelonephritis (1)Acute Pyelonephritis (1)
atypical clinical presentation fever, confusion, lethargy, nausea and vomiting often of little help in the diagnosis 15%, no fever or no leukocytosis
Laboratories three sets of blood cultures and one urine culture
Radiographic studies for urinary tract obstructive uropathy, calculous disease or abscess IVP, ultrasound or CT
Acute Pyelonephritis (2)Acute Pyelonephritis (2)
Treatments hospitalization : bed rest, adequate hydration,
symptomatic care
aminoglycoside (amikacin, gentamicin, tobramycin) + cephalosporin IV for 5~7 days
oral antibiotics for more 2 weeks
no response after 2-3 days : re-evaluation
Follow-up repeat UC at least 6 months after treatment
Preventing Recurrent UTI Preventing Recurrent UTI
Increased fluid intake no evidence, but it may be helpful
Antibiotic prophylaxis useful if >3 symptomatic UTIs/year risk of resistant organisms
Topical estrogen improves atrophic vaginitis encourages lactobacilli growth
Cranberry juice
Asymptomatic BacteriuriaAsymptomatic Bacteriuria
> 105 CFU/mL on 2 consecutive occasions no UTI symptomsmore common
in institutionalized or hospitalized patients
prevalence
Abrutyn E, et al. J Am Geriatr Soc 1988
Men Women
40 ~ 60 y.o 0.1% 5.0%
65~80
y.o
ambulatory population 6% 18%
nursing homes 23%
hospitals 32%
over 80 y.o 21% 25~50%
Clinical Significance of Asymptomatic BacteriuriaClinical Significance of Asymptomatic Bacteriuria
in the past increased mortality routine treatment Nordenstam GR, et al. N Engl J Med 1986
no direct causal association with mortalityrare proceeding to symptomatic UTInot recommend routine screening and
treatment Baldassarre JS. Med Clin North Am 1991
Kunin CM, et al. Am J Epidemiol 1992
No Screening for or Treatment of Asymptomatic BacteriuriaNo Screening for or Treatment of Asymptomatic Bacteriuria
pre-menopausal, non-pregnant women
diabetic women
older persons living in community
elderly institutionalized subjects
persons with spinal cord injury
catheterized patients while the catheter remains in situ
Boscia JA, et al. JAMA 1987Nicolle LE, et al. Am J Med 1987
Abrutyn E, et al. J Am Geriatr Soc 1988
Screening for or Treatment of Asymptomatic BacteriuriaScreening for or Treatment of Asymptomatic Bacteriuria
pregnant women
suspicious obstructive uropathy
before TURP
before urological interventions
before prosthetic device hip or cardiac valve
Nicolle LE, et al. Am J Med 1987Abrutyn E, et al. Ann Intern Med 1994
Catheter associated UTICatheter associated UTI
incidence 27% under 65, 52% over 65 10-15% of hospitalized patients with indwelling
catheter develop bacteriuria 3-5% per day of catheterization one-time catheterization ; 2% bacteriuria
gram(-) bacteremia most significant complication of CAUTI
greater antimicrobial resistanceabsence of symptoms no treatment
Garibaldi RA. N Engl J Med 1981, Gleckman R. J Urol 1982
세상에서 제일 무서운 여자는 ?세상에서 제일 무서운 여자는 ?4,50 대 남자들에게 물었습니다 .4,50 대 남자들에게 물었습니다 .바로 호랑이 마눌님 입니다 .바로 호랑이 마눌님 입니다 .
. 2How to Manage UTI in the Diabetes
DM and infection
Immune System in DM
UTI in the Diabetes
Emphysematous Pyelonephritis
Common UTIs in DM
Infection and DMInfection and DM
higher of incidence of infection complication & death - more frequent specific immunologic defects the risk factors of infection and resulting
complication duration of illness severity of non-infectious complications concurrent illnesses level of glucose control degree of medical supervision
Seymour A. Med J Aust 1963Robbins SL. N Engl J Med 1994
Pathogenesis of Renal Failure in DMPathogenesis of Renal Failure in DM
Diabetes and the Immune System (1)Diabetes and the Immune System (1)
function of PMN leukocytes depressed chemotactic index – diminished response diminished phagocytosis diminished bactericidal activity
monocyte function decreased circulating monocytes impaired monocyte chemotaxis
Mowat AG. N Engl J Med 1971Molenaar DM. Diabetes 1976
Geisler G. Acta Pathol Microbiol Immunol Scand 1982Hill HR. Clin Immunol 1983
Diabetes and the Immune System (2)Diabetes and the Immune System (2)
cell-mediated immunity decreased the transformation of lymphocytes decreased mitogenic response diminished release of migration-inhibition factor by T
lymphocytes
miscellaneous factors abnormalities in the microvascular circulation
decrease tissue perfusion
impair response to therapy
MacCuish AC. Diabetes 1974 Casey JI. J Infect Dis 1987
McMillan DE. Mayo Clin Proc 1988
Infectious Diseases in DMInfectious Diseases in DM
Infections strongly associated with diabetes Mucormycosis Malignant external otitis Emphysematous Pyelonephritis Emphysematous Cholecystitis
Infections possibly related to diabetes Urinary tract infections Fungal infections Staphylococcus aureus infections Soft-tissue infections Tuberculosis
UTI in the DiabetesUTI in the Diabetes
UTI more common more serious infections
increased risk of complicated pyelonephritis
asymptomatic bacteriuria is common cleared bacteriuria in short term but did not decrease number of symptomatic
episodes or hospitalizations does not reduce complications in diabetes
Harding, NEJM 2002
Common UTIs in DMCommon UTIs in DM
Emphysematous pyelonephritis Renal or perirenal abscess Papillary necrosis Xanthogranulomatous pyelonephritis Fourniere’s gangrene Staphylococcus bacteremia
Emphysematous Pyelonephritis (1)Emphysematous Pyelonephritis (1)
85-100% of patients ; associated with DM Michaeli J, et al. J Urol 1984
Zebbo A, et al. Urology 1985
10% of patient ; bilateral involvement glucosuria providing a substrate for
production of gas by fermentation
causative organisms E. coli, Klebsiella pneumoniae, Proteus mirabilis,
Enterobacter aurogenes Candida species
Therapy potent antibiotics, for several weeks? relieve any obstruction undertake percutaneous drainage consider nephrectomy if clinical improvement does
not occur
mortality rate medical : 75%, surgical : 23% Lowe FC & Walther JM. Urology 1986
Emphysematous Pyelonephritis (2)Emphysematous Pyelonephritis (2)
Renal Abscess Renal Abscess
twice frequency in DM Saiki J, et al. West J Med 1982
Plevin SN, et al. J Urol 1979
Pathogens E. coli, Klebsiella, Proteus
Treatment antibiotic therapy alone ; resolve prompt drainage ; no clinical improvement within a
few days, large collection, obstructive uropathy open incision and drainage ; no response to closed
drainage
Perinephric Abscess Perinephric Abscess
DM ; major contributing factor in perinephric abscess
14-75% of perinephric abscess ; DM Patterson JE. Infect Dis Clin North Am 1987
no symptoms resolving for pyelonephritis within 4-5 days prompt radiologic evaluation – CT scan
Treatment drainage in combination with a prolonged course of
antibiotics
Renal Papillary Necrosis (1)Renal Papillary Necrosis (1)
Brauner A. Diabetes Res 1987 DM increase risk of renal papillary necrosis patients with proteinuria in DM ; more infected with
P-fimbrated strains of E.coli
suspect of renal papillary necrosis frequent relapsing or difficult-to-eradicate
pyelonephritis fulminant presentation of pyelonephritis,
accompanied by hematuria more than 3 times UTI ; higher risk of papillary
necrosis
30-50% of papillary necrosis ; DM Mujais SK. Semin Nephrol 1984
Treatment eradication of infection ; intensive antibiotics catheter drainage or PCN for obstruction and
pyonephrosis appropriate duration of antibiotics ; not clearly
established nephrectomy
Renal Papillary Necrosis (2)Renal Papillary Necrosis (2)
Fungal Urinary Tract Infection Fungal Urinary Tract Infection
Candida albicans, Candida glabrata Roy JB, et al. Urology 1984
predisposing condition use of antibiotics, indwelling urinary catheter
role of DM not clear precisely
Treatment fluconazole orally
Fournier’s Gangrene Fournier’s Gangrene
subclassification of necrotizing fasciitis around the male genitalia
often in combination with DM, 40% bacteria
a mixture of gram-negative bacteria, anaerobes, streptococci
treatment wide surgical debridment of devitalized tissue
mortality rate 40-50% even with aggressive management