Page 55 - Retail Pharmacy March 2021

URINARY TRACT INFECTIONS IN THE ELDERLY: HOW AGE CHANGES MANAGEMENT APPROACH CPD ACTIVITY 53 Katherine Radnedge Katherine is an accredited pharmacist working in community pharmacy for the past 10 years. She has a passion for education and medication management and has previously worked as a professional practice pharmacist with the Pharmacy Guild’s intern training program. LEARNING OBJECTIVES After completing this CPD activity, pharmacists should be able to: • Recognise the difference between uncomplicated and complicated urinary tract infection (UTI) and how this guides treatment. • Recognise risk factors for UTIs and how these can change with age. • Identifyfirstandsecondlinetreatments for UTI. • Counsel elderly patients and their carers on UTI treatments and prevention strategies. 2016 Competency Standards: 2.3, 3.1, 3.2, 3.5, 3.6. (exp: 28/02/2023). Accreditation Number: A2103RP1. Introduction Urinary tract infections (UTIs) increase in prevalence with age and are a common cause of hospitalisation. In a 2020 report analysing Australia’s preventable hospitalisations, UTI was found to be the number one preventable complaint in women.1 The challenge in diagnosing and treating UTIs in older adults is made more complex due to the high prevalence of asymptomatic bacteriuria, chronic urinary symptoms and cognitive decline. Some prevention strategies may assist in reducing the risk of recurrent infection in older adults; however, preventable hospitalisations and overtreatment with antibiotics for suspected UTI remain significant problems facing the Australian healthcare system.2 What is a UTI? A UTI is an infection of any part of the urinary system and can vary greatly in severity. The urinary system consists of the urethra, bladder, ureters and kidneys, as well as the prostate in men. UTIs are characterised as:3,4 Lower UTIs • Urethritis – infection of the urethra. • Cystitis – infection of the bladder. Upper UTI • Ureteritis – infection of the ureters. • Pyelonephritis – infection of the kidneys. To guide treatment, UTIs can be classified as first, unresolved or recurrent infections, as well as complicated or uncomplicated. Classification includes: • First UTI: occurs in an individual with no previous UTI. • Unresolved UTI: re-infection with the same pathogen as a previously treated UTI (ie, the infective organism from a previous infection was not completely eradicated). • Recurrent UTI: generally accepted as a UTI that occurs after a previously resolved infection, where the patient has suffered more than two infections in the past six months or three episodes in the past 12 months. • Uncomplicated UTI: generally described as UTIs in women without functional or anatomical complications in the absence of pregnancy. Male UTIs are generally not considered uncomplicated.5 • Catheter associated UTI is also classified separately due to the more diverse microbiology of associated pathogens and distinct management.4 Under normal conditions, although the urinary tract has its own microbiome, it’s relatively devoid of microbes compared with the gastrointestinal or upper respiratory tract.5 UTI occurs most commonly with colonisation by uropathogens from faecal matter in the perineum, which then ascends into the urethra and bladder, and in the case of pyelonephritis to the kidneys via the ureters. Gram-negative Escherichia coli is the most common causative organism of UTIs. Likelihood of infection with an organism other than E. coli is more common in recurrent and hospital acquired UTIs. Other gram-negative species that cause UTI include Proteus mirabilis (found more commonly in aged care patients), Klebsiella pneumonia and Pseudomonas aeruginosa. Gram-positive species, including Staphylococcus saprophyticus and Streptococcus agalactiae have been found with increasing frequency.6 Why are UTIs more common in women? Urinary colonisation rates are higher in women due to the vaginal cavity and rectal opening being close together. Also, the urethra is a shorter length in women, making it easier for bacteria to ascend to the female bladder.7 Asymptomatic bacteriuria Asymptomatic bacteriuria (ASB) is the presence of bacteria in the urine without clinical signs or symptoms of UTI. Asymptomatic pyuria is the presence of white blood cells in the urine without the signs or symptoms of UTI. ASB and pyuria can present together without symptoms. These do not require antibiotic treatment, except for pregnant women and those undergoing urological procedures. Negatively, antibiotic treatment may contribute to antibiotic resistance and avoidable adverse drug reactions.4,8 The estimated prevalence of ASB increases in women with age, from one to five per cent in younger women to six to 16 per cent in women over 65 years. ASB further increases in women over 80 years and in those living in aged care facilities to 20-50 per cent. ASB also increases with age in men. ASB is uncommon in young ambulatory men. However, the prevalence can be up to 35 per cent in older men living in aged care facilities9. Other risk factors for ASB include urinary catheters (particularly in the chronic indwelling setting), structural urinary tract abnormalities, diabetes mellitus, Parkinson’s disease and stroke.10 Risk factors associated with UTIs Risk factors for developing symptomatic UTI in older adults are different to those in younger women (see Table 1 for possible mechanisms). An increase in comorbidities, poor mobility and changes in immune function put the elderly at an increased risk for developing infection.7 While frequency of sexual intercourse and use of spermicides are the main risk factors for UTI in younger women, the most consistent and strongest predictor of infection across all age groups is a history of UTI.11 UTI symptoms The three most common symptoms of UTI include:11 TO PAGE 54 RETAIL PHARMACY • MAR 2021 2 CPD CREDITS