Page 56 - Retail Pharmacy March 2021

54 CPD ACTIVITY FROM PAGE 53 1. Urinary urgency. 2. Frequent urination. 3. Stinging or painful urination (dysuria). Other symptoms can also include suprapubic tenderness, back pain, haematuria (blood in urine) and fever. In older adults, symptoms can be more difficult to identify as urinary incontinence and chronic dysuria can mimic the symptoms of cystitis. Therefore, in this population, dysuria of less than one week, new or worsening urinary incontinence, frequency or urgency, suprapubic pain or tenderness or the presence of haematuria can be more discriminating symptoms of UTI, warranting further investigation.13 Falls, delirium and changes in functional state are frequently ascribed to UTI. However, increasing evidence suggests that these factors are not reliable predictors of UTI.14 Recent studies looking at acute delirium in patients with bacteriuria found that treating the bacteriuria did not improve mental status.10 Therefore, it’s now recommended that patients with changes in functional status and bacteriuria without local genitourinary symptoms be investigated for other causes of their altered status rather than starting them on antibiotic treatment.12 Although urine colour change and malodour can be associated with bacteriuria, they are not necessarily diagnostic. Urine colour and odour can be influenced by several factors, including dehydration, medicines, diet and other non-infectious factors. When they are the only presenting complaint, changes in urine colour and odour can be treated by a physician with monitoring and increased fluid intake if appropriate.10 Diagnosing UTIs in the elderly Criteria have been developed to assist in the diagnosis of residents in aged care facilities (ACFs), due to the difficulty in differentiating between symptoms of chronic comorbidities and UTI symptoms. Physicians in ACFs are encouraged to follow either the McGeer or Loeb criteria for assessing appropriateness to start antibiotics (see Table 2 and 3).15,16 Both approaches instruct that urine culture be sent away, and rely on acute changes observed prior to the initiation of antibiotics. Outside of ACFs, best practice diagnosis of UTIs in the elderly requires the following components: • Clinical symptoms – identification of symptoms localised to the urinary tract. Prostatic hypertrophy Catheterisation Urinary retention and disturbed urinary flow Bacteria colonise the catheter Urinary retention Risk factors Potential mechanism for causing UTI Comorbidities such as stroke, dementia, Parkinson’s disease Functional decline, bladder and bowel incontinence Medications Anticholinergics - Cause urinary retention Sodium-glucose co-transporter two (SGLT-2) inhibitors - Cause glucose excretion through the urine, may cause addition growth of genital microorganisms Vaginal atrophy Facilitates microbial ascent Sexual activity Promotes colonisation Urinary and faecal incontinence Urinary contamination and promotion of bacterial ascension Impaired mobility Table 1. Possible mechanisms for risk factors for developing UTI in the elderly4,12 Presence of catheter Criteria required to be met No indwelling catheter At least three of: a. Fever ≥38C or chills. b. New or increased symptoms on urination (burning pain, frequency or urgency). c. New flank or suprapubic pain or tenderness. d. Change in character of urine (new bloody urine, foul smell, amount of sediment, new pyuria, or microscopic haematuria). e. Worsening of mental or functional status (may be new or increased incontinence). Indwelling catheter At least two of: a. Fever ≥38C or chills. b. New flank or suprapubic pain or tenderness. c. Change in character of urine (new bloody urine, foul smell, amount of sediment, new pyuria, or microscopic haematuria). d. Worsening of mental or functional status (may be new or increased incontinence). Table 2. The McGeer criteria for starting antibiotics to treat a UTI: definitions of infection in aged care facilities (adapted from: 16) Presence of catheter Either one of the following criteria Without catheter - Acute dysuria, OR - Temp >37.9C or 1.5C above baseline, AND ≥1 of the following new or worsening symptoms - Urgency - Frequency - Suprapubic pain - Gross hematuria - Urinary incontinence - Costovertebral angle tenderness With catheter At least one of the following criteria - Rigors - Temp >37.9C or 1.5C above baseline - New onset delirium - New costovertebral angle tenderness Note: Residents with intermittent catheterisation or condom catheter should be categorised as ‘without catheter’. Urine culture should be sent prior to starting antibiotics. Antibiotics should not be started for cloudy or foul-smelling urine. RETAIL PHARMACY • MAR 2021 Table 3. Loeb’s minimum criteria for initiating antibiotic therapy15 • Laboratory evidence – urine culture evidence of bacteriuria and pyuria. Note: urine sample should be mid-stream to prevent contamination. • Systemic inflammation – evidence of raised white blood cells or C-reactive protein in blood sample or presenting fever/hypothermia. • Absence of other infection or non- infectious cause – exclusion of other conditions to which the presenting symptoms could be easily attributed.4 Treatment for UTI Treatment can begin once diagnosis is confirmed. Doses may need to be modified based on the patient’s renal function. Empirical treatment of older adults is recommended and should be started post-urine sample. Specific guidelines pertaining to treatment of UTIs in the elderly are lacking and generally based on women under the age of 65.2,4,5,10 Antibiotic treatment regimens of women with uncomplicated cystitis in this age group are