Urinary Tract Infection in the Older Adult

Chronic Pyelonephritis

*Chronic pyelonephritis: kidneys can become scarred, contracted and nonfunctioning.* No symptoms of infection Signs and symptoms: Fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss. Diagnostic tests: IV urogram, Creatinine clearance, BUN Findings: Renal scarring Calyceal Clubbing at Renal poles

Causative Organisms for UTI

*E. Coli is the most common in the community* For those with indwelling catheters: Proteus Mirabilis _________men___________________ Klebsiella _________not common__________________ Pseudomonas __________very rare, in hospital__________ Staphylococcus_______________________________ Recurrent UTI Enterococcus VRE: _________contact precautions_

Upper Urinary Tract Infections

*Pyelonephritis: Bacterial infection of renal pelvis, tubules, interstitial tissue of one or both kidneys.* Causes: upward spread from bladder infection Spread from systemic sources into kidneys Bladder or prostate tumors, stricture, BPH and urinary stones - lead to obstruction - infection. Can be acute or chronic. Acute pyelonephritis usually leads to enlargement of the kidneys. Chronic pyelonephritis: kidneys can become scarred, contracted and nonfunctioning.

Upper Urinary Tract Infections: Acute Pyelonephritis

Acute pyelonephritis usually leads to enlargement of the kidneys Signs and Symptoms: Chills, Fever, Low back pain, flank pain, nausea and vomiting. Urinary urgency and frequency are common. Physical findings: CVA tenderness

Medications used to treat UTI

Antibiotics: Key is to be sensitive to the correct organism General teaching points: ____recognition, precaution, correct dose, follow regime____ _________________________________________ Antispasmodics: Phenazopyridine (100 mg or 200 mg) Teaching: Stains urine red-orange Analgesics: acetaminophen 325mg two tablets q 6 hours. Important considerations____hepatotoxicty_

Upper Urinary Tract Infections: Acute Pyelonephritis Assessment and diagnostic findings

Assessment and Diagnostic Findings: Ultrasound Study or CT Scan - look for an obstruction IV pyelogram - functional or structural renal abnormalities Urine culture and sensitivity tests CBC: leukocytosis

Gerontologic Considerations

Bacteriuria increases with older age Women more than men UTI- most common cause bacterial sepsis in older adults Mortality rate is 50% In long term care, 25-50% of women and 15-40% of men have bacteriuria

Chronic Pyelonephritis Complications Med Management Nursing intervention

Complications: End stage kidney disease HTN Formation of kidney stones Medical Management: Long-term use of prophylactic antimicrobial therapy Nursing Management: ____fluids________ _______________over all hydration

Lower UTI

Cystitis Prostatitis Urethritis Uncomplicated - community acquired Complicated - urologic abnormalities, or recent catheterization

Geriatric anatomic considerations

Decreased bladder tone: retention of large volume of urine Decreased estrogen so greater adherence of bacteria to vagina and urethra Antibacterial activity of prostate secretions decreases Prostate hypertrophy Urethral strictures more common

Factors contributing to a UTI

Function of glycosaminoglycan (GAG)- decreased in older Urethrovesical reflux Uretherovesical reflux Uropathogenic bacteria Shorter urethra in women Risk factors

Acute Pyelonephritis Medical Management

If uncomplicated treated on an outpatient basis - if NO: Sepsis, dehydration, nausea or vomiting. 2 week course of antibiotics - must be able to be adherent May need another 6 week course of antibiotic *Follow up urine 2 weeks after initial antibiotic course completed* Hydration with oral or parenteral fluids

Contributing factors in older adults

Increased cystoscopies and catheterizations High incidence of multiple chronic conditions Presence of infected pressure ulcers Immunocompromised Cognitive Impairment Immobility *Smokers highest risk for bladder cancer

UTI Clinical Presentation

Pain, burning upon urination, frequency, nocturia, incontinence, hematuria About half are asymptomatic Association of symptoms with sexual intercourse, contraceptive practices, and personal hygiene Assessment of urine, urinalysis, and urine cultures *Other diagnostic tests?cbc wbc in urinalysis

Nursing Interventions

Personal hygiene: wipe front to back Medications as prescribed: antibiotics, analgesics, and antispasmodics - see following slides, antibiotic module Application of heat to the perineum to relieve pain and spasm Increased fluid intake Avoidance of urinary tract irritants such as coffee, tea, citrus, spices, cola, and alcohol Cranberry Juice daily Frequent voiding Patient education: Other points? ________showers better____________________ ____no irritating soaps_

Upper UTI

Pyelonephritis: acute and chronic Interstitial nephritis Renal abscess and perineal abscess

CAUTI: Interventions to prevent infections

Use strict aseptic technique during insertion of the smallest catheter possible Secure catheter to prevent movement Frequently inspect urine color, odor and consistency Perform meticulous daily perineal care with soap and water Maintain a closed system Follow manufacturer's instructions when using the catheter port to obtain urine specimen

So how is it different for older adults? What systemic symptoms do they have?

delerium_-chang in mental status _____________ ___________________low grade fever__________

Mechanisms of urethrovesical and ureterovesical reflux

may cause urinary tract infection. Urethrovesical reflux: With coughing and straining, bladder pressure rises, which may force urine from the bladder into the urethra. A. When bladder pressure returns to normal, the urine flows back to the bladder (B), which introduces bacteria from the urethra to the bladder. Ureterovesical reflux: With failure of the ureterovesical valve, urine moves up the ureters during voiding (C) and flows into the bladder when voiding stops (D). This prevents complete emptying of the bladder. It also leads to urinary stasis and contamination of the ureters with bacteria-laden urine.

Comparison of Clinical Presentations younger vs older

younger: Dysuria Fever Urinary frequency Nocturia Incontinence Suprapubic or pelvic pain Hematuria Back Pain Older: Likely asymptomatic ** prostatitis - pain No fever mild elevation Urinary frequency -normal course Nocturia - normal course Incontinence - normal course Not so common Suprapubic or pelvic pain Not so common Hematuria Not so common Back Pain