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Urinary Tract Infection in the elderly: why accurate diagnosis matters

Incidence of urinary tract infection (UTI) seems to increase with age; whether this has to do with lower mobility or just a natural age-related increase of bacteria that cause UTI, we don’t know. What we do know is that historically, across all patient age groups, broad-spectrum antibiotics have been given as first-line defense against the condition and that antibiotic resistance is on the rise.

Leave the jam jar in the cupboard

UTI diagnosisI have witnessed in urology clinics patients delivering their specimen in a jam-jar or similar; despite these containers having been washed out, they are far from appropriate for a diagnostic procedure; sugar, for instance, will cling to the interior and can indicate a high glucose count where there is none.

No-one would dream of treating their blood sample with such lack of care, yet urine is used for the same diagnostic process and greater diligence is required in order to combat the rise of antimicrobial resistance (AMR), blood infections and deliver accurate treatment.

In short, if prompt, right-first-time diagnosis and treatment of UTI is going to become the norm, then attitudes have to change.

Why it matters for elderly patients

In elderly patients, a UTI can induce behaviour that may be interpreted as “challenging”; anyone with cognitive difficulties cannot adequately explain their symptoms and as millions of us know, UTI is at best uncomfortable, at worst jolly painful.

Getting a midstream urine specimen from someone in distress isn’t easy but somehow it must be done because recent research into generic elderly UTI treatment is leading to a sea-change in the way it is diagnosed.

The Science bit

planning ahead and getting started cropIn 2016, a clinical team in Birmingham decided to challenge the traditional dipstick method of UTI diagnosis in care homes and launched To Dip Or Not To Dip; simply, they cultured urine specimens to establish the precise cause of infection and only then prescribed the antibiotic appropriate to the bacteria they found.

Early evaluation of their study showed:

  • 56% reduction in the proportion of residents who had an antibiotic for a UTI
  • 67% reduction in the number of antibiotic prescriptions
  • 82% reduction in the number of residents prescribed antibiotic prophylaxis
  • Reduced unplanned hospital admissions for UTI, urosepsis and AKI reduced in NH population following implementation

Dipsticks are routinely relied upon for frontline UTI diagnosis, yet they often produce false-negative or false-positive results; “empirical” treatment is still recommended in many guidelines. This means the prescribing of a broad-spectrum antibiotic for 3 or 7 days without any urine culture taking place; up to 30% of UTI bacteria (in particular e-coli) are resistant to the most common broad-spectrum antibiotics, which means these antibiotics will largely fail.

When symptoms persist, only then will the urine be cultured and a more targeted antibiotic used, a practice that has doubtless contributed to the AMR fix that we are in today.

Statistics around UTIs
  • GPs prescribe 74% of antibiotics in the UK
  • AMR has increased by 24% in the last five years
  • 50% of AMR increase has a urinary source
  • 47% of Gram Negative Blood Infections are caused by untreated UTI
  • Blood infections can lead to sepsis

driving ageNHS Improvement is acting; its policy makers have decreed the prescribing of antibiotics in the absence of documented evidence of bacterial infection to be inappropriate. Treatment must now be targeted and this means more diligent midstream urine analysis as a routine measure.

In the USA analgesics have been developed to alleviate UTI symptoms and discomfort whilst the urine specimen is properly cultured and examined; perhaps in time the UK will follow this excellent example.

Talking the GP’s language

If you are caring for someone who suffers from routine UTI, let your GP know that you are aware of the implications of broad-spectrum antibiotic resistance and insist that the urine specimen is sent for culture. Not only will it provide a faster, targeted treatment, but repeat urine collection, analysis and unnecessary prescribing all cost the NHS millions every year so you will be doing your bit to help NHS finances too.

As with most things, accuracy pays – in this context for the patient as well as the provider.

References:

Nursing in Practice: AMR and UTI:  https://www.gov.uk/government/publications/health-matters-preventing-infections-and-reducing-amr

Public Health England: Preventing Blood Infections  (https://www.nursinginpractice.com/article/antimicrobial-resistance-and-urinary-tract-infections-community)

NICE UTI Guidelines 2015

 Symptoms of urinary tract infection

These include dysuria, increased frequency of urination, suprapubic tenderness, urgency and polyuria (Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network [2012]).

 Clinical assessment

  • Adults aged 65 years and over have a full clinical assessment before a diagnosis of urinary tract infection is made
  • A full clinical assessment should be a face-to-face review of the person’s medical history, physical examination, assessment of pulse, blood pressure, temperature and recording of symptoms (Management of suspected bacterial urinary tract infection in adults. (Scottish Intercollegiate Guidelines Network [2012]).

Rationale

  • The accuracy of dipstick testing in adults aged 65 years and over can vary. It is therefore important that factors other than the results of dipstick testing are taken into consideration when diagnosing urinary tract infections in older people to ensure appropriate management and avoid unnecessary use of antibiotics.

Service providers (such as hospitals, community services and GPs) ensure that adults aged 65 years and over receive a full clinical assessment before being diagnosed with a urinary tract infection.

Giovanna Forte is CEO of Forte Medical, a company that makes Peezy Midstream for easier, more hygienic and dignified urine specimen collection. Peezy Midstream was designed by a doctor and is available on prescription. (https/www.forte-medical.co.uk)

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