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Gerry Gajadharsingh writes:

I have previously blogged about urinary tract infections (UTI’s), but with ongoing concern about antibiotic resistance, I thought it useful to remind my audience about certain points especially in more elderly patients.

https://www.thehealthequation.co.uk/recurrent-urinary-tract-infections-whats-good-prophylaxis/

Urinary tract infections (UTIs) are very common, occurring mostly in women and are often distressing for the patient. It is thought that an episode of acute UTI, affects 50% of women by the age of 24 yoa.  The incidence of UTI in adult males younger than 50 years of age is low, approximately 5 to 8 per year per 10,000 population but with adult women, being 30 times more likely than men to develop UTI. Incident rates are also higher in elderly women and men, particularly associated with problems of the prostate and type two diabetes.

Common symptoms include, 

Dysuria — discomfort, pain, burning, tingling or stinging associated with urination.

Frequency — passing urine more often than usual.

Urgency — a strong desire to empty the bladder, which may lead to urinary incontinence.

Changes in urine appearance or consistency:

    • Urine may appear cloudy to the naked eye, or change colour or odour.
    • Haematuria may present as red/brown discolouration of urine or as frank blood.

Nocturia — passing urine more often than usual at night.

Suprapubic discomfort/tenderness.

Pyelonephritis (kidney infection) should be suspected in people with fever, loin pain or rigors.

Recurrent UTI effects, defined as at least two acute UTIs within 6 months or at least three within 12 months, affect 20 to 30% of women.  A retrospective observational study using linked health records (Clinical Practice Research Datalink [CPRD]) from almost one million patients aged ≥65 years old in England found that of 931,945 older adults, 196,358 (21%) had at least one clinically diagnosed UTI over the 10-year study period. Incidence was found to increase from 9.03 to 10.96 in women aged 65–74 years, 11.35 to 14.34 in those aged 75–84 years, and 14.65 to 19.80 in those aged over 85 years. 

Sometimes women are asymptomatic, it is estimated that 4–19% of healthy elderly women — this may increase up to 50% in women in long term care facilities, will have an asymptomatic bacterial UTI. Typical features may be absent, in particular in elderly women with underlying cognitive impairment — consider UTI if the woman presents with: Generalized non-specific clinical features such as delirium, lethargy, reduced ability to carry out activities of daily living and anorexia. Alternative sources of infection and causes of delirium other than UTI must be excluded before a working diagnosis of UTI is made.

Most UTI’s tend to be because of bacterial infection with E. coli the most common bacteria found on culture, approx. 65% to 90% of cases, with Klebsiella pneumoniae in about 10% of cases.

With increasing problems of antibiotic resistance, the trend has been to try to use non-antibiotic approaches, if possible, for UTI (assuming there is no evidence of kidney infection).

D Mannose, a monosaccharide (sugar) found in fruits is often found to be very helpful and research below seems to back this up, but it does seem to be specific to E coli infection.

Drinking too much water can be as problematic as not drinking enough water.

Other common over-the-counter remedies, such as cranberry juice seems to have conflicting evidence. One of the paradoxes, of course, is consuming too much sugar tends to be pro inflammatory and not supportive of the immune system. So, I’m generally not a fan of consuming regular amounts of any sort of fruit juices anyway.

Having a high pH (more alkaline, urine), seems to predispose to increased UTI. Reduced oestrogen in perimenopause and menopause, allows the vaginal pH to raise (more alkaline), increasing the risk of UTI. A urine pH of 7.5 is sometimes used for a diagnosis of UTI.

In clinic the first test that’s normally performed is a Urine Dipstick. If an infection is present, almost always, there will be signs of white cells (leucocytes) in the urine often with nitrates and sometimes blood. However, I’ve had several patients where leucocytes were not found on urine dipstick or on microscopy (where the urine sample is sent off to a laboratory), BUT had a positive culture, > 100,000 cfu/ml. Asymptomatic bacteriuria is the presence of bacteria in the properly collected urine of a patient that has no signs or symptoms of a urinary tract infection. 

It’s preferable to test a first morning avoid (FMV), urine sample, midstream, but there is sometimes a problem with contamination with female patients, on collecting a midstream sample.

Sending the sample off to the laboratory for microscopy and culture means that it will come back with an antibiotic sensitivity report and so the prescriber will know which type of antibiotic the patient is more likely to respond to.

The other over the counter (or prescription) medication that is increasingly used is Hiprex (methenamine Hippurate), described as a urinary antiseptic/antimicrobial, but can also be considered as antibacterial agent or an antibiotic. It seems to work by making the urine more acidic. Long-term use is discouraged as it can cause bladder irritation.

Recent research on Medscape flags up the issue of using antibiotics for recurrent UTI’s without running a culture test on the urine sample, given the increasing problem of antibiotic resistance.

In recent research a total of, 92,213 women, looked at women in Wales with recurrent UTIs and with/without prophylactic antibiotic use.

The median age was 70.6 years, 26,862 women and were included in a prophylaxis cohort; 39.1% started prophylactic antibiotics within 3 months but 32.2% had a microbiologically confirmed UTI before initiation.

The conclusion from the researchers suggests that

“It could be clinically beneficial to encourage microbiological confirmation of rUTIs in primary care and before prophylactic antibiotic initiation in line with clinical guidelines,” the authors wrote. “More frequent urine cultures in the workup of rUTI diagnosis and prophylactic antibiotic initiation could better inform antibiotic choice.”

The challenge is that to get a culture report from a lab takes at least 2 days sometimes more, it is a physical process to run the culture. However, for the sake of delaying antibiotic treatment for a few days to make sure you are at least giving the patient an antibiotic that is likely to work often turns out to be very worthwhile and reduce the risk of increasing antibiotic resistance in general population.

 

 

Liz Scherer

Medscape

TOPLINE:

Use of prophylactic antibiotics for recurrent urinary tract infection (rUTI) remains especially high in older women in Wales, despite their high levels of resistance to at least two recommended antibiotics and urine culture before treatment initiation.

METHODOLOGY:

  • A retrospective, cross-sectional analysis was conducted using anonymised, individual-level, population-scale linked health record data to describe prevalence, urine testing, susceptibility profiles in women with rUTIs and with/without prophylactic antibiotic use in Wales (2010-2020).
  • Two cohorts were created: Cohort 1 (clinical) was women meeting the clinical definition of rUTIs; Cohort 2 (prophylaxis) was women prescribed prophylactic antibiotics.
  • Definitions: rUTIs defined as at least two acute UTIs within 6 months or at least three within 12 months. Prophylactic antibiotics defined as at least three consecutive prescriptions for the same UTI-specific antibiotic (trimethoprim, nitrofurantoin, or cefalexin) within 21-56 days between prescriptions.

TAKEAWAY:

  • A total of 92,213 women, median age was 60 years, were included in the clinical cohort; 80.8% had a urine culture in preceding 12 months, 41.1% had ≥ 3 samples reported, and 28.1% had microbiologically confirmed UTI.
  • In total, 26,862 women, median age was 70.6 years, were included in the prophylaxis cohort; 39.1% started prophylactic antibiotics within 3 months but 32.2% had a microbiologically confirmed UTI before initiation.
  • Both cohorts had high resistance to trimethoprim and amoxicillin.
  • Overall, urine culture before treatment was reported in 64.2% of the cohort; 18.5% of women prescribed trimethoprim had evidence of resistance before starting treatment.

IN PRACTICE:

“It could be clinically beneficial to encourage microbiological confirmation of rUTIs in primary care and before prophylactic antibiotic initiation in line with clinical guidelines,” the authors wrote. “More frequent urine cultures in the workup of rUTI diagnosis and prophylactic antibiotic initiation could better inform antibiotic choice.”

The study was led by Leigh Sanyaolu, MRCGP, PGDip, Cardiff University, Wales, UK, and appeared online in the British Journal of General Practice.