Urinary Tract Infection in the Geriatric Population
Elizabeth Shultz

Abstract
The geriatric population is very vulnerable to Urinary Tract Infection (UTI) and its negative consequences. If left untreated, UTI in the elderly patient can have negative consequences such as delirium or even death. UTI can also contribute to the onset of acute or chronic kidney infections, which could permanently damage the kidneys and result in renal failure. In view of this, the purpose of this paper is to review related literature to find current evidence or best practices related to UTI in the geriatric population and to objectively critique the evidence. CINAHL and MEDLINE computer databases were mainly searched from January, 2005 to January, 2015 using a combination of manual and computer-based methods.
Keywords: elderly, urinary tract, elderly infection management, urinary tract infection prevention, elderly and UTI.

Introduction By convention, a Urinary tract infection (UTI) is defined either as a lower tract (acute cystitis) or upper tract (acute pyelonephritis) infection (Nicolle, 2014). Urinary tract infection (UTI) is the most common infectious problem among older adults both in the community and institutional settings (Midthun, Paur, Bruce, & Midthun, 2005). The elderly population is most likely to experience UTI due to many reasons, not the least of which is their overall susceptibility to all infections due to the suppressed immune system that comes with age and certain age-related conditions. Urinary tract infection (UTI) is a common reason for hospital admission in patients aged 75 upward and has increased approximately 65% over the last 5 years (Woodford & George 2009). According to Caterino, Ting, Sisbarro, Espinola, and Camargo (2012), each year, patients aged 65 years and over account for approximately 500,000 visits for urinary tract infection (UTI) to U.S. emergency departments (EDs). This is a problem because research indicates that there are number of instances where the geriatric patient is over diagnosed with UTI and prescribed antibiotics that are not needed.
One cannot talk about UTI in older adults without distinguishing between an asymptomatic (ASB) UTI and symptomatic UTI because current evidence recommends that the treatment of ASB in geriatric patients is not recommended. The focus of this paper is to objectively critique this evidence.
The Evidence Based Practice (EBP)
Rational use of antimicrobials in the treatment of UTI in the older adult is important to both provide appropriate care and control the spread of resistant organisms in this population. Current studies show that antibiotic treatment for ASB is not recommended in elderly patients (Midthun, Paur, Bruce, & Midthun, 2005). This position is held by a variety of professional organizations, including the Infectious Diseases Society of America (IDSA), Centers for Disease Control and Prevention (CDC), and the American Medical Directors Association (AMDA). The CDC and IDSA agree that treating ASB in nursing home residents will do more harm than good (Benton, Young & Leeper, 2006).
Evidence from the literature to support the EBP
According to Nicolle (2014), though UTI is considered the most common infection among elderly patients, a significant proportion of these patients actually have ASB. The researcher concluded that a positive urine culture in the absence of symptoms is of limited value in identifying a true UTI.
In addition, prospective randomized trials have repeatedly demonstrated that antimicrobial treatment of ASB in elderly patients is not clinically beneficial or cost effective. The presence of ASB does not increase morbidity and mortality (Nicolle, 2014). Bacteria are only temporarily eliminated with antimicrobial therapy and treatment of ASB with antibiotics has been associated with re-infection with organisms of increasing resistance (Midthun, Paur, Bruce, & Midthun, 2005). Further, C. difficile infection is a common complication of antibiotic use and adding an unnecessary antibiotic to a patient medication regimen increases the likelihood of drug-drug interactions (Woodford & George, 2009). According to Caterino, Ting, Sisbarro, Espinola, and Camargo (2012), the treatment of ASB may lead to inaccurate diagnosis and under treatment of other serious health problems. Also, the revised Centers for Medicare & Medicaid Services (CMS) guidelines for surveyors (F-441) state that LTC facility staff should not treat on the basis of a culture result if there are no clinical signs or symptoms supporting an infection (AMDA, 2011; Nicolle et al., 2011; Benton, Young & Leeper, 2006; Norman, 2011).
Moreover, the challenge for the clinician is not in deciding to treat ASB, but rather distinguishing ASB from UTI. This is because diagnostic accuracy is compromised by difficulties in communication, multiple comorbid illnesses with associated chronic symptoms, and clinical presentations that are possibly infectious but without clear localized findings.
How the EBP might be implemented
Facilities should have clear policies and practices to ensure that patients are not started on antibiotics without a credible clinical picture. Facilities can achieve this by establishing minimum criteria for initiating antibiotics, using the McGeer, Loeb or modified Loeb criteria as a starting point.
Education of nursing staff regarding appropriate criteria for requesting urine cultures should be a component of interventions to reduce inappropriate treatment of ASB in the elderly patient. A clean-catch voided urine specimen is the preferred method (male and female) but, when a voided specimen cannot be appropriately collected, a specimen should be obtained by in-and-out catheterization (Kamel, 2006)
An interdisciplinary team approach may be the ideal approach to consider in adequate management since both midlevel and physicians can be primary care providers for these older adults.
Engaging the cognitively intact older adult in the treatment plan will go a long way to promote treatment adherence and compliance. This action by providers is noted to have some potential psychosocial benefits
Based on recommendations of the Infectious Diseases Society of America, screening for or treatment of ASB are not recommended for the following persons: diabetic women; older persons living in the community or institutionalized; persons with spinal cord injury; and catheterized patients while the catheter remains in situ. Screening in older persons is only recommended before transurethral resection of the prostate and before urologic procedures in which mucosal bleeding is anticipated (Nicolle, Bradley, Colgan, Rice, Schaeffer, & Hooton, 2005).

Conclusion Urinary infection is an important clinical problem in the geriatric population affecting both the walking well to the institutionalized. Health professionals caring for this population must understand the high frequency and appropriate management of asymptomatic bacteriuria, the diagnostic uncertainty in identifying symptomatic infection, and appropriate treatment of symptomatic infection. One of the most important issue requiring further evaluation is to identify optimal approaches to antimicrobial therapy for individuals with suspected symptomatic urinary infection

References
Caterino, J., M., Ting, S., A., Sisbarro, S., G., Espinola, J., A., & Camargo, C., A. (2012). Age, nursing home residence, and presentation of urinary tract infection in U.S. emergency departments, 2001-2008. Academic Emergency Medicine, 19(10), 1173-1180. doi:10.1111/j.1553-2712.2012.01452.x
Gordon, L., B., Waxman, M., J., Ragsdale, L., & Mermel, L., A. (2013). Overtreatment of presumed urinary tract infection in older women presenting to the emergency department. Journal of the American Geriatrics Society, 61(5), 788-792. doi:10.1111/jgs.12203
Midthun, S., Paur, R., Bruce, A. W., & Midthun, P. (2005). Urinary tract infections in the elderly: A survey of physicians and nurses. Geriatric Nursing, 26(4), 245-251.
Midthun, S. J. (2004). Criteria for urinary tract infection in the elderly: Variables that challenge nursing assessment. Urologic Nursing, 24(3), 157.
Nicolle, L. (2014). Catheter-related urinary tract infection: Practical management in the elderly. Drugs & Aging, 31(1), 1-10. doi:10.1007/s40266-013-0089-5
Nicolle, L., Bradley, S., Colgan, R., Rice, J.C, Schaeffer, A., Hooton, T.M (2005). Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 40: 643–654
Woodford, H. J., & George, J. (2009). Diagnosis and management of urinary tract infection in hospitalized older people. Journal of the American Geriatrics Society, 57(1), 107-114. doi:10.1111/j.1532-5415.2008.02073.x