Clinical Notes : Urology

154. UTI in Adults over 65 years

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UTI in Adults over 65

 

Adults over 65 years with suspected UTI

This guide excludes patients with recurrent UTI (2 episodes in last 6 months, or 3 episodes in last 12 months)

 

Flowchart for men and women over 65 years with suspected UTI

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UTI = Urinary Tract Infection

RCGP = Royal College of General Practitioners

NEWS2 = National Early Warning Score 2

PHE = Public Health England

RBC = Red Blood Cells

TARGET = Treat AntibioticsResponsibly, Guidance, Education, Tools

MSU = Mid Stream Urine

NICE = National Institute for Health and Care Excellence

 

Sending urine for culture and interpreting results in all adults

  • Review need for culture when considering treatment

  • Send a urine for culture in:

    • over 65 year olds if symptomatic and antibiotic given

    • pregnancy: for routine antenatal tests, or if symptomatic

    • suspected pyelonephritis or sepsis

    • suspected UTI in men

    • failed antibiotic treatment or persistent symptoms

    • recurrent UTI (2 episodes in 6 months or 3 in 12 months)

    • if prescribing antibiotic in someone with a urinary catheter

    • as advised by local microbiologist

  • Consider risk factors for resistance and send urine for culture if:

    • abnormalities of genitourinary tract

    • renal impairment

    • care home resident

    • hospitalisation for >7 days in last 6 months

    • recent travel to a country with increased resistance

    • previous UTI resistant

  • If prescribing an antibiotic, review choice when culture and antibiotic susceptibility results are available

 

Sampling in all men and women

  • Women: mid-stream urine and holding the labia apart may help reduce contamination but if not possible, sample can still be sent for culture

  • Do not cleanse with antiseptic, as bacteria may be inhibited

  • Elderly/frail: only take urine sample if symptomatic and able to collect good sample. If incontinent, clean catch in disinfected container and condom catheters for men may be viable options but little evidence to support

  • Men: advise on how to take a mid-stream specimen 

  • People with urinary catheters: if changed, collect from newly placed catheter using aseptic technique, drain a few mL of residual urine from the tubing, then collect a fresh sample from catheter sampling port

  • Culture urine within 4 hours of collection, refrigerate, or use boric acid preservative. Boric acid can cause false negative culture if urine not filled to correct mark on specimen bottle and can affect urine dipstick tests)

 

How do I interpret a urine culture result if I suspect a UTI?

  • Culture should be interpreted in parallel to severity of signs/symptoms. False negatives/positives can occur

  • Do not treat asymptomatic bacteriuria unless pregnant as it does not reduce mortality or morbidity

  • Urine culture results in patients with urinary symptoms that usually indicate UTI:

    • many labs use growth of 107–108 cfu/L (104–105  cfu/mL) to indicate UTI

    • lower counts can also indicate UTI if patient symptomatic:

      • strongly symptomatic women—single isolate ≥105 cfu/L (≥102 cfu/mL) in voided urine

      • in men counts as low as 106 cfu/L (103 cfu/mL) of a pure or predominant organism

      • any single organism ≥107 cfu/L (≥104 cfu/mL)

      • Escherichia coli or Staphylococcus saprophyticus ≥106 cfu/L (≥103 cfu/mL)

      • ≥108 cfu/L (≥105 cfu/mL) mixed growth with 1 predominant organism

  • Epithelial cells/mixed growth:

    • the presence of epithelial cells is not necessarily an indicator of perineal contamination, culture result should be interpreted with symptoms and repeated if significance is uncertain

    • mixed growth may indicate perineal contamination; however a small proportion of UTIs may be due to genuine mixed infection. Consider a re-test if symptomatic

  • Red cells:

    • may be present in UTI

    • chemical tests may be more sensitive than microscopy as a result of the detection of haemoglobin released by haemolysis

    • refer patients with persistent haematuria post-UTI to urology

  • White blood cells/ leucocytes:

    • white cells ≥107 WBC/L (≥104 WBC/mL) are considered to represent inflammation in urinary tract, this includes the urethra

    • white cells can be present in older people with asymptomatic bacteriuria, as the immune system does not differentiate colonisation from infection

  • Sterile pyuria

    • in sterile pyuria, consider Chlamydia trachomatis (especially if 16–24 years), other vaginal infections, other nonculturable organisms including tuberculosis or renal pathology

    • if recurrent pyuria with UTI symptoms, discuss with local microbiologist as lower counts down to 105 cfu/L (102 cfu/mL) may be significant. Higher volume of urine may need to be cultured, including for fastidious organisms

  • For all patients:

    • take into account of antibiotic susceptibility results and resistance when deciding on management and reviewing antibiotic treatment

  • Follow up:

    • do not send follow-up urine unless pregnant, or advised by the laboratory

    • consider non-urgent referral for bladder cancer in patients >60 years with recurrent/persistent unexplained UTIs

 
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Diagnosis of urinary tract infections

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Urological Infections

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Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs.

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Dysuria: Evaluation and Differential Diagnosis in Adults.

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Palma F, Volpe A, Villa P, Cagnacci A,

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Management of suspected bacterial urinary tract infection in adults.

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Urinary tract infections in women

BMJ Best Practice

Last updated: January  2019

Last reviewed: March 2019

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Urinary tract infections in men

BMJ Best Practice

Last updated: September 2018

Last reviewed: March 2019

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