LOWER URINARY TRACT INFECTIONS

Urinary tract infection (UTI) is the most common infectious illness in adults age 65 and over. The most common cause of urinary tract infections (UTIs) in elderly patients are gram-negative organ-isms that colonize the urinary tract. Residents of nursing facilities or patients who have had along hospitalization are at an increased risk for multidrug-resistant organisms such as pseudomonas and MRSA.

Causes:  hygiene, sexual activity, and catheterization, bladder obstruction or poor emptying

Signs and Symptoms

–       dysuria

–       suprapubic discomfort,

–       urinary frequency and urgency.

Elderly patients may have unique presentations including incontinence, lethargy, anorexia, and altered mental status. More severe cases develop fever, chills, nausea, and vomiting.

 

Diagnosis

Urinalysis: pyuria, leukocyte esterase, nitrites, increased pH w/ proteus infection

Urine Culture: definitive diagnosis

Treatment:

All patients that are symptomatic require treatment. Patients with asymptomatic bacteriuria usually do not need treatment, depending on the clinical situation

–       1^st line- nitrofurantoin or trimethoprim- sulfamethoxazole

–       2^nd line- fluoroquinolones, cephalosporins, cefpodoxime

–       Phenazopyridine- bladder analgesic

–       Complicated cases- fluoroquinolones PO or IV, Aminoglycosides

 

Source: https://www.asn-online.org/education/distancelearning/curricula/geriatrics/Chapter31.pdf

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PYELONEPHRITIS

Pyelonephritis develops when pathogens ascend to the kidneys via the ureters. Pyelonephritis can also be caused by seeding of the kidneys from bacteremia.

Signs and Symptoms

–       Fever (>99.9°F/37.7°C)

–       Other signs or symptoms of systemic illness (including chills or rigors, significant fatigue or malaise beyond baseline).

–       Flank pain.

–       Costovertebral angle tenderness on exam

–       Urinary symptoms (similar to cystitis) and pelvic pain

Complications — bacteremia, sepsis, multiple organ system dysfunction, shock, and/or acute renal failure.

 

Labs:

–       Urinalysis: ( >10 WBCs/hpf), leukocyte esterase, nitrites, cloudy urine, bacteriuria

–       Urine culture: white cell casts, in particular, suggest a renal origin for pyuria

Imaging — Most patients with acute complicated UTI do not warrant imaging studies for diagnosis or management. Imaging is generally reserved for those who are severely ill(sepsis, shock), have persistent clinical symptoms despite 48 to 72 hours of appropriate antimicrobial therapy, or have suspected urinary tract obstruction.

–       Computed tomography (CT) scanof the abdomen and pelvis (with and without contrast) is generally the study of choice to detect anatomic or physiologic factors associated with acute complicated UTI

–       Renal ultrasound is appropriate in patients for whom exposure to contrast or radiation is undesirable.

Management:   Outpatient- 1^st line fluoroquinolone with resistance rate <10 %

IV ceftriaxone or gentamicin followed by oral fluoroquinolone if resistance rate >10%

Inpatient- 3^rd of 4^th gen cephalosporin, fluoroquinolone, aminoglycoside or extended spectrum penicillin

Source:

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/acute-complicated-urinary-tract-infection-including-pyelonephritis-in-adults?search=elderly%20pylonephritis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

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Nephrolithiasis

–       Initial presentation usually occurs in the third through fifth decades

–       more than 50% of patients will become recurrent stone formers.

There are five major types of urinary stones: calcium oxalate, calcium phosphate, struvite (magnesium ammonium phosphate), uric acid, and cystine. The most common types are those composed of calcium oxalate or phosphate (85%),

Causes:

–       Geographic factors: high humidity and elevated temperatures

–       Sedentary lifestyle, obesity, hypertension, insulin resistance and poor glycemic control, carotid calcification, and cardiovascular disease.

–       Medications: increase the risk of formation of kidney stones, including carbonic anhydrase inhibitors (topiramate, zonisamide, acetazolamide), systemic corticosteroids (prednisone), antiretroviral protease inhibitors (indinavir), gout medications( probenecid)

–       Inadequate hydration

–       Diet: high protein and salt intake, restricted dietary calcium intake

Symptoms and Signs

–       Renal colic: Pain most often occurs suddenly and may awaken patients from sleep. Localized to the flank and may be associated with nausea and vomiting. Patients with kidney stones are constantly moving trying to find a comfortable position. will often have a marked decrease in discomfort.

–       Nausea, vomiting, urinary frequency, urgency or hematuria

–       Flank pain/CVA tenderness

Laboratory Findings

Urinalysis: microscopic or gross hematuria (∼90%).

Urinary pH may provide a valuable clue to the possible stone type.

Normal urinary pH is 5.8–6.2, persistent urinary pH < 5.5 is suggestive of uric acid stones. A persistent urinary pH > 7.2 is suggestive of a struvite (infection-related) stone and pH > 7.5, a calcium phosphate stone. Patients with calcium oxalate–based stones typically have a normal urinary pH.

 Imaging

–       A plain abdominal radiograph (kidney, ureter, and bladder [KUB]) and renal ultrasound examination will diagnose up to 80% of stones.

–       Non-contrast CT is the most accurate imaging modality for evaluating flank pain given its increased sensitivity and specificity

–       Ultrasonography is a safe and effective alternative for initial evaluation of renal colic and one that can be used in the emergency department with good accuracy.

Management:

Stones< 5 mm in diameter- 80% spontaneous passage

–       IV fluids and Analgesia

–       Tamsulosin( alpha blocker) may faciliatate passage

 

Stones 5-10 mm in diameter

–       20% chance of spontaneous passage

–       Alkalization of urine if pH to >6.5 helps to dissolve uric acid stones

–       Extracorpeal shock wave lithotripsy( breaks up the stone)

–       Uretoscopy with or without stent( stent facilitates drainage of urine down bladder)

–       Percutaneous nephrolithotomy( cut away section of prostate) – for large stones > 10 mm

 

Source: https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?bookid=2683&sectionid=225131491#1166615122

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