Urinary antibody level and survival in bacteriuric institutionalized older subjects

Asymptomatic Bacteriuria and Bacterial Interference

Asymptomatic bacteriuria is very common. In healthy women, asymptomatic bacteriuria increases with age, from <1% in newborns to 10% to 20% of women age 80 years, but is uncommon in men until after age 50 years. Individuals with underlying genitourinary abnormalities, including indwelling devices, may also have a high frequency of asymptomatic bacteriuria, irrespective of age or gender. The prevalence is very high in residents of long-term-care facilities, from 25% to 50% of women and 15% to 40% of men. Escherichia coli is the most frequent organism isolated, but a wide variety of other organisms may occur. Bacteriuria may be transient or persist for a prolonged period. Pregnant women with asymptomatic bacteriuria identified in early pregnancy and who are untreated have a risk of pyelonephritis later in pregnancy of 20% to 30%. Bacteremia is frequent in bacteriuric subjects following mucosal trauma with bleeding, with 5% to 10% of patients developing severe sepsis or septic shock. These two groups with clear evidence of negative outcomes should be screened for bacteriuria and appropriately treated. Asymptomatic bacteriuria in other populations is benign and screening and treatment are not indicated. Antimicrobial treatment has no benefits but is associated with negative outcomes including reinfection with antimicrobial resistant organisms and a short-term increased frequency of symptomatic infection post-treatment. The observation of increased symptomatic infection post-treatment, however, has led to active investigation of bacterial interference as a strategy to prevent symptomatic episodes in selected high risk patients.

Asymptomatic bacteriuria: review and discussion of the IDSA guidelines

Asymptomatic bacteriuria is a common finding, but is usually benign. Screening and treatment of asymptomatic bacteriuria is only recommended for pregnant women, or for patients prior to selected invasive genitourinary procedures. Healthy women identified with asymptomatic bacteriuria on population screening subsequently experience more frequent episodes of symptomatic infection, but antimicrobial treatment of asymptomatic bacteriuria does not decrease the occurrence of these episodes. Clinical trials in spinal-cord injury patients, diabetic women, patients with indwelling urethral catheters, and elderly nursing home residents have consistently found no benefits with treatment of asymptomatic bacteriuria. Negative outcomes with antimicrobial treatment do occur, including adverse drug effects and re-infection with organisms of increasing resistance. Optimal management of asymptomatic bacteriuria requires appropriate implementation of screening strategies to promote timely identification of the selected patients for whom treatment is beneficial, and avoidance of antimicrobial therapy where no benefit has been shown.

Stress Urinary Incontinence in Women

PURPOSE

To review and synthesize existing knowledge about the epidemiology, pathophysiology, evaluation, and management of stress urinary incontinence in women.

DATA SOURCE

Selected scientific literature.

CONCLUSIONS

Stress urinary incontinence is more than merely a symptom. Instead, it is a clinically relevant disease with adverse psychosocial and physical consequences. Evaluation begins with active screening and is followed by individualized assessment when urinary leakage is detected.

IMPLICATIONS FOR PRACTICE

Traditional treatment modalities, including pelvic muscle rehabilitation, focus on behavioral strategies to reduce urine loss, and surgical correction of anatomic defects is completed in selected cases. Pharmacotherapeutic options have been limited, but one compound is undergoing clinical trials to determine whether it is a safe and effective alternative for the treatment of stress urinary incontinence.

The importance of screening, assessing, and managing urinary incontinence in primary care

PURPOSE

To present evidence that routine screening for urinary incontinence is justified because it is a clinically relevant and prevalent disorder that responds to treatment, resulting in improved outcomes for many patients managed by the nurse practitioner (NP).

DATA SOURCE

Selected scientific literature.

CONCLUSIONS

The prevalence of urinary incontinence and success of treatment options justify routine screening, individualized assessment, and treatment.

IMPLICATIONS FOR PRACTICE

Routine screening for urinary incontinence by NPs is uncommon. Based on the relative risk, the potential success of treatment and improved quality-of-life outcomes after treatment, NPs should regularly screen and assess for incontinence.

Systematic review of nursing management of urinary tract infections in the cognitively impaired elderly client in residential care: is there a hole in holistic care?

A systematic review of the current literature available exposed the deficit in nursing research as a resource for planning strategies and procedures in the care of a urinary tract infection. The cognitively impaired older client living in residential care is at particular risk because of their inability to articulate their problems, the subtle presentation of symptoms and the overuse of antibiotic therapy that has led to an increase in resistant organisms. The fiscal responsibility now required by health authorities highlights the need for a more enlightened approach to this distressing condition from those registered nurses in the front line of care.

Urinary tract infections in the elderly

The elderly population is now increasing in the world. A higher incidence of bacteriuria and urinary tract infection (UTI) is observed in elderly patients, in both long-term care facilities and at home. The management of elderly patients with UTI is increasing in clinical significance. Almost all of UTI in the elderly is complicated UTI. Control of the underlying diseases in the urinary tract is quite important in the management of UTIs in elderly patients. For pyelonephritis, switch therapy using aminoglycosides and fluoroquinolones, carbapenems, third-generation cephalosporines, or penicillins are selections of choice. The recommended duration of treatment for patients with pyelonephritis is 14 days. Seven to 10 days of treatment using fluoroquinolones or trimethoprim-sulfamethoxazole is recommended for the treatment of elderly patients with symptomatic cystitis. Although asymptomatic bacteriuria is quite common in the elderly population, antibiotic treatment has no benefit for such patients. Intravaginal estrogen replacement is one of choice for the prevention of recurrent UTIs in postmenopausal women.

Urinary tract infections in long-term-care facilities

Urinary tract infection (UTI) is the most common bacterial infection occurring in residents of long-term-care facilities. It is a frequent reason for antimicrobial administration, but antimicrobial use for treating UTIs is often inappropriate. Achieving optimal management of UTI in this population is problematic because of the very high prevalence of bacteriuria, evidence that the treatment of asymptomatic bacteriuria is not beneficial, and the clinical and microbiological imprecision in diagnosing symptomatic UTI. This position paper has been developed, using available evidence, to assist facilities and healthcare professionals in managing this common problem.

Urinary tract infection in long-term-care facility residents

Urinary tract infection is the most frequent bacterial infection in residents of long-term-care facilities. Most infections are asymptomatic, with a remarkable prevalence of asymptomatic bacteriuria of 15%-50% among all residents. The major reasons for this high prevalence are chronic comorbid illnesses with neurogenic bladder and interventions to manage incontinence. Prospective, randomized, comparative trials of therapy and no therapy for asymptomatic bacteriuria among nursing home residents have repeatedly documented that antimicrobial treatment had no benefits. However, there is substantial diagnostic uncertainty in determining whether an individual with a positive urine culture has symptomatic or asymptomatic infection when there is clinical deterioration and there are no localized findings. In the noncatheterized resident, urinary infection is an infrequent source of fever but may not be definitively excluded. The use of antimicrobials for treatment of urinary infection is part of the larger concern about appropriate antimicrobial use in long-term-care facilities and the impacts of the selective pressure of antimicrobials on colonization and infection with resistant organisms.