Managing Urinary Tract Infections in Residential Aged Care: Comprehensive Treatment and Prevention Strategies

Urinary tract infections (UTIs) are a common health concern in residential aged care settings, where residents are more vulnerable due to age-related factors and other health conditions. The incidence of UTIs increases with age for both men and women, though women are particularly affected, with up to half experiencing a UTI in their lifetime. Proper management of UTIs is crucial in aged care facilities to ensure the comfort and health of residents while avoiding unnecessary treatments that could lead to antibiotic resistance.

What is a Urinary Tract Infection?

A urinary tract infection is an infection that occurs in any part of the urinary system, including the kidneys, ureters, bladder, and urethra. Most infections involve the lower urinary tract, which consists of the bladder and urethra. In some cases, an infection may involve the upper urinary tract (the ureters and kidneys), which can lead to more serious conditions such as pyelonephritis.

Understanding the anatomy and types of UTIs is essential for appropriate diagnosis and treatment in aged care settings.

Types of UTIs

UTIs in aged care residents can be classified as either complicated or uncomplicated, depending on the health status of the urinary system.

  • Complicated UTIs: These are associated with anatomical or functional abnormalities in the urinary system, such as those caused by catheter use. Men are generally less likely to experience UTIs due to the antibacterial properties of prostatic fluid and the longer male urethra. When UTIs do occur in men, they are often complicated and linked to underlying issues such as benign prostatic hyperplasia (BPH), which can obstruct urine flow.
  • Uncomplicated UTIs: Occurring in structurally and functionally normal urinary tracts, these infections are usually seen in non-pregnant women and commonly involve the bladder (acute cystitis) or kidneys (acute pyelonephritis). The majority of uncomplicated UTIs are caused by Escherichia coli, accounting for 70% to 90% of cases, while Klebsiella pneumoniae and Proteus mirabilis are less common but also possible causes.

Risk Factors for UTIs

Certain risk factors increase the likelihood of developing UTIs in aged care residents. These include:

  • Female gender: Due to anatomical differences, women have a higher risk of UTIs.
  • Advanced age: As people age, the body’s defences weaken, increasing susceptibility.
  • Diabetes: This condition affects immune function, making infections more likely.
  • Post-menopausal women: The decline in oestrogen levels can lead to atrophic vaginitis, a condition that predisposes women to recurrent UTIs.
  • Pregnancy: Hormonal changes and shifts in anatomy during pregnancy can contribute to the risk.
  • Urinary catheters: Catheter use increases the chance of bacterial entry and infection.

Other factors include the use of diuretics, which may lead to dehydration and less frequent urination. This can result in concentrated urine that provides an environment for bacterial growth.

Recognising Symptoms of UTIs

Symptoms of UTIs can vary, but common signs include:

  • A persistent and strong urge to urinate
  • Burning sensation during urination
  • Frequent passage of small amounts of urine
  • Cloudy urine
  • Blood in the urine
  • Strong-smelling urine
  • Pain in the lower abdomen (suprapubic pain)

In cases of acute cystitis, symptoms often involve dysuria, urgency, urinary frequency, nocturia, and suprapubic tenderness. In older adults, symptoms may be less specific, with acute dysuria (painful urination) being a notable indicator in aged care residents. Additionally, confusion or altered mental status may be the only sign of a UTI in elderly individuals, particularly in those without catheters.

For upper urinary tract infections, such as pyelonephritis, systemic symptoms like fever, chills, or sepsis may occur, along with flank pain, nausea, vomiting, and costovertebral tenderness. Pyelonephritis has a higher potential for serious complications.

Asymptomatic Bacteriuria

Asymptomatic bacteriuria, or the presence of bacteria in the urine without symptoms, is prevalent in aged care settings, affecting at least 40-50% of women and 30-40% of men without chronic catheters. Routine screening for asymptomatic bacteriuria is generally not recommended, as treatment in these cases could contribute to unnecessary antibiotic use and resistance. Antibiotic therapy is only advised in specific situations, such as for pregnant women or those undergoing invasive urinary procedures. For individuals with catheters, treatment should be reserved for those who exhibit symptoms.

Diagnosis and Treatment Options

Diagnosing UTIs in aged care settings involves identifying symptoms and conducting urine tests to confirm the presence of bacteria.

Treatment Options:

  • First-line Treatment for Uncomplicated UTIs:
    • Trimethoprim: 300 mg daily for 3 days.
    • Nitrofurantoin: 100 mg every 6 hours for 5 days.
  • Trimethoprim is typically administered at night to increase effectiveness by concentrating the antibiotic in the bladder overnight. For individuals who cannot take trimethoprim or nitrofurantoin, cefalexin (500 mg twice daily for 5 days) is recommended.
  • Alternative Treatments for Resistant Infections:
    • Amoxicillin: 500 mg every 8 hours for 5 days.
    • Trimethoprim-sulfamethoxazole: 160/800 mg every 12 hours for 3 days.
    • Amoxicillin-clavulanate: 500/125 mg every 12 hours for 5 days.
  • Second-Line Treatment (Post Culture Confirmation):
    • Fosfomycin: 3g single dose.
    • Norfloxacin: 400 mg twice daily for 3 days.
    • Ciprofloxacin: 250 mg twice daily for 3 days.

Quinolone antibiotics like norfloxacin or ciprofloxacin are generally avoided as first-line treatments due to the risk of developing resistance.

Treatment for Males with Acute Cystitis: Men require longer courses of antibiotics:

  • Trimethoprim: 300 mg daily for 7 days.
  • Nitrofurantoin: 100 mg every 6 hours for 7 days.
  • Cefalexin: 500 mg every 12 hours for 7 days.

Pyelonephritis Treatment: For mild cases without systemic symptoms, oral antibiotics such as amoxicillin-clavulanate (875/125 mg twice daily for 14 days) may be effective. If penicillin hypersensitivity is an issue, ciprofloxacin (500 mg twice daily for 7 days) can be used.

Preventing Recurrent UTIs

Recurrent UTIs, defined as two or more infections in six months or three in one year, are particularly concerning. Preventative strategies may involve:

  • Antibiotic Prophylaxis:
    • Trimethoprim: 150 mg at night.
    • Cefalexin: 250 mg at night.
    • Nitrofurantoin: 50 mg at night (note that long-term use may carry risks of pulmonary and hepatic toxicity).

For postmenopausal women, intravaginal or topical oestrogen may help reduce recurrent UTIs by addressing oestrogen deficiencies that predispose them to infections. Examples include:

  • Oestriol cream (Ovestin), 1 mg/g, applied once or twice weekly.
  • Oestriol pessary (Ovestin Ovula), 500 mcg, used once or twice weekly.
  • Oestradiol pessary (Vagifem Low), 10 mcg, used twice weekly.

FAQs

Why are UTIs more common in women in aged care facilities?

Due to anatomical differences and decreased oestrogen levels in postmenopausal women, which can lead to recurrent UTIs.

Is antibiotic treatment always necessary for UTIs?

Antibiotic treatment is only recommended for symptomatic UTIs. Asymptomatic bacteriuria does not require treatment except in specific cases, like pregnancy or prior to invasive procedures.

What is the main risk of overusing antibiotics for UTI treatment?

Overuse of antibiotics can lead to antimicrobial resistance, making it harder to treat future infections effectively.

How can UTIs be prevented in residents prone to recurrent infections?

Preventive options include low-dose antibiotics, intravaginal or topical oestrogen for postmenopausal women, and proper hydration to promote regular urination.

Can UTIs in men be uncomplicated?

Traditionally, UTIs in men were considered complicated due to underlying factors like prostatic hyperplasia, though uncomplicated UTIs can occur in rare cases.

What differentiates upper from lower UTIs?

Lower UTIs typically involve the bladder and urethra, while upper UTIs affect the kidneys and ureters and often present with more severe, systemic symptoms.

Key Takeaways

  • UTIs are prevalent in aged care: The incidence of urinary tract infections increases with age, particularly affecting women in residential aged care.
  • Differentiating complicated and uncomplicated UTIs: Complicated UTIs often involve anatomical abnormalities or catheter use, while uncomplicated UTIs occur in a healthy urinary tract, mostly in women.
  • Asymptomatic bacteriuria should not be routinely treated, as it often leads to unnecessary antibiotic use and increases resistance risks.
  • Common symptoms include a strong urge to urinate, burning during urination, and cloudy or strong-smelling urine; in older adults, confusion may be a symptom.
  • First-line antibiotic treatments are available and vary by infection type and patient gender, with alternative treatments used for resistant cases.
  • Prevention strategies: For recurrent UTIs, preventive antibiotics and oestrogen treatments for postmenopausal women can help reduce infection rates.

Final Thoughts

UTIs are a significant health issue in residential aged care homes, especially for elderly women. Effective management requires an understanding of the different types of UTIs, appropriate use of antibiotics, and recognition of when treatment is unnecessary to prevent antimicrobial resistance. By following evidence-based practices, aged care providers can manage UTIs effectively, enhancing residents’ quality of life while minimising risks associated with overtreatment and antibiotic resistance.

For more information on safe medication management, consult with Webstercare today.