Ahhh, the joys of growing older

03/08/2017

By: Louann Bruno-Murtha, DO, CHA Division Chief of Infectious Disease

Growing older has its rewards and challenges. We’re wiser and we get to spoil our grandchildren, but we also face new and unexpected health issues. While it may not be anyone’s favorite topic, urinary tract infections (UTIs) are one of life’s surprises that affect many of us later in life.

What is a UTI?
A UTI is simply an infection of the urinary system, most often in the bladder. It is the second most common infection in older adults, behind respiratory illness, and one of the leading reasons doctors prescribe antibiotics nationwide.

Women are more prone to UTIs than men, due to anatomical differences. The urethra is shorter in women, allowing easier access for bacteria to reach the bladder resulting in infection. There are also normal hormonal changes with aging that can predispose women to bladder infections. While older women who have a history of these infections are at higher risk, older men also get UTIs.

Mrs. B (not her real name) struggled with mental health issues and was delusional when she was admitted to the hospital. For the past several months her son demanded that she be given an antibiotic to treat what he thought was a recurring UTI. Mrs. B was confused and had cloudy urine. It was clear she needed medical care. But it was difficult to determine exactly what she needed.

Common Symptoms of UTI

  • Pain or burning while urinating
  • Frequent urination
  • Feeling the need to urinate despite having an empty bladder
  • Fever
  • Blood in the urine
  • Flank tenderness  (localized back pain on the right or left of the mid back)
  • Lower abdominal discomfort

Please see your primary care provider if you’re having any of these symptoms.

The use of antibiotics
UTIs are the number one reason doctors prescribe antibiotics to older people. However, not all patients prescribed antibiotics for a UTI have one. In order to diagnose a UTI, a patient should have specific urinary tract symptoms.

According to the Centers for Disease Control and Prevention, “at least 30 percent of antibiotics prescribed in the U.S. are unnecessary.”  That’s nearly one in three prescriptions. As a result, bacteria have become resistant and antibiotics are often less effective than in the past. With antibiotic resistance rising to epidemic levels, we need to ask whether antibiotics are truly necessary to resolve symptoms.

Antibiotics may also have side effects. They destroy helpful bacteria in our stomach and intestines, which may result in diarrhea and other complaints. Far more feared is Clostridium difficile (C.diff) infection, a potentially deadly complication of antibiotic therapy.  And, for older adults on multiple medications, there can be unintended interactions like cardiac arrhythmia.

Another concern is expense. Overprescribing antibiotics adds unnecessary health care costs and antibiotic-resistant infections cost us an estimated $20 billion each year.

How do we know if it is a UTI? 
When our patients or loved ones are uncomfortable, we want to make them feel better. But with Mrs. B, it was not clear what was causing her symptoms. Although her family wanted a quick solution, we counseled them that prescribing an antibiotic without proper tests was not the best medicine. Did you know that cloudy urine is not a sign of UTI?

A common myth: Many online resources suggest that sudden confusion, disorientation, change in behavior, fatigue or cloudy urine in older people indicate a UTI. Infection can cause these symptoms, but these complaints should not be attributed to a UTI without careful consideration. If we simply prescribe antibiotics, we may miss other issues. These symptoms can be caused by medication interactions or side effects, malnutrition, constipation, dehydration or other infections. It’s important to do a thorough exam to best determine the causes before prescribing any medication.

A clean catch: While UTI symptoms are well known (see sidebar), testing urine is the best method to determine an infection. This can be more difficult than people realize, especially for older adults. We need a “clean catch” – a sample collected in the middle of the urine stream after proper skin disinfection. Urine that is first released has higher contaminants and can lead to false positives. Being honest about whether you or your loved one can achieve a “clean catch” is important. There are other methods that can be used if needed.

An aseptic sample: Older adults with a bladder catheter will inevitably have bacteria in a urine sample. In these situations, the specimen should be obtained by aseptic technique after a new catheter is placed.

A positive test for bacteria: It’s common for some patients to have bacteria in the bladder and as we get older, this increases. A urine test from older adults may show bacteria even if there are no symptoms – called asymptomatic bacteriuria. In these situations, there’s no need for antibiotics. People need to have symptoms AND have a positive test to benefit from antibiotic treatment.

Mrs. B’s condition made it nearly impossible to obtain a clean urine sample. This may be why antibiotics were prescribed in the first place. So we re-evaluated her medications and found that her prescriptions were interacting in a way that worsened her mental health symptoms instead of improving them. With a modified course of medications, her mental health improved. After appropriate testing, no antibiotics were needed.

How can you help?
CHA is taking a proactive approach to ensure that patients are properly diagnosed and treated. If you care for an older adult, be aware that antibiotics may not be appropriate in every situation.

You can be the most effective advocate for your loved one. For information please read more from the Massachusetts Infection Prevention Partnership

Cambridge Health Alliance

Contributed By: Cambridge Health Alliance

Cambridge Health Alliance is an academic community health care system committed to serving all members of our communities. We have expertise in primary care, mental health and substance abuse, and caring for diverse and complex populations. CHA patients receive high quality care in convenient neighborhood locations, and have seamless access to advanced care through CHA’s affiliation with Beth Israel Deaconess Medical Center. With over 140,000 patients in Cambridge, Somerville Everett and Boston’s Metro North, CHA is working hard to offer the integrated services its communities need now, and in the future.