Urinary Tract Infections In Older Adults Research Articles

Exploring treatment burden of Oral Nutritional Supplements (ONS) and impact on antibiotics using a data linkage approach

Abstract Introduction Treatment burden associated with thickeners is significant1. Understanding of potential treatment burden associated with ONS is lacking, however wastage due to ONS partial or full nonconsumption, and stock piling are recognised2. Wastage is evidence of over prescribing. Improving fluid intake by increasing variety is evidence based3 - ONS reduces opportunity. Whether thickener or ONS is prescribed, patients can withdraw consent by not drinking (verbally/silently). We investigated a potential correlation between ONS and low intake dehydration, and if detectable using a proxy measure: antibiotic prescribing for urinary tract infection (UTI). We explored using ePACT2 data to investigate co-prescribing of interventions that inter-relate, a type of data linkage study. Improved fluid intake can decrease laxative use, but did not reduce antibiotic use3. We hypothesized that with a large data set, it may be possible to detect associations of treatment burden and antibiotic use. Aim To explore the relationship between prescribing of ONS with antibiotics for UTIs in older adults in Primary Care (England). Methods We investigated co-prescribing of antibiotics prescribed for UTI (nitrofurantoin, trimethoprim) and ONS in older adults (> 65 years) in Primary Care. Data was obtained from the NHS Business Services Authority Data Services Support as bespoke analysis of prescribing ePACT2 data linked by NHS number. Retrospective analysis was performed on anonymised data for 3 years (January 2019 to December 2022). Ethical approval was not required. Data unattributable to a specific region was excluded. Results Initial analysis suggested that prescribing of UTI antibiotics was 3 times more common in older adults prescribed ONS compared with controls (an average 2.86% of the patients on GP list were prescribed an antibiotic for a UTI, increasing to 8.59% for those co-prescribed ONS). This correlation appeared consistent, however, due to high volume and level of detail of UTI antibiotic prescribing, this interpretation is incorrect. On further analysis, the population rate of UTI antibiotic and ONS was plotted to show trend over time, demonstrating no correlation. Prescription of UTI antibiotic over time is consistent, reflecting that acute lower UTI is not very reducible, and antibiotic prophylaxis use is common and repeated monthly. Additionally, from this data set you cannot ascertain if frequency of antibiotic prescription(s) pre-dates initiation of ONS. We did not investigate confounding factors such as co-prescribing of catheter use, gender, frailty and advancing age. Our oldest patients with decreased thirst, reduced appetite cues and ability to eat and drink will also be those most likely to get an UTI. Discussion/Conclusion Future data linkage work in this area should include a wider range of data e.g. detailed demographics, medical and prescribing history over time and all adverse events from low intake dehydration. Exploration of the impact of ONS and thickener prescription on patient experience, perceived treatment burden and the impact on fluid intake would be useful. Audit of shared decision making at initiation and review would also be beneficial in obtaining baseline data on consent at start and throughout duration of prescription.

Clinically relevant and explainable feature extraction from remote monitoring data for the prediction of urinary tract infections

AbstractBackgroundA frequent cause for hospitalisation in people living with dementia (PLWD) is urinary tract infections (UTIs) (Dufour et al., 2015). Early detection aids in avoiding unplanned hospitalisations and machine learning and connected sensors enable development of risk analysis models based on in‐home monitoring data. This work makes use of data from the ongoing Minder study at the UK Dementia Research Institute, including in‐door movement, appliance use, physiology, sleep, and environmental information. Previous work (Li et al., 2020) shows complex models can achieve high accuracy when detecting UTIs, but interpretability and generalisability remain an open issue. This work evaluates how clinically interpretable features and simple models perform.MethodThe engineered features reflect visible symptoms of UTIs in older adults and are daily aggregated and pre‐processed information from PLWD’s homes containing passive sensors. 14 activity, sleep and physiological features were engineered relating to bathroom visits, entropy rate, physiological readings, and sleep behaviour. Raw data consisted of frequencies of the activity sensor firings. Their use in predicting cases of UTIs was compared by evaluating multilayer perceptron models on labelled data (643 negatives and 311 positives, from 39 PLWD), using 5‐fold cross‐validation (80%/20% train/test split), with 5 repeats. Prior to training and testing, the data was z‐normalised using unlabelled data. When evaluating, recall is most essential because reducing false positive rates is crucial in our setting.ResultThe highest performing model achieved the best accuracy, recall, precision and F1 score (85.6%, 69.9%, 81.5%, 74.8%) on combinations of engineered and raw features; though not significantly higher than with raw features alone (83.2%, 63.5%, 80.5%, 70.8%). Full results can be seen in the attached figure.ConclusionOur engineered features do not significantly improve results but add interpretability and generalisability to predictions. The models' hidden layers have a high capacity for learning patterns in the raw data, however, may not be clinically interpretable and we hypothesise that engineered features improve generalisation. Engineered features are homogeneous across the cohort and new data, and so create a way of representing the data which is not single device dependent. To verify this, we will continue our data collection and will conduct further experiments.

Association between osteoarthritis and urinary tract infection in older adults: A nationwide population-based cohort study.

Osteoarthritis (OA) may increase urinary tract infection (UTI) in older adults. However, this issue remains unclear. We identified 8599 older patients (≥65 years) with OA, and an equal number of older patients without OA, matched by age, sex, and index date from the Taiwan National Health Insurance Research Database between 2001 and 2005. Past histories, including UTI and underlying comorbidities, were included in the analyses. Comparisons for any UTI, ≥1 hospitalization for UTI, and ≥3 hospitalizations for UTI between the 2 cohorts by following up until 2015 were performed. In both cohorts, the percentages of age subgroups were 65–74 years (65.7%), 75–84 years (30.1%), and ≥85 years (4.2%). The male sex was 42.4%. Patients with OA had an increased risk of any UTI compared with those without OA after adjusting for all past histories (adjusted hazard ratio [AHR]: 1.72; 95% confidence interval [CI]: 1.64–1.80). Compared with patients without OA, patients with OA also had an increased risk of ≥1 hospitalization for UTI and ≥3 hospitalizations for UTI (AHR: 1.13; 95% CI: 1.06–1.19 and AHR: 1.25; 95% CI: 1.13−1.38, respectively). In addition to OA, age 75–84 years, female sex, history of UTI, benign prostatic hyperplasia, indwelling urinary catheter, cerebrovascular disease, dementia, and urolithiasis were independent predictors for any UTI. This study showed that OA was associated with UTI in older adults. We suggest appropriately managing OA and controlling underlying comorbidities to prevent subsequent UTI.

Associations of delirium with urinary tract infections and asymptomatic bacteriuria in adults aged 65 and older: A systematic review and meta‐analysis

ObjectiveTo determine the associations of delirium with urinary tract infection (UTI) and asymptomatic bacteriuria (AB) in individuals aged 65 and older.MethodsThe protocol for this systematic review and meta‐analysis was published on PROSPERO (CRD42020164341). Electronic databases were searched for relevant studies, professional associations and experts in the field were additionally contacted. Studies with control groups reporting associations between delirium and UTI as well as delirium and AB in older adults were included. The random effects model meta‐analysis was conducted using odds ratios (ORs) with 95% confidence intervals (CIs) as effect size measures. The Newcastle‐Ottawa scale was used to rate the studies' quality. Heterogeneity was assessed using the Q and I 2 tests. The effects of potential moderators were investigated by both subgroup and meta‐regression analyses. The risk of publication bias was evaluated using the funnel plot and Egger's test.ResultsTwenty nine relevant studies (16,618 participants) examining the association between delirium and UTI in older adults were identified. The association between delirium and UTI was found to be significant (OR 2.67; 95% CI 2.12–3.36; p < 0.001) and persisted regardless of potential confounders. The association between delirium and AB in older adults in the only eligible study found (192 participants) was insignificant (OR 1.62; 95% CI 0.57–4.65; p = 0.37). All included studies were of moderate quality.ConclusionThe results of this study support the association between delirium and UTI in older adults. Insufficient evidence was found to conclude on an association between delirium and AB in this age group. These findings are limited due to the moderate quality of the included studies and a lack of available research on the association between delirium and AB. Future studies should use the highest quality approaches for defining both delirium and UTI and consider AB in their investigations.

Antibiotic prescribing for lower UTI in elderly patients in primary care and risk of bloodstream infection: A cohort study using electronic health records in England

Research has questioned the safety of delaying or withholding antibiotics for suspected urinary tract infection (UTI) in older patients. We evaluated the association between antibiotic treatment for lower UTI and risk of bloodstream infection (BSI) in adults aged ≥65 years in primary care. We analyzed primary care records from patients aged ≥65 years in England with community-onset UTI using the Clinical Practice Research Datalink (2007-2015) linked to Hospital Episode Statistics and census data. The primary outcome was BSI within 60 days, comparing patients treated immediately with antibiotics and those not treated immediately. Crude and adjusted associations between exposure and outcome were estimated using generalized estimating equations. A total of 147,334 patients were included representing 280,462 episodes of lower UTI. BSI occurred in 0.4% (1,025/244,963) of UTI episodes with immediate antibiotics versus 0.6% (228/35,499) of episodes without immediate antibiotics. After adjusting for patient demographics, year of consultation, comorbidities, smoking status, recent hospitalizations, recent accident and emergency (A&E) attendances, recent antibiotic prescribing, and home visits, the odds of BSI were equivalent in patients who were not treated with antibiotics immediately and those who were treated on the date of their UTI consultation (adjusted odds ratio [aOR] 1.13, 95% CI 0.97-1.32, p-value = 0.105). Delaying or withholding antibiotics was associated with increased odds of death in the subsequent 60 days (aOR 1.17, 95% CI 1.09-1.26, p-value < 0.001), but there was limited evidence that increased deaths were attributable to urinary-source BSI. Limitations include overlap between the categories of immediate and delayed antibiotic prescribing, residual confounding underlying differences between patients who were/were not treated with antibiotics, and lack of microbiological diagnosis for BSI. In this study, we observed that delaying or withholding antibiotics in older adults with suspected UTI did not increase patients' risk of BSI, in contrast with a previous study that analyzed the same dataset, but mortality was increased. Our findings highlight uncertainty around the risks of delaying or withholding antibiotic treatment, which is exacerbated by systematic differences between patients who were and were not treated immediately with antibiotics. Overall, our findings emphasize the need for improved diagnostic/risk prediction strategies to guide antibiotic prescribing for suspected UTI in older adults.

Management of Extended-Spectrum Beta-Lactamase Urinary Tract Infections: Diagnostic and Treatment Considerations for the Older Adult

OBJECTIVE: To review the treatment options for extended-spectrum beta-lactamase (ESBL) urinary tract infections (UTIs) in the long-term care facility setting.<br/> DATA SOURCES: A PubMed search from January 1, 1990, through December 31, 2018, using terms "extended spectrum beta lactamase" and "urinary tract infection" was performed. Current guidelines, drug databases, and manufacturer package inserts were also used.<br/> STUDY SELECTION: All English-language articles during the above time frame appearing in these searches were reviewed for relevance to this paper. In addition, their bibliographies were reviewed to identify any articles not originally identified.<br/> DATA SYNTHESIS: ESBL UTIs are a growing concern in the long-term care facility as these pathogens are becoming more prevalent. Patients residing in long-term care facilities have fewer treatment modalities because of medication administration and care issues. This review highlights the data on different antibiotics and their efficacy toward ESBLs in the setting of UTI.<br/> CONCLUSIONS: Despite the challenges and limitations, there are still options for clinicians to provide optimal care, including antibiotics with different routes of administration, as well as different administration techniques. Clinicians can be successful with treating ESBL UTIs in older adults.

Management of Extended-Spectrum Beta-Lactamase Urinary Tract Infections: Diagnostic and Treatment Considerations for the Older Adult.

OBJECTIVE: To review the treatment options for extended-spectrum beta-lactamase (ESBL) urinary tract infections (UTIs) in the long-term care facility setting.<br/> DATA SOURCES: A PubMed search from January 1, 1990, through December 31, 2018, using terms "extended spectrum beta lactamase" and "urinary tract infection" was performed. Current guidelines, drug databases, and manufacturer package inserts were also used.<br/> STUDY SELECTION: All English-language articles during the above time frame appearing in these searches were reviewed for relevance to this paper. In addition, their bibliographies were reviewed to identify any articles not originally identified.<br/> DATA SYNTHESIS: ESBL UTIs are a growing concern in the long-term care facility as these pathogens are becoming more prevalent. Patients residing in long-term care facilities have fewer treatment modalities because of medication administration and care issues. This review highlights the data on different antibiotics and their efficacy toward ESBLs in the setting of UTI.<br/> CONCLUSIONS: Despite the challenges and limitations, there are still options for clinicians to provide optimal care, including antibiotics with different routes of administration, as well as different administration techniques. Clinicians can be successful with treating ESBL UTIs in older adults.

Effectiveness of Methenamine for UTI Prevention in Older Adults.

Background: Methenamine is a drug used for the prevention of lower urinary tract infections (UTIs). However, efficacy has not been established in older adults or patients with varying degrees of kidney function. Objective: To evaluate the effectiveness of methenamine for the prevention of UTI in adults 60 years and older. Methods: This was a retrospective, pre-post, observational study. The study included primary care patients 60 years and older who were taking methenamine between January 1, 2015, and September 30, 2018. The primary outcome was the time to first UTI after methenamine initiation compared with the average time between UTIs in the 12 months prior to methenamine initiation. Results: Of 434 patients reviewed, 150 met inclusion criteria. The average time to UTI was 3.3 months prior to methenamine initiation compared with 5.5 months after methenamine initiation (P = 0.0004). There were 33 patients (22%) who did not have a UTI after methenamine initiation. Also, 14 patients (9.3%) had a calculated CrCl <30 mL/min at baseline. The average time to UTI in these patients was 3.3 months prior to methenamine initiation compared with 12.7 months after initiation (P < 0.0001). Conclusion and Relevance: Methenamine use was associated with a longer time to UTI in older adults with varying degrees of kidney function. The effectiveness of methenamine appeared to be similar regardless of kidney function, which is new evidence. Because of a lack of acquired resistance, methenamine may be an effective option for UTI prophylaxis in older adults.

Gaps in communication between different staff groups and older adult patients foster unnecessary antibiotic prescribing for urinary tract infections in hospitals: a qualitative translation approach

BackgroundStudies have reported large scale overprescribing of antibiotics for urinary tract infection (UTI) in hospitalised older adults. Older adults often have asymptomatic bacteriuria, and clinicians have been found to diagnose UTIs inappropriately based on vague symptoms and positive urinalysis and microbiology. However, the joined perspectives of different staff groups and older adult patients on UTI diagnosis have not been investigated.MethodsThematic analysis of qualitative interviews with healthcare staff (n = 27) and older adult patients (n = 14) in two UK hospitals.ResultsInterviews featured a recurrent theme of discrepant understandings and gaps in communication or translation between different social groups in three key forms: First, between clinicians and older adult patients about symptom recognition. Second, between nurses and doctors about the use and reliability of point-of-care urinary dipsticks. Third, between nurses, patients, microbiologists and doctors about collection of urine specimens, contamination of the specimens and interpretation of mixed growth laboratory results. The three gaps in communication could all foster inappropriate diagnosis and antibiotic prescribing.ConclusionInterventions to improve diagnosis and prescribing for UTIs in older adults typically focus on educating clinicians. Drawing on the sociological concept of translation and interviews with staff and patients our findings suggest that inappropriate diagnosis and antibiotic prescribing in hospitals can be fuelled by gaps in communication or translation between different staff groups and older adult patients, using different languages and technologies or interpreting them differently. We suggest that interventions in this area may be improved by also addressing discrepant understandings and communication about symptoms, urinary dipsticks and the process of urinalysis.

Evaluation of methenamine for urinary tract infection prevention in older adults: a review of the evidence.

Urinary tract infections (UTI) commonly occur in older adults and can lead to more severe, life-threatening infections. Physiological factors that change with age are thought to contribute to the increased frequency of UTI recurrence in older adults. Unfortunately, there are limited methods to prevent UTI in older adults, and utilization of antimicrobial agents for prevention can have many negative consequences. Methenamine has been proposed as a useful drug for the prevention of UTI as it works as a urinary antiseptic, safely producing formaldehyde to prevent bacterial growth while avoiding bacterial resistance. The objective of this review is to evaluate the existing literature and discuss the use of methenamine in older adults for prevention of UTI. A PubMed search was conducted to identify studies evaluating the effectiveness of methenamine to prevent UTI in older adults, and 10 publications were selected based on relevant criteria. Based on the literature, methenamine appears to be a safe and effective option to prevent UTI in older adults with recurrent UTI, genitourinary surgical procedures, and potentially long-term catheterization. Studies have not evaluated the safety of methenamine in patients with impaired renal function or CrCl <30 ml/min. When selecting a treatment approach to preventing UTI in older adults with adequate renal function, clinicians may consider methenamine as a viable option.

Urine Cytokine and Chemokine Levels Predict Urinary Tract Infection Severity Independent of Uropathogen, Urine Bacterial Burden, Host Genetics, and Host Age.

Urinary tract infections (UTIs) are among the most common infections worldwide. Diagnosing UTIs in older adults poses a significant challenge as asymptomatic colonization is common. Identification of a noninvasive profile that predicts likelihood of progressing from urine colonization to severe disease would provide a significant advantage in clinical practice. We monitored colonization susceptibility, disease severity, and immune response to two uropathogens in two mouse strains across three age groups to identify predictors of infection outcome. Proteus mirabilis caused more severe disease than Escherichia coli, regardless of mouse strain or age, and was associated with differences in interleukin-1β (IL-1β), beta interferon (IFN-β), CXCL5 (LIX), CCL5 (RANTES), and CCL2 (MCP-1). In a comparison of responses to infection across age groups, mature adult mice were better able to control colonization and prevent progression to kidney colonization and bacteremia than young or aged mice, regardless of mouse strain or bacterial species, and this was associated with differences in IL-23, CXCL1, and CCL5. A bimodal distribution was noted for urine colonization, which was strongly associated with bladder CFU counts and the magnitude of the immune response but independent of age or disease severity. To determine the value of urine cytokine and chemokine levels for predicting severe disease, all infection data sets were combined and subjected to a series of logistic regressions. A multivariate model incorporating IL-1β, CXCL1, and CCL2 had strong predictive value for identifying mice that did not develop kidney colonization or bacteremia, regardless of mouse genetic background, age, infecting bacterial species, or urine bacterial burden. In conclusion, urine cytokine profiles could potentially serve as a noninvasive decision support tool in clinical practice and contribute to antimicrobial stewardship.

A Review of Cranberry Use for Preventing Urinary Tract Infections in Older Adults.

Urinary tract infections (UTIs) are one the of the most common types of infections in adults older than 65 years of age. Preventing UTIs with prophylactic antibiotics increases the risk of side effects and microbial resistance, and is costly. Cranberry fruit and juices contain the compound proanthrocyanidins (PACs), specifically proanthrocyanidin-A, which exerts antiadhesion characteristics against bacteria. Cranberry products therefore have been an attractive, nonantibiotic preventative option for UTIs; however, the current literature supporting cranberry use in older adults is controversial. This could be multifactorial owing to the heterogeneity of the older population as well as inconsistencies in the recommended dose of PAC in the current literature. Evidence supports that cranberry may be beneficial in preventing UTIs in specific populations such as catheterassociated UTI and postradiotherapy prostate cancer. The cost of daily capsules versus the cost of preventing a UTI in older adults is an important consideration for initiating therapy.

Urinary tract infections in the elderly

Urinary tract infections (UTIs) and asymptomatic bacteriuria are frequent in elderly patients. Distinguishing UTI from asymptomatic bacteriuria in older adults, particularly those living in long-term care facilities, might be achallenge for physicians due to the presence of confounding factors, such as an overactive bladder, prostate enlargement, and an indwelling bladder catheter. The absence of standards in the definition and treatment of UTI in the elderly frequently leads to overtreatment. Consequently, antibiotic selection pressure increases and as aresult multidrug-resistant organisms might arise. On the other hand, insufficient treatment can result in prolonged and complicated courses of infections or increased morbidity. This review covers the definition, prevalence, diagnosis and management of UTI in older adults.