Update in Infectious Diseases in Older Adults: UTI Manisha Juthani-Mehta, MD

Update in Infectious Diseases in Older
Adults: UTI
Manisha Juthani-Mehta, MD
Associate Professor of Medicine
Section of Infectious Diseases
American Geriatrics Society Annual Scientific Meeting 2013
May 5, 2013
SLIDE 0
Illustrative Patient
• 96 year old female nursing home resident
• History of CHF, atrial fibrillation not on coumadin, hemorrhagic
stroke, seizures, Alzheimer’s dementia, AS, MR s/p MVR, and recent
ORIF of the left hip
• Presents with acute change in mental status, a question of left facial
droop, and cloudy urine
• Well until the morning of admission when she became responsive
only to painful stimuli. By the evening of the day of admission, she
had returned to her baseline mental status.
• Upon returning to her baseline level of consciousness, she reported
no fever, chills, SOB, cough, or dysuria. Mild left facial droop
present.
• Allergies: sulfa
SLIDE 1
Illustrative Patient
 PE: Temp 98.4, HR 98, BP 115/72, RR 18
CV: irregularly irregular, 3/6 SEM
Lungs: few crackles at left lung base
Abd: no suprapubic tenderness
Back: no CVA tenderness
 WBC 9.2, Cr 1.0, BNP 300, Head CT negative,
CXR neg.
 UA: LE positive, nitrite negative, >30 WBCs,
2-5 RBCs, moderate bacteria; Urine culture
pending
 Received a dose of ceftriaxone in the ER
SLIDE 2
Background on UTI
• Asymptomatic bacteriuria: bacteria in the urine without
symptoms referable to the urinary tract
• Symptomatic UTI: ≥ 105 CFU/mL in one urine
specimen in the presence of urinary tract specific
symptoms
• Risk factors for UTI in post-menopausal women:
– Sexual activity
– History of UTI
– Treated diabetes
– Incontinence
– No protective effect of oral estrogen
Hu KK, Boyko EJ, Scholes D, Normand E, Chen CL, Grafton J, Fihn SD. Risk factors for urinary tract infections in postmenopausal women.
Arch Intern Med 2004;164(9):989-93.
SLIDE 3
Diagnostic Challenges for UTI
• Do Not Screen or Treat ASB in:
– Premenopausal, non-pregnant women
– Diabetic women
– Persons with spinal cord injury
– Catheterized patients while catheter remains in place
– Older persons living in the community
– Elderly, institutionalized subjects
• Three randomized controlled trials of antibiotic
treatment (versus no treatment) of asymptomatic
bacteriuria were conducted among institutionalized
adults; none of these trials showed any decrease in
mortality with treatment.
Nicolle LE, Bjornson J, Harding GK, MacDonell JA. Bacteriuria in elderly institutionalized men. N Engl J Med 1983;309(23):1420-5.
Boscia JA, Kobasa WD, Abrutyn E, Levison ME, Kaplan AM, Kaye D. Lack of association between bacteriuria and symptoms in the elderly.
Am J Med 1986;81(6):979-82.
Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in
institutionalized elderly women. Am J Med 1987;83(1):27-33.
SLIDE 4
Clinical Features Predicting Bacteriuria plus Pyuria
Juthani-Mehta M, Tinetti M, Perrelli E, Towle V, Van Ness P, Quagliarello V. Clinical Features to Identify UTI in Nursing Home
Residents: A Cohort Study. JAGS 57:963-970, 2009 (with editorial).
SLIDE 5
Diagnostic Utility of the Urinary Dipstick
Juthani-Mehta M, Tinetti M, Perrelli E, Towle V, Quagliarello V. Role of dipstick testing in the evaluation of
Juthani-Mehta M, Tinetti M, Perrelli E, Towle V, Quagliarello V. Role of dipstick testing in the evaluation of urinary
tract
infection
in nursing
homeHosp
residents.
Infect
Control Hosp Epidemiol 2007;28(7):889-91.
tract infection urinary
in nursing
home
residents.
Infect Control
Epidemiol
2007;28(7):889-91.
SLIDE 6
Microbiology of urinary isolates
Das R, Perrelli E, Towle V, Van Ness P, Juthani-Mehta M. Antimicrobial Susceptibility of Urinary Isolates from Nursing
Home Residents. Infect Cont Hosp Epidemiol 2009;30:1116-1119.
SLIDE 7
Antimicrobial susceptibility of E.coli
Das R, Perrelli E, Towle V, Van Ness P, Juthani-Mehta M. Antimicrobial Susceptibility of Urinary Isolates
from Nursing Home Residents. Infection Control and Hospital Epidemiology 2009; 30:1116-1119.
SLIDE 8
Current prescribing patterns and abx resistance
• Quinolones are more commonly prescribed than sulfa antibiotics
• Patients > 80 years living in community:
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–
–
–
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Increased quinolone resistant E.coli isolates
Increased TMP-SMX resistant E.coli isolates
Increased quinolone + TMP-SMX resistant E.coli isolates
Increased extended-spectrum cephalosporin resistant E.coli isolates
Increased 3 drug classes resistant E.coli isolates
• Three days of therapy for uncomplicated UTI is sufficient
• Nitrofurantoin should be considered as a first line agent when
organism is known; bactrim preferable as a first line empiric
therapy agent
Kallen AJ, Welch HG, Sirovich BE. Current antibiotic therapy for isolated urinary tract infections in women. Arch Intern Med 2006;166(6):635-9.
Swami SK, Liesinger JT, Shah N, Baddour LM, Banerjee R. Incidence of antibiotic-resistant Escherichia coli bacteriuria according to age and
location of onset: a population-based study from Olmsted County, Minnesota. Mayo Clin Proc 2012;87(8):753-9.
Vogel T, Verreault R, Gourdeau M, Morin M, Grenier-Cosselin L, Rochette L. Optimal duration of antibiotic therapy for uncomplicated urinary tract
infection in older women: a double-blind randomized controlled trial. CMAJ 2004;170(4):469-73.
McKinnell JA, Stollenwerk NS, Jung CW, Miller LG. Nitrofurantoin compares favorably to recommended agents as empirical treatment of
uncomplicated urinary tract infections in a decision and cost analysis. Mayo Clin Proc 2011;86(6):480-8.
SLIDE 9
When to suspect UTI and what to do
Vague change in clinical status
No localizing signs on PE
Wait to send
urine studies
Hydrate (PO or IV) for 48 hours
Evaluate for medication interactions or adverse effects
Try to treat underlying incontinence
If change in mental status and change in
character persist, perform urinary dipstick
If negative for LE and nitrite, STOP
If positive, send UA and UCx. If UA>10 WBC
and UCx>100,000 CFU of 1-2 organisms
AND precipitating signs/symptoms have not
resolved, consider treatment with antibiotics.
S L I D E 10
History of the cranberry
• Cranberries, blueberries and Concord grapes are the only berries
native to North America.
• Cranberries were first used by Native Americans
– versatility as a food, fabric dye and healing agent
– used the berries to draw poison from arrow wounds, calm nerves, and
treat bladder and kidney ailments (1550)
• The name “cranberry” derives from the Pilgrim name for the fruit
– “craneberry”: small, pink blossoms that appear in the spring resemble
the head and bill of a Sandhill crane
Vaccinium macrocarpon
Sandhill crane
S L I D E 11
Cranberry for UTI prevention
Proanthocyanidins (PAC): condensed tannins, A-type are concentrated in cranberries
(different than grapes and chocolate), inhibit P-piliated E. coli adherence to
uroepithelial cells.
S L I D E 12
Cranberry studies in older adults to date
• 153 elderly women
• 300ml daily cranberry beverage
or placebo drink – 36mg PAC
• Baseline urine specimen and
clean catch monthly specimens
for 6 months
• 58% reduction in bacteriuria
plus pyuria
• No change in urinary pH
• Greatest critique is UTI rate in
past 12 months was higher
(33% vs. 17%) in the placebo
group than in the cranberry
group
Avorn J, Monane M, Gurwitz JH, Glynn RJ, Choodnovskiy I, Lipsitz LA. Reduction of bacteriuria
and pyuria after ingestion of cranberry juice. JAMA. Mar 9 1994;271(10):751-754.
S L I D E 13
Pilot dosing study results
Bianco L, Perrelli E, Towle V, Van Ness PH, Juthani-Mehta M. Pilot Randomized Controlled Dosing Study of Cranberry Capsules
for Reduction of Bacteriuria plus Pyuria in Female Nursing Home Residents. Journal of the American Geriatrics Society S L I D E 14
2012;60(6):1180-1181.
The CRANNY Study
CRANberry capsules for prevention of UTI in Nursing homes at Yale
Funded by 1R01AG041153-01A1, NIA, 05/01/2012-04/30/2016
16 nursing homes – rescreening every three months
Two capsules vs. placebo in female LTCF residents ≥ 65 years
Capsules donated by Pharmatoka (36mg PAC per capsule)
Sample size: 180
Follow up per participant: one year
Primary outcome: bacteriuria (>100,000 cfu/ml of one or two
organisms) plus pyuria (any WBC on urinalysis
• Urine specimens obtained at baseline and every 2 months (6 outcome
assessments)
• Urinary tract specific symptoms assessed at each time point
• Secondary outcomes: symptomatic UTI, hospitalization, death,
antibiotic prescriptions, resistant organisms
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S L I D E 15
Study progress to date
• Ongoing recruitment in six nursing homes to date
• Recruitment progress:
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1299 residents screened
348 residents eligible (26.7% eligibility rate)
114 residents/surrogates consented (32.8% consent rate)
66 participants enrolled (57.9% enrollment rate)
• Unable to obtain baseline urine specimen
• Discharged from nursing home
• Terminal
• Adverse events and secondary outcomes assessed monthly
• Four new homes being enrolled
• Outcome assessments ongoing
S L I D E 16
Acknowledgements
• The CUTIE, PACS, CranDose,
and CRANNY Teams:
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Luann Bianco
Eleanor Perrelli
Sandy Ginter
Andrea Rink
Sabina Rubeck
Lauren Perley
Christine Bailey
Denise Acampora
Stephanie Argraves
Virginia Towle
Peter Charpentier
Shu Chen
Jim Dziura
Peter Van Ness
Peter Peduzzi
Mary Tinetti
Vincent Quagliarello
• Funding Agencies:
– T. Franklin Williams Award
– Hartford Foundation
– Donaghue Foundation
– National Institute on Aging
(T32, R03, K23, R01)
– Yale Pepper Center
– Yale Center for Clinical
Investigation (YCCI, Yale
CTSA)
S L I D E 17
Association of Increasing Episodes of Bacteriuria
with Adverse Clinical Outcomes
Das R, Towle V, Van Ness PH, Juthani-Mehta M. Adverse Outcomes of Bacteriuria in Nursing
Home Residents. Infection Control and Hospital Epidemiology 2011, 32(1):84-6.
S L I D E 18