Recurrent Urinary Tract Infections in the Elderly

Urinary tract infections (UTIs) are the second most common cause of infection in the elderly, and the leading cause of bacteraemia. The frequent use of different antibiotics (AB) has produced ecological collateral damage in the population, modifying the colonic flora and increasing the rate of resistance and selecting multi-resistant bacteria strains, especially with the use of quinolones and cephalosporins. The elderly patient who is institutionalised with fragility criteria and who has been treated with AB for the last three months constitutes a reservoir of bacteria with broad-spectrum resistance (WSBR) and the development of Clostridium difficile or methicillin-resistant staphylococci (MRSA).

At the end of 2013, the Spanish Society of Urology developed a multidisciplinary clinical practice guide on uncomplicated cystitis, with the aim of reducing clinical variability.
The changes inherent to ageing in both sexes must be known. In the elderly, the frequent presence of urological pathology (nephrolithiasis, chronic pyelonephritis, abscesses, neoplasms) may condition treatment as they are complicated UTIs.

The presence of microorganisms in the urine, without the presence of a clinic, is known as asymptomatic bacteriuria. In patients over 70 years of age this can reach 15%, which increases to 30-40% in hospitalised or institutionalised people, and treatment is not indicated because it increases the rate of resistance to AB without any effectiveness. The microorganism responsible for UTI is E. Coli and in patients with urological enterobacterial pathology and enterococcus spp.

When analysing the resistance to OA to select the most suitable ones, there is a relevant bias when obtaining microbiological data mainly from those patients with recurrent UTIs, previous therapeutic failures or high rates of resistance, which may not reflect the flora of uncomplicated patients. The 5-day treatment guidelines are of similar effectiveness as the 7-day treatment guidelines for beta-lactams, the use of phosphomycin can be administered every 72 hours given its half-life and the IMCs guarantee a treatment duration of 10 days. It is usually advisable to obtain a urine culture prior to the start of treatment, without the need for post-treatment control cultures.

Recurrences of UTIs may be due to reinfections, if by different microorganisms or by recurrence when it is the same. If there are less than 3 UTIs per year, isolated treatment should be carried out. If there are more than 3 UTIs per year, a prophylactic guideline can be considered for 6 to 12 months (starting after confirming the eradication of the causative microorganism), and in the event of recurrence, it should be prolonged further, although there are no clinical trials of its own in the elderly. As regards treatments, we recommend phosphomycin 3 grams every 10 days, cotrimoxazole 40/200 mg, and the use of furantoin should be avoided in the elderly due to undesirable effects on the liver and lungs. In menopausal women, treatment with topical oestrogens or blueberries may be considered.

In the geriatric patient with communication problems (dementia, sequelae of stroke) and the frequent atypical presentation of the disease, UTI often acts as a drawer for many pathologies, such as in the study of delirium or non-specific febrile syndromes, where the presence of a significant urine culture may indicate asymptomatic bacteriuria.

To this end, in 2005 Loeb's group established criteria for the application of urine cultures, with the aim of reducing the inappropriate use of antimicrobials. Special sensitivity must be taken into account in the presence of tachypnea, tachycardia, hypotension that may indicate the presence of a urinary sepsis with high mortality. The multidisciplinary work with the services of infectious diseases, microbiology, preventive medicine allows to know the most appropriate AB spectrum and to work together.

*www.guiasalud.es/cistitis not complicated in women