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: – – – – – 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 • • • • • • • • S L I D E 15 Study progress to date • Ongoing recruitment in six nursing homes to date • Recruitment progress: – – – – 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: – – – – – – – – – – – – – – – – – 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