Editing Urinary Tract Infections (section)

== Bacteriuria in the elderly ==

=== Epidemiology ===
* '''> 20% of women and 10% of men age > 65 have bacteriuria'''

=== Pathogenesis ===
* Age-related changes related to increased risk of bacteruria include:
*# Decline in cell-mediated immunity
*# Neurogenic bladder dysfunction
*# Increased perineal soiling as a result of fecal and urinary incontinence
*# Increased incidence of urethral catheter placement
*# In women, changes in the vaginal environment associated with estrogen depletion

=== Pathogens ===
* '''E. coli remains the most common uropathogen, causing 75% of these infections.'''
* '''S. saprophyticus is not seen in this population.'''

=== Diagnosis and Evaluation ===
* '''Diagnosis of bacteriuria and UTIs in the elderly can be difficult.'''
* Most elderly patients with bacteriuria are asymptomatic
* '''Urinary tract symptoms are often absent, and concomitant disease can mask or mimic UTI. Even severe upper tract infections may not be associated with fever or leukocytosis'''
* '''Screening for asymptomatic bacteriuria in elderly residents in the community or long-term care facilities is not recommended.'''
** In RCTs of antimicrobial vs. no therapy in elderly male and female nursing home residents with asymptomatic bacteriuria, no decrease in symptomatic episodes and no improvement in survival. In fact, treatment with antimicrobial therapy increases the occurrence of adverse drug effects and reinfection with resistant organisms and increases the cost of treatment.

=== Management ===
* '''Asymptomatic'''
** '''Not recommended'''
** '''The treatment of asymptomatic bacteriuria to improve incontinence has not been justified'''
* '''Symptomatic'''
** '''For elderly patients with symptomatic UTI, 7 days of therapy is recommended.'''
*** The goal in this population is to eliminate symptoms but not sterilize the urine
* '''Other scenarios'''
** '''Bacteriuria that leads to UTIs in elderly in the presence of underlying structural urinary tract abnormalities''' '''(e.g., obstruction with hydronephrosis) or systemic conditions (e.g., severe diabetes mellitus) are clinically significant, can''' '''lead to renal failure, and require prompt therapy.'''
** '''UTIs caused by urea-splitting bacteria, such as Proteus or Klebsiella species that cause formation of infection stones, may also lead to severe renal damage.'''
*** '''Urea in the urine is split into large amounts of ammonia by urea-splitting bacteria which is absorbed systemically and may result in encephalopathy or even coma at high levels, particularly in obstruction'''