/p>>an article of javier praisesPhysician of
The urinary tract infections (UTI) are the second most frequent cause of infection in the elderly, and the main cause of bacteremia. 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 strains of multi-resistant bacteria, especially with the use of quinolones and cephalosporins.
The institutionalized elderly patient with frailty criteria who presents occasional hospitalizations and who has been treated with AB in the last three months constitutes a reservoir of bacteria with broad-spectrum resistance (ESBL) and the development of Clostridium difficile or methicillin-resistant staphylococci (MRSA). ).
At the end of 2013, the Clinical Practice Guideline on uncomplicated cystitis was developed in a multidisciplinary way, and directed by the Spanish Society of Urology, with the aim of reducing clinical variability.*
The changes typical of aging in both sexes must be known, since in the elderly the frequent presence of urological pathology (nephrolithiasis, chronic pyelonephritis, abscesses, neoplasms) may condition the treatment as they are complicated UTIs.
The presence of microorganisms in the urine, without the presence of symptoms, is known as Asymptomatic bacteriuria, in patients older than 70 years it can reach 15%, which increases to 30-40% in hospitalized or institutionalized people, its treatment not being 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 pathology enterobacteria and enterococcus spp.
When analyzing resistance to ABs to select the most suitable ones, there is a relevant bias as microbiological data is obtained mainly from those patients with recurrent UTIs, previous treatment failures or high rates of resistance, which may not be a reflection of the bacterial flora. uncomplicated patients.
The 5-day treatment regimens are of similar efficacy to the 7-day treatment regimens in case of use of beta-lactamsthe use of fosfomycin can be administered every 72 hours given its half-life and the WCC guarantee a duration of treatment for 10 days. It is usually advisable to obtain a urine culture prior to the start of treatment, without the need for control post-treatment urine cultures.
UTI recurrences may be due to reinfections, if it is by different microorganisms or by recurrence when it is the same. If there are less than 3 UTIs per year, an isolated treatment of the same must be carried out, if there are more than 3 UTIs per year, a prophylactic regimen can be considered for 6 to 12 months (start it after confirming the eradication of the causative microorganism), and if it reappears, prolong it over time, although there are no proper clinical trials in the elderly.
Regarding the treatments, it is recommended fosfomycin 3 grams every 10 days, cotrimoxazole 40/200 mg, avoiding the use of furantoin in the elderly due to undesirable liver and lung effects. In menopausal women, treatment with topical estrogens or cranberries can be considered.
In geriatric patients with communication problems (dementia, stroke sequelae) and the atypical presentation of the disease being common, the UTI frequently behaves like a mixed bag of many pathologies, such as in the study of delirium or syndromes. Nonspecific febrile patients, where the presence of a significant urine culture may indicate asymptomatic bacteriuria.
To this end, in 2005 Loeb’s group established some criteria for requesting urine cultures (Table 2), with the aim of reducing inappropriate use of antimicrobials. Special sensitivity must be taken in the presence of tachypnea, tachycardia, and hypotension that may indicate the presence of urinary sepsis with high mortality. The multidisciplinary work with the services of infectious diseases, microbiology, preventive medicine allows knowing the most appropriate AB spectrum and working together.
* not complicated in women