Mrs. M is a 91-year-old female presenting with worsening urinary frequency, incontinence, and feelings of spaciness. She has a history of recurrent UTIs and multiple failed treatments. A urine dipstick and culture confirmed another UTI caused by E. coli. She was prescribed a 5-day course of nitrofurantoin or trimethoprim-sulfamethoxazole to treat the uncomplicated UTI. Mrs. M was educated on prevention and encouraged to follow up if no improvement within a week.

1. 1
CASE
STUDY

2. 2
Mrs. M is 91 years old and lives in a retirement community with her male partner. Her medical problems include coronary artery
disease, hyperlipidemia, hypertension, diabetes mellitus, cerebrovascular disease, and hypothyroidism. She recently visited Dr N,
her primary care physician for many years, for worsening chronic urinary frequency and incontinence. Mrs. M began having
urinary tract infections (UTIs) in her college years and for the past several years, urinary incontinence. Currently, she has urinary
frequency (every 2–3 hours) and nocturia (awakening her as often as every 2 hours). In 2008, Mrs. M was instructed by her
primary care physician to limit fluid intake at dinner to 1 cup, and then drink only enough water to take her nighttime
medications. During the past few months, Mrs. M noted an increase in her urinary frequency and incontinence. Recently, she
started wearing adult diapers every day. Mrs. M is sexually active. Dysuria or hematuria are not present. She has felt more
“spacey” and unsteady but does not have dizziness or lightheadedness. She does not have syncopal symptoms and has not
fallen. Drug treatment of an overactive bladder with oxybutynin and tolterodine was not effective and she experienced only
transient improvement with desipramine and solifenacin. All these agents were stopped. Six times in the past year, Mrs. M’s urine
cultures were positive for more than 10 5 colony-forming units (CFU)/mL of Escherichia coli ( E coli ). Worsening incontinence
resulted in Mrs. M’s treating physicians obtaining urine cultures. She has received multiple courses of antibiotics but states that
the antibiotics don’t make her incontinence or spaciness any better.
CASE STUDY
How would you approach the Evaluation and Treatment of Older Women With a Suspected UTI ?

3. 3
PATIENT DEMOGRAPHICS
Mrs. M is a 91-year-old female who
lives in a retirement community with
her male partner. Patient is sexually
active. She has a past medical history
significant for:
Coronary Artery Disease
Hyperlipidemia
Hypertension
Diabetes Mellitus
Cerebrovascular Disease
Hypothyroidism

4. 4
PRESENTING SYMPTOMS
Mrs. M presents with typical symptoms of UTI
Urinary Frequency (Every 2–3 Hours)
Incontinence
Nocturia (awakening her as often
as every 2 hours)
Feeling “spacey”
PERTINENT NEGATIVES
Denies dizziness, lightheadedness,
or syncopal episode
Denies Hematuria
Denies Dysuria

5. 5
HISTORY
OF
S&S
Reports a long history of UTI’s and worsening chronic urinary frequency
and incontinence. Reports treatment of an overactive bladder with
oxybutynin and tolterodine, which were not effective and medications were
stopped. Reports six times in the past year, her urine cultures were positive
for 10 5 colony-forming units (CFU)/mL of Escherichia coli ( E coli ) and she
has received multiple courses of antibiotics without relief.

6. 6
DIAGNOSIS
Complicated UTI
DIFFERENTIAL DIAGNOSIS
Cystitis
Urethritis
Pyelonephritis
PATHOPHYSIOLOGY
The urinary tract, from the kidneys to the
urethral meatus, is normally sterile and
resistant to bacterial colonization despite
frequent contamination of the distal urethra
with colonic bacteria. The major defense
against urinary tract infection (UTI) is complete
emptying of the bladder during urination.
Other mechanisms that maintain the tract’s
sterility include urine acidity, the vesicoureteral
valve, and various immunologic and mucosal
barriers. Systemic infection can result from UTI,
particularly in older patients.

7. 7
TREATMENT PLAN
The most common organism responsible for causing UTI in both community and healthcare settings is Escherichia coli,
followed by other Enterobacteraciae (Mody, 2014).
TREATMENT
UTI is the most common indication for antibiotic prescriptions in older adults.
Treatment for uncomplicated UTI in older adults is similar to younger women.
Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days, or
trimethoprim–sulfamethoxazole 160/800 mg twice daily for 3 days for Mrs. M
will be prescribed. E. coli has low resistance rates to nitrofurantoin; however,
other Enterobacteraciae species, which are more common in older adults, may
have intrinsic resistance to nitrofurantoin (Mody, 2014).
In addition, nitrofurantoin is contraindicated in patients with chronic kidney
disease, which is more prevalent in older adults. Therefore, trimethoprim–
sulfamethoxazole should be the preferred empiric oral option for treatment of
clinically suspected UTI in older adults. Fluoroquinolones are among the most
prescribed antibiotics for UTI, but resistance to these antimicrobials is high and
they should only be used if sensitivity testing is performed (Mody, 2014).

8. 8
PROCEDURES
Testing for UTI can be performed in the clinic using a urine dipstick test. When there is a low
pretest probability of UTI, a negative dipstick result for leukocytes and nitrites excludes infection.
However, to confirm the diagnosis of UTI a positive urine culture (≥105 CFU/mL) with no more
than 2 uropathogens and pyuria is needed.
Six times in the past year, Mrs. M’s urine cultures were positive for more than 10 5 colony-
forming units (CFU)/mL of Escherichia coli (E coli).

9. 9
Patients with acute complicated UTI can
also present with:
 Bacteremia
 Sepsis
 Multiple organ system dysfunction
 Shock
 Acute renal failure
COMPLICATIONS/ CHALLENGES
 It is likely to occur in patients with urinary tract
obstruction, recent urinary tract instrumentation, or
other urinary tract abnormalities, and in patients
who are elderly or who have diabetes mellitus.
 UTI presents in elderly patients with nonspecific
signs or symptoms, such as falls, change in
functional status, and change in mental status.
(Mrs. N confirms feeling “spacy” and unsteady).

10. 10
OUTCOMES
 It is well documented that genitourinary infection is the most common type of infection in older adults. Mrs. M has multiple
risk factors that contributes to her recurring UTI’s (i.e. the use of multiple antibiotics, history of UTI and other co-morbidities).
 Asymptomatic bacteriuria, urinary incontinence is prevalent in the elderly. Treatment was selected understanding Mrs. M’s
medication regiment, antibiotic adverse effects and potential interactions with other medication.
We provided education on urinary tract infection that
can assist Mrs. M in the prevention of UTI. She was
educated on the importance of:
 Void before and after sexual intercourse
 Perinial care: wiping from front to back.
 Establish voiding schedule (i.e. every 2 hours)
 Reduce stressors when voiding.
 Take time to empty the bladder completely.
 We also educated her on potential foods that
irritate the bladder and should be avoided: tea,
coffee, alcohol, cola, chocolate, and spicy foods.
F/U:
Mrs. M is encouraged to follow up in 1 wk at clinic if
there is no improvement or if symptoms worsen.

11. 11
REFERENCES
Hooton, T., & Gupta, K. (2019, August). Retrieved October 28, 2020, from
https://www.uptodate.com/contents/acute-complicated-urinary-tract-infection-
including-pyelonephritis-in-adults/contributors
Mody, L., & Juthani-Mehta, M. (2014). Urinary tract infections in older
women: a clinical review. JAMA, 311(8), 844–854
https://doi.org/10.1001/jama.2014.303