UTIs 101—Caring for Urinary Tract Infections Among PACE Participants

Urinary tract infections (UTIs) are one of the most common infections found in adults age 65 and older, including PACE participants. Unlike in younger adults, UTIs are often overlooked or mistaken for other conditions in seniors because older adults are less likely to present with typical symptoms. Because of this, it’s essential for PACE pharmacy providers and other members of the PACE center’s multidisciplinary team to know the symptoms associated with these infections, as well as how best to treat them. Let’s take a look at how UTIs uniquely affect seniors and how these infections can be effectively prevented and treated. [Tweet “#UTIs often present different symptoms in older adults than in younger adults.”]

A Closer Look at UTIs Among PACE Participants

Many providers are aware of some of the most tell-tale signs of a UTI, such as changes in urine color, scent, and frequency, pain or burning during urination, and a low-grade fever.
However, the elderly very often present with atypical symptoms, including:

  • confusion or delirium
  • agitation
  • hallucinations
  • poor motor skills or loss of coordination
  • dizziness
  • falling

Sometimes, these are the only symptoms that present in seniors, making it vital to keep an eye out for these sudden cognitive and behavioral changes.

UTI Risk Factors and Types Among PACE Participants

There are a variety of risk factors that make older adults—including PACE participants— more susceptible to UTIs than other populations. These risk factors include decreased immune function, weakened bladder and pelvic floor muscle, and comorbidities such as diabetes, Parkinson’s disease, and dementia.

Because UTIs stem from a number of different causes and they come in multiple forms, treating these infections must be handled on an individual basis. UTI diagnoses are usually broken down into two variations:

  • cystitis, which affects the bladder
  • pyelonephritis, which affects the kidneys

Within each category, there is further differentiation, characterized by complicated and uncomplicated diseases. The most common form of UTI is uncomplicated cystitis, which may be characterized by the following:

  • painful urination (dysuria)
  • abnormal nighttime urination
  • pressure in the lower pelvis
  • urinary urgency

It’s important to note that only female participants with no urologic abnormalities and no known kidney/bladder dysfunction or comorbidities can develop this type of UTI.

Complicated cystitis is characterized by the same symptoms as those of uncomplicated cystitis. However, complicated cystitis also includes additional criteria, such as having:

  • bladder or kidney problems, such as kidney stones, catheters, or polycystic kidney disease
  • a past kidney transplant
  • comorbidities

Similar to uncomplicated cystitis, gender plays a role in complicated cystitis: Whereas only females can get the former, only males can develop complicated cystitis.

For both UTI types, the first wave of antibiotic therapy, known as empiric therapy, can be provided based on symptoms alone. Empiric therapy aims to start fighting the infection and reduce the risk of further complications, and usually consists of broad-spectrum antibiotics, such as ciprofloxacin (Cipro®) and doxycycline (Vibramycin®, Adoxa®), that can fight against many different strains of bacteria. In addition to starting antibiotic therapy, a urine culture/analysis is often collected, providing more in-depth results to help guide treatment.

Antibiotic treatment of either two types depends on a variety of factors, including the severity of disease, previous history of infections, resistance rates in the local population, and kidney function, among others.

Pyelonephritis is a form of UTI that reaches the kidneys, causing inflammation in the region. Similar to cystitis, this diagnosis can be classified as either complicated or uncomplicated.

Uncomplicated pyelonephritis displays similar symptoms found in cystitis, but also presents:

  • fever
  • chills
  • flank pain
  • nausea
  • altered mental status

The good news, though, is that other than these symptoms, the participant is generally healthy and can receive antibiotic treatment on an outpatient basis.

Complicated pyelonephritis, on the other hand, is extremely serious. In this case, the participant is hemodynamically unstable and immunosuppressed, has a form of anatomic abnormality or urologic dysfunction, and/or has a multiple-drug-resistant (MDR) strain of bacterial infection. Any participant falling into this criteria should be referred to the hospital immediately for evaluation and treatment.

Appropriate Use of Antibiotics to Treat UTIs in PACE Participants

Effectively treating a UTI entails eliminating the bacterial infection, providing supportive therapy to relieve pain and symptoms, and employing strategies to reduce recurrence of these infections.

For symptomatic relief of dysuria, phenazopyridine (Azo®, Pyridium®) can be given to residents without renal impairment. Moreover, non-pharmacologic treatment options—such as proper hydration, timed voiding, and heat-pad therapy—can help relieve symptoms and discomfort.

Preventive options to reduce recurrence of UTIs involve employing pharmacologic options, such as taking lactobacillus probiotics (Florajen 3®), maintaining hydration, and treating underlying diseases, like BPH or low estrogen levels in indicated participants.

While antibiotic therapy is used to treat UTIs, antibiotics generally aren’t chosen for preventive therapy, unless specific criteria is met.

If, for example, a participant is diagnosed with three or more UTIs within a year and proper non-pharmacologic steps have been unsuccessful, the participant may be a candidate for continuous, low-dose antibiotic preventive therapy. It’s important to note, though, that, if this care path is chosen, the participant must be monitored for potential side effects, prevention of symptoms, and necessity of antibiotic therapy.

Finally, once a PACE participant completes antibiotic therapy for a UTI infection, a follow-up urine culture is generally not recommended. A follow-up is only necessary if the participant complains of recurrence of symptoms, at which point an alternative antibiotic therapy and urine culture can be provided.

By taking preventive measures and properly following treatment guidelines, we can work to reduce the recurrence and symptoms of UTIs in PACE participants, and, ultimately, decrease the number of antibiotics prescribed and improve health outcomes in our participants.

Seniors, including PACE participants, have unique and specialized needs. Our Grane Rx team of geriatric-specialized pharmacists understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504 or emailing paceteam@granerx.com.

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