Criteria for urinary tract infection in the elderly: variables that Challenge Nursing assessment.(Continuing Education)

Urinary tract infections (UTIs) are common in the elderly, yet there is much disagreement in the literature regarding many aspects of this condition. To assist the nurse in developing optimum care strategies, UTI criteria in the elderly are discussed. Using the most recent knowledge to guide clinical assessment and intervention skills, the long-term care facility nurse and nurses who care for the elderly can influence positive outcomes in this challenging population.

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Urinary tract infections (UTIs) are the most common type of nosocomial infection found in long-term care facilities (LTCFs) (Warren, Palumbo, Fitterman, & Speedie, 1991). Yet, there is much to be understood about UTIs in the elderly (generally considered to be those over 64 years old). Just as children are medically not small adults, the elderly are not necessarily older adults. They are unique in many ways. Urinary tract infection requiring antibiotic treatment is defined in the general population as the presence of significant amounts of a single microorganism in the urine (Winsinger, 1996). In the elderly, researchers have found that significant bacteriuria, even with accompanying pyuria, is not sufficient as an indicator for a UTI or antibiotic therapy (Nicolle, 2000). Further, symptoms of a UTI in the general population are not always applicable to the elderly. However, at present, there is no consensus on the definition and management of an elderly UTI. To give optimal care, the LTCF nurse, who plays a key role in initiating assessment and determining treatment, should be aware of both the uniqueness of UTIs and the contentious nature of their diagnosis in this population (Beier, 1999; Nicolle, 2000; Smith, 1998). The three criteria that, at present, are considered diagnostic for a UTI in the institutionalized elderly are: bacteriuria, pyuria, and symptoms (Garner, Jarvis, Emori, Horanm, & Hughes, 1988; Jackson et al., 1992; Loeb et al., 2001; McGeer et al., 1991). See Table 1 for a composite of the proposed criteria for a UTI. It should be noted that these authors do not share consensus regarding diagnostic criteria. Other possible symptoms as well as nursing implications for managing UTI in the elderly population will also be discussed.

CRITERIA FOR URINARY TRACT INFECTIONS

Bacteriuria

Colony counts. The hallmark of a UTI has been the presence of a single microorganism of [greater than or equal to] [10.sup.5] colony forming units (cfus) per ml in a clean-catch or midstream urine specimen, with lower numbers usually indicating contamination (Kass, 1957). Studies of the general population have suggested lower colony counts for reasons which include: an early stage of infection, recent use of antibiotics, cleaning the perineum with an antiseptic, frequency of urination, urinary tract obstruction, state of hydration (including the time of day the specimen was collected), urine pH or specific gravity, or antibiotic therapy (Kass, 1957; Kunin, White, & Hua Hua, 1993; Pollack, 1983; Strand, Bryant, & Sutton, 1985).

In studies of UTIs in the elderly, there is a lack of agreement with research findings. One study recommended increasing the significant level of bacteriuria to [10.sup.6] cfu/ml due to the spontaneous recovery of elderly individuals with [10.sup.5] cfu/ml and the increased likelihood of contamination (Nordenstam, Sundh, Lincoln, Svanborg, & Eden, 1989). Conversely, another study found lower colony counts acceptable for elderly men (Lipsky, Ireton, Fihn, Hackett, & Berger, 1987). The third article did not dismiss the possibility of lower counts diagnostic for women as well with further research needed in this area (Gleckman, 1992).