Treatments for recurrent UTI in elderly patients
Many women with uncomplicated UTI willing to delay antibiotics
Is there a role for suppressive antibiotic therapy in geriatric patients with recurrent urinary tract infections (UTIs)? Is there any scientific evidence in support of cranberry supplements (especially if the patient cannot drink cranberry juice daily)? — ELIZABETH HALL, MSN, APRN, FNP-C, Dayton, Ohio
Cranberry juice inhibits adherence of uropathogens to uroepithelial cells, thus preventing pathogenic colonization. Clinical research shows that consuming cranberry juice cocktail 300 ml daily or cranberry capsules 400 mg b.i.d. daily for six months significantly reduced UTIs in elderly women compared with placebo (Nutr Rev. 1994;52:168-170). There is no evidence that cranberry juice or tablets are effective for treating an acute infection.
Suppression antibiotic therapy in the geriatric population is another concern. Prophylaxis has been advocated for women who experience two or more symptomatic UTIs within six months or three or more in 12 months. The choice of antibiotic should be based on susceptibility patterns causing the patient's previous UTI.
Eradication of a previous UTI must be assured by obtaining a negative culture one to two weeks after treatment. Numerous studies have demonstrated that continuous prophylaxis decreases recurrence by up to 95% compared with placebo. However, antibiotic resistance is always a concern, as is the risk of the development of Clostridium difficile diarrhea.
Consider topical estrogen cream in postmenopausal women, which helps normalize the vaginal flora and greatly reduces the risk of UTI. Patients treated with estrogen cream had an increase in lactobacilli and decrease in Escherichia coli vaginal colonization (Clin Pharmacol Ther. 1998;64:204-210). Explained to the patient that the full effect of estrogen replacement is gradual and can take about six months.
It is important to perform an appropriate physical examination to be sure the patient does not have a cystocele, rectocele, or uterine prolapse contributing to the recurrent problem. Pelvic-floor-muscle weakness can contribute as well. Estrogen can help with bulking tissue, but the best way to restore full closure of the bladder is through pelvic-muscle therapy (Kegel exercises), which improves the tone of these muscles. — Deborah L. Cross, MPH, CRNP, ANP-BC (152-04)
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