Thursday, 29 March 2007

Elderly Females and UTIs

UTI in elderly patients is a relatively easy diagnosis to make especially with urine analysis and urine culture providing the best clues.

Often, elderly patients present with fever and no urinary symptoms or they may present with just new or worsening confusion.

Obvious causes include long term Foley catheter usage and faecal incontinence causing contamination of the genital tract.

Atrophic female genitalia and with advancing age are other risk factors especially as the female urethra is shorter compared to the male.

Bacteriuria in the elderly is very common and may also be asymptomatic.

When a patient presents with recurrent UTI then further investigation may be warranted.

Patients in hospital or care homes may be infected by medical staff due to poor hygiene or other infectious patients in close proximity.

The infection may be due to a multi-drug resistant bacteria that was not effectively treated previously or the patient has been auto-infected in some way.

Of course, in younger patients, UTI can be precipitated from sexual intercourse. Also remember, elderly patients may also still be sexually active!

Other more unusual things to consider include fistula between bladder and bowel which might be due to malignancy, inflammatory bowel disease, diverticular disease as examples, which leads to direct faecal contamination of the urine.

Questions to ask include: Is your urine dark brown and cloudy? Faeces in the urine. Are there bubbles in your urinary stream on passing urine ? (not just bubbles in the toilet); this is pneumaturia and signifies gas from the bowel escaping into the urine.

The other questions of urinary frequency, nocturia, suprapubic discomfort, dysuria, haematuria, sexual activity and bowel symptoms should also be asked.

With the problem of re-infection, one question to ask the female patient is how they clean themselves following defecation. Females may put themselves at risk of faecal contamination of their genitourinary tract if they clean their anus from posterior to anterior i.e. downwards and forwards between their legs rather than away from the genitourinary tract (inferior to superior direction) i.e. from below upwards and behind them.

As mentioned, the female genital tract is anatomically more at risk of infection as the urethra is shorter than that of the male and it is more exposed to potential contamination.

Recently, on advising a junior doctor of this line of quite intimate questioning for a patient with her second severe UTI, I was met with a look of astoundment from the doctor that this question should be asked at all.

However, when he did ask the question, it was soon determined that the patient was indeed contaminating her genitourinary tract with faeces when finishing defecation and hence, she was auto-infecting herself causing recurrent UTI.

I appreciate that this questioning is delicate and perhaps embarrassing for both doctor and patient, but if established as the cause of the recurrent UTI, then the patient can be advised on how to avoid such problem in the future. Please consider!

Finally and perhaps most importantly, it should be noted that Foley catheters should only be introduced if the patient actually needs a catheter and not for aiding the nurses by reducing their workload. Remember, nursing care also includes patient toileting and if you as doctors are pressurised into inserting a catheter as the nurse is too busy to toilet the patient, then you may be putting your patient at risk of developing a UTI. If the patient does have a catheter, it should be removed as soon as possible and when practicably possible.

Also, hospitals and care homes should have appropriate Infection Control procedures whereby patients with severe infections e.g. pseudomonas, MRSA, are moved to areas where they pose less danger to other patients. That may mean putting patients in single rooms until the infection is cleared.

Infection control staff also advise medical staff on proper hygiene such as hand washing, disinfection and how to manage outbreaks and their importance in the hospital and community setting cannot be taken for granted.

Please let me know your opinions !!!

Tuesday, 27 March 2007

Influenza and Asthma!

This week was supposed to be my Winter Holiday, and my family and I had arranged to go travelling in Japan.

However, my whole family developed an Influenzal-like illness thereby putting an end to any travelling !

My son saw a doctor who diagnosed an infective viral exacerbation of asthma and gave him nebulised beta agonist and theophylline powder and my wife was told something like-- 'don't use the inhaler' (albuterol beta-agonist metred dose inhaler from the USA)......without being given any explanation why she should stop.....

This left me confused as it was against all the UK medical training and evidence I had come to know.

I am not a paediatrician, but this did not sound at all right to me, so I have investigated further.

So, on checking UpToDate for childhood asthma, it confirmed that Mild Acute Asthma should firstly be treated with beta-stimulant either via a nebuliser or metered inhaler via a spacer (as was done) and following this, an inhaled steroid should be provided too.

In the UK British Thoracic Society November 2005 guidance for asthma (some 98 pages !!), no where in the acute guidance does Theophylline feature apart from when all else fails in severe acute asthma !!

In fact, moderate to severe asthma suggests substituting inhaled corticosteroid for intravenous steroid, adding ipratropium, and failing that, to give intravenous magnesium or iv beta stimulant (salbutamol / albuterol).

As for adults with acute asthma, theophylline does not show any more improvement in acute asthma than the combined use of beta-stimulant, ipratropium and steroid administration.

I have heard of cases where patients at local clinics have been given iv aminophylline as a primary treatment in acute asthma and then sent to our hospital when they should have been given a beta-stimulant nebuliser and steroids. This kind of therapy is clearly against the current evidence base.

The main place for aminophylline is in chronic respiratory conditions such as childhood chronic asthma, COPD or in patients who are unable to use an inhaler or have poor compliance.

In such cases of chronic asthma, there is evidence that combined with beta-stimulant and steroid, there is better control of asthma symptoms. Here again though, it should not be given in place of beta-agonist or inhaled corticosteroids but rather compliments their beneficial effects. In this setting, aminophylline can allow the reduction of steroid dose and frequency of beta-stimulant use (UpToDate 15.1)

I appreciate that the Japanese Guidelines advocate aminophylline as a second line agent but as far as I am aware, they have not been updated recently.

Aminophylline is a cheap drug and has alot of physiological effects such as bronchodilatation, anti-inflammatory effects and anti-chemotaxic effects against eosinophils, but obtaining therapeutic levels may be problematic and patients already on oral preparations or who drink coffee can develop toxicity which includes: tachycardia, tremor, seizure (<1%),> In such patients, IV preparations should be avoided to prevent such toxicity.

The treatment of acute asthma in the UK and USA is certainly different compared to what I have seen in Japan.

The UK Guidance can be viewed here:
Guidelinessince%201997_asthma_html (PLEASE CUT AND PASTE TO GO TO THE SITE)

The UK guidelines only institute IV aminophylline in the acute setting when nothing else works and patients are in intensive care (adults) or Pediatric ICU (PICU) but certainly not in place of other measures mentioned above.

Please consider before using this drug.

Do you have extensive experience in the use of this drug and agree or disagree with the above blog? If so, please leave a reply as this is an open forum (albeit moderated) and your opinions would be helpful for other junior doctors to learn.