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TOPLINE: Accurately diagnosing recurrent urinary tract infections (rUTIs) in older women is challenging and requires careful weighing of the risks and benefits of various treatments, according to a new clinical insight published in JAMA Internal Medicine.
METHODOLOGY: Research indicates that women aged over 65 years have double the rUTI rates compared to younger women. However, detecting the condition in this demographic is complicated due to several age-related factors. For example, menopause can cause overactive bladder symptoms, which overlap with UTI symptoms. Additionally, up to 20% of older women have bacteria in their urine, which may not necessarily indicate a rUTI.
The overuse of antibiotics in these patients can lead to significant risks, including the development of antibiotic-resistant organisms and potential pulmonary or hepatic toxic effects, especially in those with compromised kidney function. Diagnosing rUTIs becomes even more challenging when patients have dementia or cognitive decline, which can impair their ability to accurately report symptoms.
TAKEAWAYS: To address these challenges, clinicians are advised to test for rUTIs in older female patients only when symptoms are clearly present. All potential diagnoses should be carefully considered before concluding that an rUTI is the cause.
Vaginal estrogen has been highlighted as a potentially effective treatment, although the clinical review notes a lack of a standard formulation for recommendation. Oral estrogen, however, is not supported by evidence. Instead, vaginal creams or rings are suggested.
Methenamine, a non-antibiotic prophylactic agent, may be as effective as antibiotics but may pose safety concerns for women with other health issues. Current evidence supports the daily use of methenamine at 1 gram.
Cranberry supplements and behavioral changes are also mentioned as possible aids in managing rUTIs, though the evidence supporting their effectiveness, particularly in women living in long-term care facilities, is limited.
IN PRACTICE: “Shared decision-making is especially important when the diagnosis of an rUTI episode in older women is unclear,” states the clinical review. In these cases, clinicians should openly discuss the limitations of the available evidence and invite patients or their caregivers to participate in the decision-making process. This collaborative approach helps balance the potential benefits of earlier symptom relief or decreased UTI complications against the risks of adverse drug effects or multidrug resistance.
SOURCE: The paper was led by Alison J. Huang, MD, MAS, an internal medicine specialist and researcher in the Department of Medicine at the University of California, San Francisco.
LIMITATIONS: The authors reported no limitations.
DISCLOSURES: Huang received grants from the National Institutes of Health. Other authors reported receiving grants from the Agency for Healthcare Research and Quality, the US Department of Veterans Affairs, the Kahn Foundation, and Nanovibronix.
