Catheter-Associated UTIs (CAUTIs)

Catheter-Associated UTIs (CAUTIs)

• CAUTIs are common nosocomial infections in geriatric patients
• CAUTIs happen due to increased urinary retention risk, immune decline, and frequent catheterization in long-term care

CAUTI Risk Factors

• Prolonged catheter use presents increased risk
• Females at higher risk due to shorter urethra
• Diabetes mellitus increases risk due to immunosuppression and glucosuria
• Recent antibiotic use disrupts normal flora
• Poor catheter care increases risk

Common Pathogens

• Gram-negative bacteria includes Escherichia coli (most common, 50-60%), Klebsiella pneumoniae, Pseudomonas aeruginosa, Proteus mirabilis, Enterobacter spp.
• Gram-positive bacteria includes Enterococcus spp. and Staphylococcus aureus
• Fungal pathogens include Candida spp., especially in immunocompromised patients

Diagnosis

• Clinical symptoms include fever, suprapubic pain, flank pain, cloudy/foul-smelling urine, or new-onset confusion
• Urinalysis will show positive leukocyte esterase, positive nitrites (gram-negative infection), and WBC count ≥ 10 per high-power field
• Bacterial colony-forming units (CFU) ≥ 10^5 CFU/mL from urine culture confirms infection
• Asymptomatic bacteriuria should not be treated

Treatment

• Removal of a catheter is most effective
• Empirical antibiotics are based on urine culture and local resistance patterns
  • Uncomplicated CAUTI can be treated with ciprofloxacin, levofloxacin, or TMP-SMX
  • Complicated CAUTI (sepsis, obstruction) can be treated with IV cefepime, piperacillin-tazobactam, or carbapenems
• Supportive therapy includes increased fluids and bladder irrigation as needed

Prevention

• Avoid unnecessary catheterization
• Use intermittent catheterization when possible
• Maintain sterile technique during insertion
• Daily assessment of catheter necessity
• Early removal protocols

Nosocomial Infections (Hospital-Acquired Infections - HAIs)

• Defined as infections occurring ≥48 hours after hospital admission that were not present at admission

Most Common Nosocomial Infections in Elderly Patients

• CAUTIs
• Hospital-Acquired Pneumonia (HAP) / Ventilator-Associated Pneumonia (VAP)
• Surgical Site Infections (SSIs)
• Bloodstream Infections (BSIs) / Central Line-Associated Bloodstream Infections (CLABSIs)
• Clostridioides difficile colitis (C. diff colitis), often after antibiotic use

Common Pathogens

• MRSA (Methicillin-resistant Staphylococcus aureus)
• Pseudomonas aeruginosa
• Klebsiella pneumoniae
• Escherichia coli
• Clostridioides difficile (diarrheal illness after antibiotic use)

Risk Factors

• Prolonged hospital stay
• Invasive devices like catheters, central lines, and ventilators
• Immunosuppression
• Antibiotic overuse disrupts normal microbiota
• Malnutrition and chronic diseases raise risks

Prevention

• Hand hygiene is the most effective measure
• Follow strict infection control protocols
• Early removal of invasive devices helps
• Antimicrobial stewardship limits unnecessary antibiotic use

Vaccination in the Elderly

• Older adults have weakened immune responses making vaccinations critical
• Higher dose influenza vaccine recommended for patients >65 annually as it prevents pneumonia & hospitalization
• Pneumococcal Vaccines should be administered PCV13 (Prevnar 13) first, then PPSV23 (Pneumovax 23) 6-12 months later, protecting against Streptococcus pneumoniae
• Herpes Zoster (Shingles) Vaccine (Shingrix) is recommended at age 50+, which prevents postherpetic neuralgia
• Tdap (Tetanus, Diphtheria, Pertussis) Booster needed every 10 years
• COVID-19 Vaccines administered per CDC guidelines for updated boosters

Rx Influenza in a Nursing Home

• Influenza in elderly nursing home residents can lead to outbreaks and high mortality
  • Management of Influenza Outbreaks requires antiviral therapy with Oseltamivir (Tamiflu) or Zanamivir (Relenza), started within 48 hours of symptom onset to reduce severity & duration
  • Isolation & Infection Control of cohort infected patients requires mask use, hand hygiene, and PPE
  • Post-exposure prophylaxis and annual vaccination campaigns plus antivirals to high-risk residents during outbreaks all help

Hematology: Iron Deficiency Anemia (IDA)

• Most common cause of anemia in elderly patients

Common causes

• Chronic GI blood loss from colon cancer, ulcers, diverticulosis
• Malabsorption from celiac disease and atrophic gastritis
• Nutritional deficiency

Signs/Symptoms

• Labs indicate low Hgb count, Hct amount and Ferritin levels with high TIBC
• Microcytic hypochromic anemia

Diagnosis/Treatment

• Oral Iron (Ferrous sulfate 325 mg TID). IV Iron for intolerance or severe cases.
• Treat underlying condition

Lab Findings in Multiple Myeloma (MM)

• Hallmarks include M-protein spike on SPEP, Bence Jones proteins in urine, and hypercalcemia, anemia, lytic bone lesions

Diagnosis of Polycythemia Vera (PCV)

• Common, acquired disorder of bone marrow → overproduction of all 3 blood cell lines (predominantly RBCs)
• Considered a myeloproliferative disorder

Key Findings

• Presence of JAK2 mutation (found in over 90% of cases)
  • May convert to CML or myelofibrosis
  • Signs and Symptoms include generalized pruritus after bathing

Signs/Symptoms of late stage

• Burning pain and redness of extremities
• HA, dizziness, blurred vision, fatigue
  • Patient is at risk for DVTs and CVA's thrombosis with increased morbidity/mortality
• Patient is a bleeding risk

Labs

• Hct >54% males / >51% females
• PBS shows neutrophilic leukocytosis, increased basophils/ eosinophils, increased large platelets, and EPO is low

Treatment

• Therapeutic phlebotomy to maintain Hct at 45%
• May consider allopurinol, antihistamines, ASA to reduce thrombosis risk
• Myelosuppressive therapy with hydroxyurea may be indicated

Diagnosis of Chronic Lymphocytic Leukemia (CLL)

• Lymphocytosis (>5000/μL)
  • Smudge cells on peripheral smear
  • CD5+ B-cells on flow cytometry
• Often presents with painless lymphadenopathy & recurrent infections
• Often asymptomatic and doesn't require treatment

Treatment

• Treatments implemented if patient has B symptoms, cytopenias, LAD, or rapidly increasing lymphocyte count
  • Bruton tyrosine kinase(BTK) inhibitor ibrutinib
  • Combination of an alkylating agent(chlorambucil or bendamustine)
  • Anti-CD 20 monoclonal antibody rituximab or obinutuzumab

Colon Cancer Screening in the Elderly

• Recommended for adults 50-75 years
  • Colonoscopy every 10 years
  • Fecal Occult Blood Test (FOBT) annually
  • FIT-DNA (Cologuard) every 3 years

PSA Testing for Prostate Cancer

• Ages 55-69: Screening is based on patient preference
• PSA >4 ng/mL or abnormal DRE → consider biopsy

Geriatric Neurological Disorders: Delirium vs Dementia

• Delirium has an acute onset with fluctuating course, impaired attention, common hallucinations, and is often reversible
• Dementia has a chronic onset with progressive decline, impaired attention in later stages, less common hallucinations, and is irreversible

Common Causes

• Common causes for delirium include infection, medications, electrolyte imbalance, and dehydration
• Common causes for dementia is Alzheimer’s, Lewy body dementia, and Vascular dementia

Diagnosis

• Delirium is diagnosed via the Confusion Assessment Method (CAM) while Dementia can be detected using the Mini-Mental State Exam (MMSE) or the Montreal Cognitive Assessment (MoCA)
• CAM assessment consists of acute onset + inattention + disorganized thinking OR altered LOC

Tremors (Intentional vs. Unintentional)

• Intentional Tremor (Worse with movement)
  • Cerebellar disorders (e.g., stroke, MS, tumors)
  • Essential tremor (worsens with stress, improved with alcohol)
• Resting Tremor (Improves with movement)
  • Parkinson's disease (“pill-rolling" tremor)

Essential Tremor vs Parkinsons

• Essential Tremor → Postural/Intentional (worse with activity, alcohol improves)
• Parkinson's Disease → Resting (disappears with movement)
• Cerebellar Disorders → Intentional Tremor (worse as hand reaches target)

Progression

• Alzheimer's Disease has a slow progression (years) with memory loss first
• Lewy Body Dementia has a fluctuating cognitive decline with hallucinations
• Vascular Dementia has a stepwise decline due to strokes
• Creutzfeldt-Jakob Disease has a rapid progression (months) with myoclonus

Normal Pressure Hydrocephalus (NPH)

• Commonly misdiagnosed as dementia or Parkinson's

Symptoms

• Triad of Symptoms (Hakim's Triad) include gait disturbance, urinary incontinence, and dementia/cognitive impairment
  • Gait disturbance resembles a “magnetic gait" because feet appear stuck to floor

Diagnosis and Treatment

• Enlarged ventricles on MRI/CT with LP test improvement
• Ventriculoperitoneal (VP) shunt is the typical procedure