Long-term Antibiotic Prophylaxis for Recurrent Urinary Tract Infection in Senior Patients: A Systematic Review

This systematic review aims to find the degree of the long-term antibiotics on the senior patients that are having recurrent UTI. The impact of the long-term antibiotics on bacterial resistance is also analyzed.

Running head: INDEPENDENT STUDY
Independent Study
Name of the Student
Name of the University
Author Note

1INDEPENDENT STUDY
Abstract
Background- The Urinary Tract Infection (UTI) is stated as the infection that effects the
urinary system along with the urinary bladder and urethra. The senior people come up against
this infection more frequently as compared to the younger people.
Objective- To find out the time by which the antibiotics of long-term minimizes the danger
of the recurrence in the senior people.
Methodology- By inquiring the three databases CINAHL, MEDLINE and PMC a systematic
review of the study is conducted. The Google Scholar was also utilized for the finding the
articles by utilizing the main terms which were mixed with the Boolean operators. The
articles which were published in English from the year 2010 till date were selected. For the
determination of the quality of the evidence that are report within the article.
Result- For the data analysis total nine articles were selected which helped in the
identification of three researches. The research are as followed (i) antimicrobial resistance (ii)
most effective antibiotics (iii) extent of reduction of UTI.
Conclusion: Different variations were reported in the result by the researchers. In accordance
with the recurrence management of the impact of the antibiotics prophylaxis of the long-term
on the UTI. The researches in the future should consist of the due emphasis and meta-analysis
should also be put on the assessment of the effects of the non-pharmacological interventions.
Keywords- urinary tract infection, senior, long-term, UTI, effect, recurrence, antibiotics.

2INDEPENDENT STUDY
Chapter 1: Introduction
The antibiotics are also stated as antibacterial, the antibiotics have the ability to slow
down or destroy the proliferation and growth of the bacteria. It can be stated that the
antibiotics contain various powerful drugs that are utilized for the medication of the bacterial
diseases, and are stated as ineffective towards the viral infections such as flu, cold and cough
(Speelberg, Bartlett and Gilbert 2013). The beneficial results of the antimicrobial therapy
which consists of the antibacterial compounds which are depended on the excess of factors
such as the pharmacokinetic and pharmacodynamics characteristics of the antibiotic agent,
host’s defense mechanism and site of the infection (Cotter, Ross and Hill 2013). Flores-
Mireles et al. (2015) stated that the urinary tract infections (UTIs) is note to appear more in
the senior people due to the invasion of the bacteria. However, the infection may have
consequences of infection due to the presence of some type of fungi. To alleviate the simple
symptoms of the UTI such as rhe cloudy and bloody urine, burning pain, frequent urination,
the urine consisting of strong odor and pelvic pain in women, the senior people are usually
prescribed with antibiotics (Hooton 2012). The impact of utilization of the antibiotic for long-
term in senior population who are suffering from UTI will be reviewed systematically.
Problem Statement
The extensive popularity of the UTI in the senior people can be backed by the
outcomes of the study which reported 16.55% of the senior women reported the presence of
UTI, where the Escheria coli is held responsible for the cause of the infection in76.56%
cases. In addition, the estimated 21.42% and 34.69% were noted to be resistant of the
fluoroquinolones and trimethoprim-sulfamethoxazole respectively (Marques et al. 2012).
The popularity of UTI in the senior people was also explained in details by Mirsaidov and
Wagenlehner (2016) who found the challenges that are faced by the physician while treating

3INDEPENDENT STUDY
asymptomatic bacteriuria for the long-term care facilities such as the overactive bladder,
prostate enlargement and indwelling bladder catheters. The absence of the standards have
also been associated with the increment in the pressure of the antibiotic selection which
results in the development of the multidrug-resistance organism. According to Rowe and
Juthani-Mehta (2014), identifying that which patient requires the antibiotic management of
symptomatic UTI is very stimulating. In such cases, the doctors usually choose the modalities
of the treatment with the empiric antibodies, that changes the outcomes into overdo of
antimicrobials and lead toward the manifestation of the bacterial resistance’s increased rates.
The guidelines projected by the IDSA and the ESMID as the International Clinical Practice
Guidelines recommended the authorities 100mg of nitrofurantoin macrocrystal/mohydrate to
be given twice and also recommended the authorities to 160/800 g TMP/SMX, twice daily,
for three days.
Discussing about the over-diagnosis of the UTI in the senior people, the prophylaxis
may basically be approved for the indications which is to be characterize the restricted
bladder dysfunction or vaginal symptom, comparatively than the real UTI, and hence will not
confer the listed advantages (Marschall et al. 2013). Moreover the results of the research
report states that the 15.5% of the total infectious disease hospitalization is due to the UTIs
contribution that appears in the senior people, whose age is above 65 years, and are also
pneumonia patients. It is notes to the fact that the UTIs is highly responsible for the 6.2% of
the deaths that occurs due to the infectious disease, the proper diagnosis of the UTI is still
controversial in the principal of the provider of the healthcare (Detweiler, Mayers and
Fletcher 2015). The researcher also stated that there are number of studies that failed to
describe the morbidity or mortality advantages to the antibiotic therapy, in either community-
dwelling residents or long-term care facilities with the UTI.

4INDEPENDENT STUDY
Multimorbidity, polypharmacy and multimorbidity has been found to be more
extensive in the seior people and performs in the form as the factor of contribution for the
possible harm like interactions to the drug (Herr et al. 2015). According to Crompton (2015)
the utilization of more or equivalent to five medications in the aged population forces them to
increment the drug associated and risk of the falls that alter the status of the health. The pain
related to the UTI in the aged people also consist of the Parkinson’s disease dementia, stroke
that in return increments the time of the hospitalization and degrades the quality of the life of
the aged people (Genao and Buhr 2012). The Continuous Antibiotic Prophylaxis (CAP) is
vey importantly suggested for effective management and prevention of the UTI. The children
that were reported for high grade HN and also received the CAP were recorded to be at a
lesser rate of UTI in comparison with the senior people those did not have the CAP
administrated after conduction of the systematic review, thus explaining the whole level of
the efficiency of the CAP in the prevention of the UTI (Braga et al. 2013).
According to William and Craig (2011), it was suggested that the even though the
lowering the risk of the symptomatic UTI among the children was failed by the antibiotic
therapy, checking the impact of the therapy in the trial that described low risk, upon the
exceptional reduction in the outcome was noted in the observation of the symptom (RR 0.68,
95% CI 0.48 to 0.95). The report based on the systematic review also displayed that
nitrofurantoin comparatively had lower level of risk resistance, compared to the
cotrimoxazole (RR 0.54, 95% CI 0.31 to 0.92) (William and Craig 2011). The existence of
many compelling clinical uncertainty including the long-term antibiotic authorities in the
senior people that were reported of recurrent UTI, the consequences of the optimal period
prophylaxis, danger of the relapse accomplishing cessation of prophylaxis, frequency of the
infective situations, urinary antibiotic resistance and effects of the contrary. Hence, the main
aim of systematic review is to review the research studies on the evidence that have already

5INDEPENDENT STUDY
been conducted, so that the comparison of the degree and extent that the long-term antibiotic
prophylaxis is preventing the recursion of the UTI in the senior people compared to the
placebo or non-antibiotic therapy.
Research questions
To what extent the recurrence of urinary tract infection in the elderly is prevented by
the long-term antibiotics?
The research questions that are mention are categorized on into the four components
of the PICO framework, with the objective of the creation of the concise search strategy and
the succinct for the eradication of the literature. The below stated table describes the four
elements of the framework, related to the research questions:
PICO components Research question components
P/Population Senior people (>60 years) effected from
urinary tract infections
I/Intervention Long-term antibiotic therapy
C/Comparison Placebo or non-antibiotic therapy
O/Outcomes Extent of the impact
Table 1- PICO components
Research objective
 To find the degree of the long-term antibiotics on the senior patients that are having
recurrent UTI.
 To analyze the unfavorable situation that are usually reported during the long-term
antibiotics on the senior patients suffering from the UTI.
 To find the impact of the long-term antibiotics on bacterial resistance

6INDEPENDENT STUDY
Therefore, the main objective of the systematic review is, collection of the data, obtaining
the complete summary of the advantages and challenges related to the long-term antibiotics
prophylaxis for the senior people, to inform the patients and clinicians, at the time of making
decision for the clinical.
Chapter 2: Literature review
The main aim of this chapter is to give theoretical review and the comprehensive
structure of the researches evidences that are published before, and are closely pertinent and
associated to the research question. The literature review was achieved by the conduction of
an accurate exploration, discussion and identification of the data that was accessible, during
the illustration of the implication of recognizing gaps and applicable research in the present
study. Thead chapter starts with the appropriate and clear definition of the associated
objective and literature review, inclusion and exclusion criteria and the review process and
accomplished by the evidence of the literature search policy.
Definition and Uses
The literature review of the study is basically defined as the complete study which
include the analysis of the scientific literature that is related to the phenomenon that is
researched or studied. The literature review are compulsory for the determination of many
stages of the research study (both qualitative and quantitative) (Machi and McEvoy 2016).
The literature review includes the qualitative articles that guides in the finding the specific
study, with respect to the study that has been already acquired, the aim of the research is
stated by the quantitative articles, a theoretical framework and the summarizing of the related
number of the information on the research topic.

7INDEPENDENT STUDY
Search strategy
For the scientific literature the literature review includes the conduction of the
computerized search that was determined by the research questions research aim and research
objectives. The literature review is aimed for the collection of the data from the appropriate
published articles, professional-bodies publication and the peer-reviewed journals. The
additional searches were also performed for including the ‘grey’ sourcecs of the literature that
were made in electronic or/and paper formatted by the academic, government, business
organization and industry. The strategy of searching also includes the utilization of the
snowball technique, to determine the supplementary importance of the literature the
references and the bibliography related to the journal were examined. The exploration of the
literature were updated and executed at different phases of the research to support the
literature. The literature was searched from the electronic databases of medical, these
databases were suggested by the library services of the university and Aveyard for the
students and the researchers that undertook the investigation connected to the medicine and
health (Aveyard 2014). The databases that were searched and the search engines involved
are:
 Cumulative Index of Nursing and Allied Health Literature (CINAHL)
 Medical Literature Analysis and Retrieval System Online (MEDLINE)
 PubMed Central (PMC)
The above mentioned search engines and databases were selected due to their relation
between the healthcare and bioscience domain. The published literature in these
databases were cited. With the objective of the preventing the bias of the publication that
in return will develop an effect on the literature review, the grey literature searches was
also conducted from some additional sources that are given below:

8INDEPENDENT STUDY
 Google Scholar
Key terms
The important terms that are utilized for the searching the related literature from the
databases are ‘UTI’, ‘senior patients’, ‘elderly’, ‘Urinary Tract Infection’, ‘prophylaxis’,
‘recurrence’, ‘antibacterial’, ‘therapy’, ‘relapse’. To make sure that all the pertinent literature
are possibly acknowledged, many strategy were involved:
 Probing of the catchphrases in the symbol of quotation
 Searching of groups of applicable keywords along with their synonyms by the
medical subject head (MeSH) and free text terms, with or without the use of the
truncations (‘*’ or ‘$’) for the facilitation of additional stem words.
Inclusion and exclusion criteria
The articles that are obtained from the databases were marked pertinent only when meeting
upon the pre-defined that guided in identifying the evidences that are prospective for the
research questions. Any article that did not meet the criteria was excluded from the review of
the research (Moule, Aveyard and Goodman 2016). The table that is provided defines the
exclusion and inclusion criteria for the articles that were involved in the systematic review.
Criteria Quantitative research Qualitative research
Inclusion Criteria Published in English Published in English
Published between 2010 –
till dat
Published between 2010 –
till dat
Any country of publication Any country of publication
Focuses on the senior patient
suffering from UTI
Focuses on the senior patient
suffering from UTI
With full-text availability With full-text availability

9INDEPENDENT STUDY
Focus on the antibiotic
therapy.
Focus on the antibiotic
therapy.
It represent the impact of the
antibiotics in treating UTI in
the terms of the statistical
data
It represent the impact of the
antibiotics in treating UTI in
the terms of the statistical
data or narrative analysis.
Exclusion Criteria Published in foreign
language
Published in foreign
language
Published prior to 2010 Published prior to 2010
Focusing on the UTI among
the patient population, other
than the elderly
Focusing on the UTI among
the patient population, other
than the elderly
Abstract, manuscripts Abstracts, manuscripts
Table 2- Inclusion and exclusion criteria for the literature review
Literature review:
The informations that are collected from various selected article are arranged in a tabular
form in the table given below;
Autho
rs
Aim Populatio
n and
setting
Outcome
measures
Results Conclusio
n
Implicati
on
Ahmed
et al.
(2017)
To examine
several
clinical
An
effective
systematic
The vital
concern of
this article
As
discussed in
the aim,
The danger
of relapse
in case of
In order to
effective
execute

10INDEPENDENT STUDY
uncertaintie
s that are
linked with
the
efficiency
as well as
safety of
the
prophylaxis
; an
effective
antibiotic
that is most
preferable
in turning
aside the
problem of
Urinary
tract
infections(
UTIs)
among the
adults
review has
carried out
by surfing
different
articles
from the
CINAHL
MEDLIN
E. Embase
along with
Register of
the
Controlled
trials. The
articles
have
chosen
from
initiation
till 2016
August.
Apart from
that, four
numbers of
RCTs has
is to
emphasize
on the
primary
result
during the
process of
prophylaxi
s, which is
nothing but
the
calculation
of UTI
relapse per
patient
year. The
number of
patients
those are
expiring 1
relapse in
the process
of
prophylaxi
s time and
according to
this
particular
article,
young adults
are taken as
samples;
hence, none
of the trials
conducted
on any older
men.
Furthermore
, three RCTs
are equated
as the long
term
prophylaxis
antibiotics
along with
the vaginal
oestrogens
(n=150), D-
mannose
power (n-
the
postmenop
ausal
females in
repeated
UTI can be
decreased
by the use
of the
suggested
long- term
antibiotics
the entire
process,
the nurses
in the
hospitals
need to go
through
effective
training
regarding
the
effective
adoption
of
encounteri
ng the
antibiotic
resistance
in case of
UTI
affected
patients.

11INDEPENDENT STUDY
selected in
order to
incorporate
this
particular
article.
the
duration of
that relapse
along with
the patient
proportion
with the
resistance
of
antibiotic is
the
secondary
outcome
that need to
be focused.
94) and oral
lactobacilli
(n=238).
These
discussed
antibiotics
are
considered
as the
effective
ones to
minimize
the risk of
UTI relapse
by an
amount of
24
percentage
[(RR) 0.76,
95 percent
of CI 0.61-
0.95]. The
stoical
significant
of upswing

12INDEPENDENT STUDY
risks and
side effects
of the
antibiotic
are resulted
as null.
Ahmed
et al.
(2018)
To examine
the
extensivene
ss of the
prophylaxis
antibiotic
along with
the
expected
clinical
outcomes
of the older
adults, who
are
suffering
from
repeated
UTIs.
A proper
coherent
retrospecti
ve study
has carried
out by
focusing
on the
records of
exactly
19696
numbers of
adults aged
equal
above than
65 years
and with
In order to
ascertain
the
prophylaxi
s that are
more than
3 months
for
nitrofuranti
on or
trimethopri
m, the old
prescriptio
n records
are taken.
Furthermor
e, to
estimate
the hazard
14.2 percent
(2229) of
women
along with
12.6 percent
(508) men
has
prescribed
with the
antibiotic
prophylaxis.
This
particular
process help
to minimize
the clinical
relapse risk
in males
(HR, 0.54;
The
discussed
antibiotic
prophylaxi
s is directly
related to
the
minimizati
on of UTI
relapse rate
along with
the severe
antibiotic
prescriptio
n between
the older
adults.
In order to
ascertain
the effect
and
impact of
the
resistance
on the
antimicro
bial over
the
patients,
further
researches
need to be
conducted
.
Furthermo
re, the

13INDEPENDENT STUDY
ratio (HR)
the
significant
Cox
recurrent
event
model has
used. To
evaluate
the clinical
recurrence
is the
initial
outcome
here.
Moreover,
the
secondary
outcome
here
comprises
with
prescribing
the acute
antibiotic
95 percent
of CI, 0.51-
0.57), and
the
hospitalizati
on. In
addition to
that, the
same, in
case of
females also
registered
low (HR,
0.57; 95
percent CI,
0.55-0.59).
nurses
should be
provided
with
efficient
training
about the
numerous
antibiotics
that can
be used
for
decreasin
g the UTI
recurring
rate
among the
elder
patients

14INDEPENDENT STUDY
and
hospitalizat
ion. (HR,
0.57; 95
percent of
CI, 0.55-
0.59).
Beveri
dge et
al.
(2011)
To
determine
the
diagnosis,
epidemiolo
gy and the
efficient
treatment
process of
the UTI
between the
elder
patients.
Narrative
review
A effective
comprehen
sive review
carried out
by taking
43 numbers
of
scholarly
verification
. The vital
outcome
here is to
focus on
the
Antimicrob
ial
prescribing
that is
Expanding
this
discussion,
it can be
described
that the
major issues
that affect
the health
care are the
narrow
spectrum
antimicrobia
ls, infection
and the
resistance.
Trimethopri
m can be
Glitches
along with
the process
of
antimicrobi
al can
easily
carried out
with a
sensible
administrat
ion of the
antibiotics
like,
trimethopri
m,
nitrofuranti
on and
The
implicatio
n process
here
indicates
to provide
sound
knowledg
e to the
nurses for
examining
different
antibiotic
that they
can use
for
minimizin
g the UTI

15INDEPENDENT STUDY
related
with the
process of
UTI
manageme
nt.
administrate
d as one of
the first line
antibiotic
amid in the
older
females,
who are
suffering
from the
severe issue
of
uncomplicat
ed UTI.
Apart from
that,
nitrofurantio
n can be
considered
as the
secondary
alternative
for UTI
management
.
trimoxazol
e UTI.
rates.

16INDEPENDENT STUDY
Furthermore
, another
threating
process of
Trimethopri
m
sulfamethox
azole can be
can be
carried out
for
minimizing
the UTI
within the
females for
initial days.
The
combination
of the
fosfomycin
and
nitrofurantio
n need to be
used in
order to

17INDEPENDENT STUDY
observe the
antibiotic
resentence
amid the
older
patients.
Cerelli
n et al.
(2018)
To
understand
the use of
trimethopri
m in the
UTI
treatment,
which is
connected
with the
risk of
severe
hyperkalem
ia causing
kidney
injury else
sudden
death.
A proper
study has
carried out
by
considerin
g the
primary
care
prescriptio
ns and
records,
which
emphasize
s on the
patients
aged from
65 years
and more.
Apart from
The
primary
outcomes
of this is to
outline the
fact of
major
kidney
injury,
hyperkale
mia and
death
resulted
within 14
days of
detecting
UTI.
Total
178238
numbers of
individuals
are
acknowledg
ed with at
least single
UTI
antibiotic
management
. After the
process of
trimethopri
m, (ORI.72,
95 percent
CI; 1.13-
2.24) the
measure of
Taking an
average,
for 1000
UTIs, those
are
managed
with the
antibiotics
resulted
among the
older
adults, can
lead to
some extra
case of the
hyperkale
mia along
with
dangerous
The
efficient
dosages
along
with their
duration
associate
with
providing
the
antibiotic,
need to br
effectivel
y
acknowle
dged by
the
nurses.

18INDEPENDENT STUDY
that, the
prescriptio
ns for the
ciprofloxac
in,
amoxicillin
,
trimethopri
m, along
with the
UTI
diagnosis
records are
also taken
in to
considerati
on.
kidney
injury were
more. Apart
from that,
the
ciprofloxine
admirations
(ORI.48,
1.03-2.13) ,
are also
resulted.
Major odds
of the
hyperkalemi
a evidenced
by the usage
of
trimethopri
m.
kidney
injury due
to the
treatment
with
trimethopri
m contrast
to the
amoxicill
Drekon
ja et
al.
(2013)
To conduct
a study on
the
treatment of
UTI and the
related
A coherent
and proper
study that
emphasize
s on the
Veteran
The related
episodes of
the UTI are
detected as
well as
characteriz
The
Antimicrobi
al agents,
which are in
maximum
use, are the
More than
one week
of the
antibiotic
treatment
applied to
Before
carrying
out the
long time
antibiotic
treatment

19INDEPENDENT STUDY
clinical
outcomes
between the
veteran
males
affairs data
in the
fiscal year
2009
ed as an
early
recurrence
( more than
30 days)
instance.
The
particular
antibiotic
along with
the
treatment
duration,
outcomes
and related
infection to
the same
are
measured.
trimethopri
m and
ciprofloxaci
n (62.7
percent). 65
percent of
the patients
go through a
long term
treatment
process ,
which is
more than
one week,
35 percent
of them
faced a
treatment
period of
less than or
equals to
one week,
4.1 percent
individuals
were related
the older
males
suffering
from the
UTI had
effectively
linked with
no
significant
decrease in
the early or
late
recurrence.
method,
the nurses
need to
examine
the
numerous
risks
associated
to CDI
infection.

20INDEPENDENT STUDY
to the index
cases.
However,
high amount
of late
relapse
resulted in
the short
period
treatment,
whereas the
patients who
had gone
through a
long
treatment
period,
subjected no
relapse.
Nevertheles
s, it had
connected to
the risk of
infection
related to

21INDEPENDENT STUDY
the
C.difficile.
Mailk
et al.
(2018)
To
determine
the effect of
antibiotic
allergies
found in
older
women
with the
recurring
UTI
The study
carried out
by
considerin
g the
databases
comprises
with the
UTI
reports of
the female
patients
aged above
than 65
years.
The
primary
outcome
emphasize
on the
antibiotic
susceptibili
ties as well
as the drug
allergies.
The overall
count of the
older
women
resistance
additions to
the allergic
along with
the
fluoroquinol
allergic was
counted to
34 percent
and 14
percent with
the TMP-
SMX was
counted to
29 percent,
34 percent
and 1
percent
respectively.
Considerin
g the fact
of presence
of the
particular
antibiotic
resistance
or allergies
due to the
adoption of
antibiotics
are unable
to obtain in
case of
several
older
females
with
recurring
UTIs.
In such
cases, the
nurses
should
poses
sound
knowledg
e about
the impact
of the
nitrofuran
toin in the
UTI
treatment.

22INDEPENDENT STUDY
Mody
and
Juthani
-mehta
(2014)
To
determine
the
symptomati
c UTI
treatment
along with
the
asymptoma
tic bacteria
and the
prevention
methods of
relapsing
UTI
between the
aged
female.
A
comprehen
sive and
effective
literature
review
process has
carried out
by the
Ovid
( medicine,
psyelNFO,
Embase)
database
along with
the
databases,
which
were
published
between
1945-2013.
The
asymptoma
tic bacteria
are found
transient
amid older
females,
which are
likely to be
resolve
without
adulating
the
treatment.
On the
other hand,
the
symptomat
ic
bacteriuria
are
recognized
effective in
the
cradicating
In such
cases, the
antibiotics
are designed
by
surveying
the
uropathogen
, by
determining
the local
resistant rate
and the
adverse
effect
profile.
Apart from
that, the
therapy
related to
the vaginal
estrogen and
6-12 months
of chronic
oppressive
In case of
the older
women, the
asymptoma
tic
bacteriuri
should not
taken into
considerati
on for the
treatment
process and
it need to
effectively
distinguish
ed from the
symptomat
ic UTIs.
The
nurses
need to be
careful
about the
pro of
observing
the
resistance
s in case
of older
women
and
concern
about the
different
antibiotics
.

23INDEPENDENT STUDY
bacteriuria.
Neverthele
ss, the
antimicrobi
al drug
allergies
and the
reaction
rate along
with the
isolation of
progressive
resistant
microorgan
isms have
resulted
relevant in
the therapy
groups. In
such case,
fluoroquin
olone is
considered
to be the
most
antibiotic
treatment
can also
minimize
the impact
of
symptomati
c UTI
resulted in
case of the
older
patients.

24INDEPENDENT STUDY
effective
antibiotic
suggested
to the older
women
suffering
from the
UTI and its
related
resistance
is
registered
as
maximum
for the
target
individuals.
Moreover,
the another
incident
evidences
that, E.coil
isolates are
resistance
to the

25INDEPENDENT STUDY
fluoroquin
olone in
combine
with the
trimethopri
m have
resulted
upswing.
Myria
m et
al.
(2019)
To study
about the
interrelatio
n among
the adverse
health
outcome of
the elderly
patients in
the primary
care and
the
antibiotic
treatment
related to
the UTI
treatment.
An
effective
coherent
retrospecti
ve study
had
conducted
by taking
the
primary
records
and data
from the
clinical
practice
research
data link
In this
case, the
measure
outcome
that need to
be focus is
the
bloodstrea
m
infection,
hospital
admission
along with
the
mortality
within the
recent 60
In the
312896
pieces of the
UTI
( including
157264
unique
individuals)
, calculated
7.2 percent
(n=22534)
has failed to
provide any
single
records of
prescription
regarding
Amid elder
patients in
the primary
care,
diagnosed
with UTI
and
suggested
any
antibiotics
or no
antibiotics,
were allied
in a
upswing in
bloodstrea
m
In such
cases,
several
precaution
need to be
adopted
by the
nurses
when
conductin
g the
administra
ting
process of
the
antibiotics
and they

26INDEPENDENT STUDY
(2007-
2015)
along with
the records
of the
157264
older
individuals
having at
least one
conformed
else
suspected
UTI.
days
following
the UTI
diagnosis.
the
antibiotics,
which is
simply the
contrast of
6.2 percent
patients
(n=19292)
registered in
the
antibiotic
prescribing.
Apart from
that, high
amount of
bloodstream
infections
are also
determined
within the
patients, to
whom no
antibiotics
had
prescribed.
infection. need to
have
effective
training to
handle the
older
patients
more than
65 age, as
they have
more
chances
of getting
bloodstrea
m
infection.

27INDEPENDENT STUDY
Rowe
and
Juthani
-Mehta
(2014)
To explore
various
methods of
diagnosis
and
treatment
strategies of
the UTI in
case of
older
individuals
Comprehe
nsive
review has
carried out
The
diagnosis
techniques
including
the
treatment
strategies
ate the
major
outcome
here.
In case of
the older
women
reporting
nonspecific
conditions
of the UTI,
interruption
and
hydration in
the process
of
administrati
ng the
antibiotic
need to be
effectively
adopted by
the
physicians.
Apart from
that, for
conducting
the
treatment
Identifying
the
effective as
well as
essential
antimicrobi
al agent for
the
treatment
process of
the older
adults is
necessary.
The
nurses
associated
to this
process
requires
to shape
up their
knowledg
e
regarding
each type
of
antibiotic
and their
dosages in
order to
nullifying
the
adverse
effect
related to
the same.

28INDEPENDENT STUDY
process of
the
uncomplicat
ed UTI in
case of the
older
individuals,
100 mg of
the
Nitrofuranto
in need to be
allocated
twice in a
day as an
antibiotic
management
process.
Table 3: Summary of the related articles
Chapter 3: Methodology
This chapter mainly gives a summary of all the strategies which are methodological
and different approaches which had been adopted especially for this specific research. All the
parts which are present in this chapter are explained properly in short, along with a particular

29INDEPENDENT STUDY
rationale in the conduction of them. The methods are also explained including the processes
of the analysis of data for obtaining all the results which are expected for performing
investigation under phenomenon.
Approaches of Research Methodology
The approaches of research methodology can be describes properly as structures
which helps a lot in collating assumptions which are wide, into a plan which will be both
details as well as comprehensive (Creswall 2014). It also includes the process of the
collection of data, collected data analysis and result interpretation. The procedural approaches
of research can be either quantitative, qualitative or can also be mixed methods (Flick 2015).
The approach of qualitative research is main used when all the systematic reviews are
conducted. It has been noticed that there are certain disadvantages which are associated with
the use of quantitative research methods. A broad range of research which can be conducted
by utilizing quantitative methods increases several possibilities of glitches and allied with a
significance testing which will be manifold (Bresler and Stake 2017). One more disadvantage
of adopting an approach which will be based on quantitative approach of the survey is that it
will need an insight which will be a prior one for the conduction of the examination among
the elderly patients affected by UTI (Kumar 2019). There is another feature of the conduction
of a review. Some other feature of the conduction of review is that it will help in interpreting
as well as explaining phenomenon related to the effect which is brought about in the
population which is targeted.
Inductive reasoning
Inductive reasoning is also referred to as an inductive research and this process starts
with an observation typically. It is then followed by a number of theories which are being
proposed towards the research investigation’s culmination as collected from the observation

30INDEPENDENT STUDY
(Mc Abee, Landis and Burke 2017). Adoption of an approach which is inductive involves the
conduction of a search which is comprehensive for all the patterns which are specific of the
information from seeing different studies of research and has also included all the
explanations which are developing for the patter elucidation which is got from the research.
There is no hypothesis or any kind of theories which are used at the starting of the review,
which has provided the discretion in diverting the investigation’s direction after the
commencement of the process of research.
It is also to be mentioned that an inductive approach of research does not apply
merely to the hypothesis and also the theories which are disregarded while formulating the
questions of research, aims as well as the objectives (Jebb, Parrigon and Woo 2017). This
approach helps in facilitating the definite meaning’s generation from the sets of data which
are collected during the process of research. The sole purpose remains the identification of
the patterns and theory building.
Figure 1- Inductive approach
The table which is provided below clearly elaborates all the concepts which are
associated with the inductive approach adoption for the conduction of a review which will be
systematic
Characteristics Concepts of review
Question Type Open-ended
Reasoning Type Induction
Tests Themes and
Patterns
Theory

31INDEPENDENT STUDY
Analysis Type Description which is narrative
Table 4- Perspective of the approach of inductive research
Research Paradigm
Paradigm of research mostly includes the way of the description of the view of the
world, which in turn will get informed by the philosophical assumptions which are held about
the social reality type, several processes of knowing and the systems of value which are
associated with the research (Chodhury 2014). Several methodologies of research comprises
of particular paradigms (Rose, Spinks and Canhoto 2014). There is no one theoretical
structure which is recognized as appropriate and the paradigm view determination helps in
informing the design of the research for the responding to the phenomenon in the best way
(Potrac, Jones and Nelson 2014). The figure which has been given below mainly highlights
all the several factors which influences the research paradigms selection.
Figure 2- Factors which influences the paradigm of research
Character Description

32INDEPENDENT STUDY
Purpose of the research The effects of the antibiotic therapy which
are long termed are interpreted for the
reduction relapse of UTI among the patients
which are elderly.
Ontology There are a number of realities which are
constructed as well as explored with the
help of actions which are meaningful.
Epistemology Interaction with several social context
mostly governs a number of events.
Methodology A systematic review
Table 5- Interpretivism characteristics
Data Collection
Extraction of articles mostly involves the conduction of a search which will be
comprehensive of the three main electronic databases named PMC, MEDLINE and CINAHL
(Moher et al. 2015). Apart from the databases, Google Scholar is also utilized for the retrieval
of the scientific literature. With the help of the PRISMA flowchart, there is an improvement
in the quality of the reporting of the systematic review (Morgan et al. 2016).

33INDEPENDENT STUDY
Figure 3- Flow Chart of PRISMA
Data Analysis
The framework of the approach of GRADE is followed for both the development as
well as the presentation of the collected evidence’s summaries (Neumann et al. 2015). The
table which has been provided below suggests all the reasons which mainly rates the
evidences as high or low:
Rating down Rating up
Imprecision Gradient which will be dose-responded
Bias Risk Huge effect of magnitude

34INDEPENDENT STUDY
Inconsistency Confounding which is residual increases the
effect magnitude
Publication bias
Indirectness
Table 6- Reasons for the quality of the rating evidence up or down
Quality Interpretation
High The effect is quite closer to the effect
estimate
Moderate The effect which is true mainly shows the
likelihood of being much closer to the
estimated effect, but there is a probability
that it is much different considerably.
Low The effect which is true is noticeably slight
different from the estimated effect
Very low The effect which is true is expected as
noticeably diverse from effect estimation
Table 7- GRADE ratings of the evidence quality and the interpretation of them.
Following the determination of the evidence’s quality which is collected for
the research, the thematic analysis process is utilized for making a sense of the collected
information obtained from all the evidences which are scholarly (Braun et al. 2019).

35INDEPENDENT STUDY
Collection of Data
Any kind of extraction from articles involves the conduction of comprehensive and
thorough search. For this particular data set, three databases (electronic) are extracted to get
the required information. They are CINAHL, PMC and MEDLINE. Other than the mentioned
resources for data collection, for the retrieval of scientific literature Google scholar has also
been put into use. The search terms include both biological and computer terms. AND
operator and OR operator, “ infection in the urinary tract”, “elderly”, “antibiotics”, “UTI”,
“therapy”, “recurrence”, “prophylaxes”, “old patient”, “antibacterial” an “replapse”.
Truncations have also been used mainly $ and *. PRISMA which is known as Preferred
Reporting Items for Systematic Reviews and Meta Analyses was selected for refining the
scholarly articles and also to report to the wide selection choices which involved extraction of
reports from databases and various search engines. The selection of the process for data
collection helped to facilitate complete and transparency in the reporting of the research.
(Moher et al. 2015).
Following the structured PRISMA flowchart kind of enabled the improvement of the
reporting quality. The quality of the systematic review improved. The flowchart provided
transparency in all the assortment process in systematic review of the articles. This lead to the
enhancement of the reliability of the values and findings of all the collected literature based
on medical research. To conclude the end of the collection method, for suitable addressing of
the questions based on research, nine articles have been considered. Data collection method is
graphical represented in the below figure.

36INDEPENDENT STUDY
Figure 3- PRISMA flowchart
Data analysis
For the presentation and development, the GRADE framework – Grading of
Recommendations, Assessment, Development and Evaluations had been followed. The
approach was selected to develop the summaries of all the data and evidences collected. The
main reason for approaching this method to develop and present collected evidences as the
method is highly reliable and recognized widely for its efficiency in the grading technique
and maintaining quality of the evidence. The process or the approach also suggests
recommendations. There are four stages or levels in the GRADE framework. The different
stages in ascending order are – lowest, low, average and highest. (Morgan et al. 2016). The
stage cannot be mechanically implemented. This lead to the evaluation of the collected
articles and evidences from the database to search and find any biased data like publication.

37INDEPENDENT STUDY
Inconsistency in the database and also imprecision was carefully evaluated. The table which
is presented below shows the suggested reasons for rating evidences.
Ratings ( down) Ratings (Up)
Inaccuracy Dose response gradient
Bias risk High effect
Inconsistency Increase of effect by residual confounding
Publication of bias
Indirectness
Table 6- Reasons for rating evidence quality up or down.
The nine articles present in the databases which was taken to analyze, five out of the
nine were found to be cohort studies and the rest four were reviews. The evidences included
in the article were of highest and moderate quality. (Neumann et al. 2015). The entire
approach followed the guidelines which as enforced by the GRADE framework. The
guidelines are provided below.
Quality Interpretation
Highest The estimated effect and true effects are
close.
Average There is a likelihood that the estimated
effect and the true effect might me close but

38INDEPENDENT STUDY
a probability of difference is considered.
Low The true effect noticeably and highly differs
from the estimated effect.
Lowest The difference between the true and
estimated effects are diverse.
Table 7- GRADE ratings on the quality and interpretation of evidences.
Thematic analyses of the data has been used in determining the quality of the data
evidences which has been collected to do the research. The thematic analyses provided
sensible information for all the data and evidences collected from scholars. This method
made the analyzing of the acquired information which was presented in the articles and
helped to gain huge amount of knowledge on the research questions. The main objective for
conducting the analyses is to get an comprehensive hold on the subject, the data collected and
for outlining conclusions (Braun et al. 2019). The analyses holds examination, identification
of different data and also recording the data patterns received from the research results. This
helped in understanding the impacts on antibiotic therapy for older adults.
Chapter 4: Results
The chapter shows the findings which are collected from all nine articles that are
included in all the reviews. It is done through identification, and the patterns are analyzed for
themes. The thematic analyzing method is completely independent and highly descriptive in
nature and contains all the research results. The entire research is perspective based. The
approach which involves six steps in developing the three themes from the evidences ae
shown below.

39INDEPENDENT STUDY
Figure 4: Thematic analyses process

40INDEPENDENT STUDY
Effective Antibiotics
Ahmed et al. 2017 has conducted a review. His objective was to determine various
impacts that antibiotic therapy which are long term in nature exerts on older adults who have
recurring UTI. Thorough search through databases brought them to the conclusion that
nitrofurantoin and trimethoprim- sulfamethoxazole contained the antibiotics needed by the
old patients. 50 mg -100mg nitrofurantoin tablets were given to the patients at night.
Evidences of 480mg capsules of trimethoprim- sulfamethoxazole were given to old patients
at night. (Ahmed et al, 2018). BFN has suggested different dosages of nitrofurantoin,
trimethoprim and cephalein for female and male patients. On elucidating the various
techniques used, it was noted that usage of antimicrobial agents are effective and reduces
chances of Clostridium difficile. The results highlighted that the recommended antibiotic is
trimethoprim which helps prevent recurrence of UTI. An alternative was also found out by
them which was nitrofurantoin.
Extent to which UTI can be reduced.
The findings of Myriam et al. (2019) presents that nitrofurantoin is antimicrobial
agent which is highly effective to control and manage the treatment of UTI in old patients.
People who were not given the antibiotics were highly effected by the infection.
Trimethoprim is very effective in the treatment of old patients for UTI. It has lowered the
risks in older patients effectively mostly in postmenopausal women.
Resistance
The study which was conducted by Ahmed et al. (2017), compared the antibiotics
with lactobacilli, showed that women who received trimethoprim, there was an upsurge in the
isolation of the bacteria from urine and feces. 20% resistance occurred when the older
persons were not subjected to such antibiotics sometime before. Drekonja et al. (2013) could

41INDEPENDENT STUDY
not identify the occurrence of the resistance in case of long term antibiotics for UTI patients.
Others studies also showed there was not much connection among antibiotic allergy,
sensitivity and resistance to age, ethnicity and time period of UTI in patients. Old women
who showed signs of allergy and resistance to trimethoprim-sulfmethoxazole, were highly
sensitive to other antibiotics as well. Women who were resistant to fluroquinolone were also
found to be highly resistance to antibiotics. Facts elaborated by Mody and Juthani-Mehta
(2014), nitrofurantoin has lower plasma concentration and resistance levels are low. Proteus
mirabilis have shown resistance towards nitrofurantoins. This made the researchers comment
that trimethoprin-sulfamethoxazole administration in patients the patients have gram negative
infections.
Chapter 5: Discussion.
The chapter gives an overall view of several findings and presentation of the reported
analyses of the data and evidences collected. Therefore the chapter will help in determining
the veracity of information collected by thematic analyses.
Overall discussion
Many gas had been identified while commencing system review. There has been very
les evidence on the effects of antibiotic prophylaxis on the management and treatment of UTI
in older people. The aims which ahs been put forward in the previous chapters, addresses
qualitative interpretation of research design. Scholarly sources were exhaustively searched
for evidences and data to determine the recurrence of UTI, when long-term antibiotics are
given to patients. The perceptions of the researchers varied greatly on how effective is long
duration antibiotic therapy helps in prevention of UTI. Few articles had results that said that
on subjecting old people with antibiotics have considerably helped in the reduction of any

42INDEPENDENT STUDY
kind of infection in the blood stream. The subjection has also improved their health and
reduced their stay at hospitals. Contradictory to this others researches shoed the reverse of the
mentioned effect. Recurrence of UTI was abundant Riet et al. (2012). Beerepot et al. 2013
stressed on the necessity of long duration non-antibiotic which prevents UTI recurrence in
hospital patients. Other studies suggests that low dosage of antibiotics can curb UTI
recurrence. Th antibiotics were expensive for patients and many could not afford it. Matulay,
Mlynarczyk and cooper (2016) stated that short duration courses of antibiotic can reduce
uncomplicated UTI situations. Certain critical aspects were taken into consideration while
suggesting the methods. The findings were in sync with thematic analysis, but they also
stated that certain empirical gents need to be considered to administer the lowering of UTI
occurring rates.
The results of the finding done by Heijer et al. (2012) were also in accordance with the
outcomes that are discussed in the systematic analysis section, in relation to the resistance to
the antibacterial. The evidence for the case that the trimethoprim-sulfamethoxazole authority,
three months prior to the involvement of the female patients with the recurring UTI, was
basically related with the urine E. The coli resistance against the trimethoprim (OR 3.9, 1.4-
10.5), amoxicillin- clavulanic acid (OR 4.4, 1.5-13.3), amoxicillin(OR 3.6, 95% confidence
interval: 1.3-9.9), and trimethoprim-sulfamethooxazole (OR 3.2, 1.2-8.5). it is also
highlighted by the researcher that the presense of the faecal E. coli resistance against the
trimethoprim (OR 2.0, 1.0-3.7), thus it is indicated that the case that prior utilization if the
antimicrobials results in the resistance against the pathogens and subsequently decreases their
efficiency in the managing UTI Saha et al. (2014) also pointed that E. coli was the most

43INDEPENDENT STUDY
prevalent uropathogen (67.1%) that accomplished by Klebsiella spp. And Pseudomonas spp.,
with the 22% and 6% respectively. The researchers further highlighted the ineffectiveness of
pencillin against E. coli that caused UTI. The evidence are also given about the maximal
resistance of Klebsiella spp against the broad-spectrum penicillin, followed by the third
generation cephalosporin and the aminoglycosides. These are the findings were also
congruent with the data on the antibiotic resistance that are discussed in the systematic
analysis, and are knows for the need of the implementation novel non-pharmaceutical
approaches for the prevention of the UTI relapse.
Staphylococcus haemolyticus (23.88%) and the Enterococcus faecaalis (23.38%). In addition
the researcher also stated the validity of the result that are discussed in the previous chapters
by postulating that while gram-negative bacterial isolated the demonstration increased in the
antimicrobial resistance against the cefuroxime, gram positive bacteria were resistant to the
linezolid, vancomycin, tigecycline and nitrofurans (Assafi et al. 2015). Stalenhoef et al.
(2015) also demonstrated the efficiency of the long term authority of the intravescial
gentamicin prophylactic treatment among the patients having the recurrence of UTI. Hence,
the fact that upon the subjecting patients to the antimicrobial prophylaxis for a longer
duration helps in the lowering their likelihood of again being affected by the UTI was
adequately placed.

44INDEPENDENT STUDY
Chapter 6: Conclusion
There are number of evidences on the exact extent by which the long term antibiotics
therapy lowers the risk of the UTI recurrence among the older adults, it can be stated that the
findings were not completely successful in the describing the difference between the short-
term and the long term antibiotic prophylaxis. Owing to the nature of the lack of information
on the topic, as it is identified in the literature review that the included common antibiotics
used among the older patients, effects of the long term authority of the antibiotics and the
resistance to the antibiotics by the uropathogens, the research employed an interpretive
approach for the study. The research was quite unique in its intensity and the approach and
the given opportunity to the comprehensive search that is conducted on the electronic
databases for drawing the definite conclusions to the postulate the aims and the objectives.
In addition to the reviewing of the results of the number articles helped in the
generation of subsequent theme that are given below:
The research helped in highlighting that the UTI is common among the elder adults who face
high risks of the relapse.
The systematic analysis of the topic revealed that some of the most effective antibiotics that
are lowered recurrence rated of the UTI amid elder that were trimethoprim-sulfamethoxazole,
nitrofurantoin, cephalexin fosfomycin and fluroquinolones.
It was also concluded from the systematic analysis that the long-term administration of the
nirtofurantoin and trimethoprim-sulfamethoxazole brings about the significance reduction in
the rates of the UTI recurrence, concomitant with the lessing in the prevelance of the blood
stream associated infections and the other health complications. Single dose antimicrobial
prophylaxis was identified as the most preferred treatment regimen by the senior people.

45INDEPENDENT STUDY
The findings from the systematic analysis also provided evidence for the popularity of the
prevelance of the antimicrobial resistance in UTI patients. It was found that most E coli
demonstrated resistance to the commonly administered antibiotics such as the trimethoprim-
sulfamethoxazole, amoxicillin and the fluoroquinolones.
Recommendations
The future research should focus on the conduction of the meta analysis for the
combination of the results to the extent of the degree by which the long term administration
of the antibiotics prevent the recurrence of the UTI among the elder adults. Conducting the
meta analysis will largely contribute the body of the evidence about the antibiotics
prescribing and their effects. There is a requirement for the conduction of the multicentred
randomized controlled trail as well, for the analyzing the effect that the authority of the
antibiotics for a long duration will develop on the target population, in comparison to the
placebo or the control treatment. Hence the investigation should be conducted on the various
alterantive medicine startegies that have the infection fighting policies.

46INDEPENDENT STUDY
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