Long-term antibiotics prevent urinary tract infections in the elderly

Running head: INDEPENDENT STUDY
To what degree do long term antibiotics prevent the recurrence of urinary tract infections in
the elderly?
Name of the Student
Name of the University
Author Note

1INDEPENDENT STUDY
Abstract
Background- Urinary tract infections (UTI) refer to infections that affect the urinary system,
including the urethra and urinary bladder. Older adults face this infection more often, when
compared to their younger counterparts.
Objective- To determine the extent by which long-term antibiotics reduce the risks of relapse
of UTI in older adults.
Methodology- A systematic review has been conducted by searching the three electronic
databases PMC, CINAHL, and MEDLINE. Google scholar search engine was also used for
retrieving articles with the use of key terms that were combined with boolean operators.
Articles published in English, from 2010, till date were extracted. The GRADE approach was
used for determining the quality of evidences reported in the article.
Results- Nine articles were included in data analysis that resulted in the identification of
three research themes namely, (i) most effective antibiotics, (ii) extent of reduction of UTI,
and (iii) antimicrobial resistance.
Conclusions- There were variations in the results reported by researchers, in relation to the
impacts of long-term antibiotic prophylaxis on UTI relapse management. Further research
should involve meta-analysis and due emphasis must also be placed on assessing the effects
of non-pharmacological interventions.
Keywords: urinary tract infection, UTI, older, antibiotics, long-term, effect, relapse

2INDEPENDENT STUDY
Table of Contents
Chapter 1: Introduction..............................................................................................................4
Problem statement..................................................................................................................4
Research question...................................................................................................................6
Research aim..........................................................................................................................7
Research objectives................................................................................................................7
Chapter 2: Literature review......................................................................................................8
Definition and Uses................................................................................................................8
Search strategy.......................................................................................................................8
Key terms...............................................................................................................................9
Inclusion and exclusion criteria...........................................................................................10
Literature review results.......................................................................................................11
Chapter 3: Methodology..........................................................................................................30
Research methodological approaches..................................................................................30
Inductive reasoning..............................................................................................................31
Research paradigm...............................................................................................................32
Data collection.....................................................................................................................34
Data analysis........................................................................................................................35
Chapter 4: Results....................................................................................................................38
Most effective antibiotics.....................................................................................................38
Extent of reduction of UTI...................................................................................................40
Antimicrobial resistance.......................................................................................................42

3INDEPENDENT STUDY
Chapter 5: Discussion..............................................................................................................44
Overall discussion................................................................................................................44
Chapter 6: Conclusion..............................................................................................................50
Recommendations................................................................................................................52
References................................................................................................................................54

4INDEPENDENT STUDY
Chapter 1: Introduction
Also referred to as antibacterials, antibiotics are medications that have the capability
of destroying or slowing down the growth and proliferation of bacteria. In other words, these
encompass several powerful drugs that are used for the treatment of bacterial diseases, and
are particularly ineffective against viral infections like cough, cold, and flu (Spellberg,
Bartlett and Gilbert 2013). The fruitful consequence of antimicrobial therapy that comprise of
antibacterial compounds primarily depends on a plethora of factors such as, defence
mechanism of host, the site of infection, and the pharmacodynamics and/or pharmacokinetic
properties of the antibacterial agent (Cotter, Ross and Hill 2013). According to Flores-
Mireles et al. (2015) urinary tract infections (UTIs) occur more in the elderly, due to bacteria
invasion. However, they might also be a consequence of infection due to some kind of fungi.
The elderly people are commonly prescribed antibiotics for alleviating the classic symptoms
of UTI that commonly comprise of frequent urination, burning pain, bloody and cloudy urine,
pelvic pain among women, and urine having a strong odour (Hooton 2012). This systematic
review will explore the impacts of long-term antibiotic usage in the elderly population,
suffering from UTI.
Problem statement
The widespread prevalence of UTI among the elderly can be supported by results
from a study where an estimated 16.55% elderly women reported presence of UTI, with
Escheria coli being responsible for the infections in 76.56% of the cases, Furthermore, an
estimated 34.69% and 21.42% were also found resistant to trimethoprim-sulfamethoxazole
and fluoroquinolones, respectively (Marques et al. 2012). The prevalence of UTI in the older
population was also elucidated by Mirsaidov and Wagenlehner (2016) who identified the
challenges faced by physicians in treating asymptomatic bacteriuria in long-term care
facilities, such as, prostate enlargement, overactive bladder, and indwelling bladder

5INDEPENDENT STUDY
catheters. Absence of standards have also been correlated with an increase in antibiotic
selection pressure that results in the origin of multidrug-resistant organisms. Rowe and
Juthani-Mehta (2014) also opined that recognising which patients need antibiotic
management of symptomatic UTI is thought-provoking. Under such circumstances, clinicians
often select treatment modalities with empiric antibiotics, which in turn results in overdo of
antimicrobials, and leads to the manifestation of increased rates of bacterial resistance. The
International Clinical Practice Guidelines projected by the IDSA and the European Society
for Microbiology and Infectious Diseases recommend the administration of 100mg
nitrofurantoin monohydrate/macrocrystals, twice, for consecutive five days, and also
encourage the administration of 160/800 mg TMP/SMX, for three days, twice daily.
Taking into consideration the over-diagnosis of UTI among older people, antibiotic
prophylaxis might essentially be approved for indications that characterise restricted vaginal
symptoms or bladder dysfunction, rather than real UTI, and therefore will not confer the
proposed advantage (Marschall et al. 2013). Further evidences from research reports suggest
that UTIs contribute to as much as 15.5% of the total infectious disease hospitalisations that
occur in older adults, aged beyond 65 years, and are second to pneumonia. Owing to the fact
that UTIs are largely responsible for roughly 6.2% deaths due to infectious diseases, true UTI
diagnosis remains controversial among the principal healthcare providers (Detweiler, Mayers
and Fletcher 2015). The researchers also illustrated that there are numerous studies that have
failed to demonstrate any mortality or morbidity benefits to antibiotic therapy, in either long-
term care facility or community-dwelling residents with UTI.
Frailty, multimorbidity, and polypharmacy have been identified to be more
widespread in older adults and act in the form of contributory factors for possible harms such
as, those connected to drug interactions (Herr et al. 2015). Compton (2013) stated that usage
of more than five or equivalent medications in the geriatric population predisposes them to

6INDEPENDENT STUDY
increased risks of falls, and drug associated cognitive changes that alter their health status.
Comorbidities related with UTI in older adults also comprise of stroke, Parkinson’s disease,
diabetes, dementia, which in turn increases their length of hospitalisation and brings about a
deterioration in the overall quality of life of the elderly (Genao and Buhr 2012). Continuous
antibiotic prophylaxis (CAP) is typically recommended for the effective prevention and
management of UTI. Results from a systematic review suggested that children who reported
high-grade HN and received CAP manifested a meaningfully lesser rate of UTI, in
comparison to their counterparts who had not been administered CAP, thus demonstrating the
overall levels of efficacy of CAP in UTI prevention (Braga et al. 2013).
Results from another systematic review conducted by Williams and Craig (2011) also
suggested that although antibiotic therapy failed to lower the risks of symptomatic UTI
among children, upon assessing their impacts in trials that demonstrated low bias risks, a
statistically noteworthy reduction was observed in the symptoms (RR 0.68, 95% CI 0.48 to
0.95). Reports from the systematic review also highlighted that nitrofurantoin had
suggestively lesser risk of resistance, when compared to cotrimoxazole (RR 0.54, 95% CI
0.31 to 0.92) (Williams and Craig 2011). There also exist several significant clinical
uncertainties involving long-term antibiotic administration in older adults who report
recurrent UTI, together with consequence on frequency of infective incidents, optimal period
of prophylaxis, contrary effects, danger of relapse succeeding cessation of prophylaxis, and
outcome on urinary antibiotic resistance. Therefore, this systematic review aims to review
scholarly pieces of evidences that have already been conducted before, in order to compare
the extent and degree to which long-term antibiotic prophylaxis prevent the recurrent of UTI
in geriatric population, when compared to non-antibiotic therapy or placebo.

7INDEPENDENT STUDY
Research question
To what degree do long term antibiotics prevent the recurrence of urinary tract
infections in the elderly?
The aforementioned research question was categorised into the core four elements of
the PICO framework, with the aim of creating a succinct and concise search strategy for
extraction of literature. The table given below denotes the components of the framework, in
relation to the research question:
PICO components Research question components
P/Population Older adults (>60 years) having urinary
tract infections
I/Intervention Long-term antibiotic therapy
C/Comparison Placebo or non-antibiotic therapy
O/Outcomes Extent of impact
Table 1- PICO components
Research aim
To investigate the degree do long-term antibiotics avert the recurrence of urinary tract
infections (UTIs) in the elderly.
Research objectives
 To determine the effects of long-term antibiotics on elderly patients having recurrent
UTI
 To explore the adverse events that are commonly reported during long-term
antibiotics on elderly patients having recurrent UTI
 To determine the impacts of long-term antibiotics on bacterial resistance