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Recurrent urinary tract infection in females is a benign disease
G Model
EURGER-739; No. of Pages 4 European Geriatric Medicine xxx (2016) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Research paper
Recurrent urinary tract infection in females is a benign disease M. Wuorela a,*, H. Isoaho b, S. Arve a,c, A. Lehtonen a, M. Viitanen a,d a
Department of Geriatrics, Turku City Hospital and University of Turku, Kunnallissairaalantie 20, 20700 Turku, Finland Statcon Ltd, Paltankatu 10 B, 24260 Salo, Finland c Department of Nursing Science, University of Turku, Turku, Finland d Department of Geriatrics, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1st November 2015 Accepted 18 February 2016 Available online xxx
Background: Little is known about long-term consequences of recurrent urinary tract infections although 60% of women develop urinary tract infection during their lifetime and 20–40% of them have a recurrence. Objective: To study the role of recurrent urinary tract infections in mortality or development of kidney dysfunction or hypertension in women. Design: Retrospective analysis of prospective, population-based 20-year follow-up study. Setting: Community. Subjects: A birth cohort of 764 older females living in the defined geographical area in Southwestern Finland who were 70 years old at baseline. Methods: The participants were examined and interviewed to assess health history, health behaviors, cardiovascular risk factors, morbidity and physical, social and psychocognitive functioning at the age of 70, 80, 85 and 90 years between 1991–2011. Results: Recurrent urinary tract infections in females were not associated with increased mortality, development of hypertension or kidney dysfunction. Urinary incontinence predisposed females to receive antimicrobial treatment for recurrent urinary tract infections. Conclusions: The results indicate that recurrent urinary tract infection in females is a benign disease in the absence of abnormalities of the urinary tract even in the older population. ß 2016 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Urinary tract infection Female Kidney failure
1. Introduction Recurrent urinary tract infection refers to at least 2 infections in 6 months or 3 or more infections in one year. Most recurrences are thought to represent reinfection rather than relapse [1]. The pathogenesis of recurrent urinary tract infection in females is assumed to be the same as with sporadic infection. However, several host genetic, biologic, and behavioural factors appear to predispose young healthy women to uncomplicated urinary tract infections [2]. The strongest and most consistent risk factor of urinary tract infection for postmenopausal women is a history of urinary tract infection at a younger age. Urinary tract infections in postmenopausal women are also consistently associated with chronic incontinence [2,3]. A single acute cystitis is benign from the perspective of longterm outcomes. Acute infections including urinary tract infections
* Corresponding author. Tel.: +358 40 8372507; fax: +358 2 2662107. E-mail address: maarit.wuorela@turku.fi (M. Wuorela).
are, however, associated with a transient increase in the risk of vascular events in outpatients [4]. Nosocomial urinary tract infections increase morbidity in nursing homes [5]. We investigated if recurrent urinary tract infections have a role in mortality or in the development of kidney dysfunction or hypertension in women.
2. Methods 2.1. Study design and population All community-living older females at the specified age and living in the defined geographical area (n = 764), were offered the possibility to participate a survey investigating the health of older people in the city of Turku, Southwest Finland. The participants were 70 years old at baseline and the follow-up time was 20 years (1991–2011). Eighty-six percent of them returned the questionnaire and participated in clinical examination. They were considered eligible for the follow-up (Fig. 1). To investigate the
http://dx.doi.org/10.1016/j.eurger.2016.02.006 1878-7649/ß 2016 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Please cite this article in press as: Wuorela M, et al. Recurrent urinary tract infection in females is a benign disease. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.02.006
G Model
EURGER-739; No. of Pages 4 M. Wuorela et al. / European Geriatric Medicine xxx (2016) xxx–xxx
2
2.5. Statistical analysis In statistical analysis we used descriptive statistics, cross tabulation with Fisher’s exact test, analysis of variance and KaplanMeier survival curves with log-rank test. Our statistical packages were NCSS 2007 NCSS 8 (Hintze, J. 2012, Kaysville, UT, USA) and SPSS 16.0 (SPSS Inc., Chicago, IL, USA). 3. Results Cognitive function of the participants was relatively stable during the 20-year follow-up time. The mean MMSE ( SD) values of the 70, 80, 85 and 90-year old females were 26.9 2.5, 25.7 3.0, 25.3 3.3 and 27.2 2.9 respectively. Fig. 2 shows that the mean estimated glomerular filtration rate was about 60 mL/min/1.73 m2 corresponding to a moderately reduced kidney function. The prevalence of hypertension increased from 36% to about 70% during the 20-year follow-up time. 3.1. Prevalence of recurrent urinary tract infection
Fig. 1. Flow chart of the participants.
determinants of successful aging, the participants were examined and interviewed at the age of 70 (n = 660), 80 (n = 381), 85 (n = 202) and 90 (n = 91) years to assess health history, health behaviors, cardiovascular risk factors, and physical, social and psychocognitive functioning. Incident cognitive impairment was ascertained on clinical interviews with the Mini-Mental State Examination (MMSE) as a screening instrument [6]. All eligible participants signed a written informed consent and the study protocol was approved by the ethical committee of the Hospital District of Southwest Finland.
Twenty-two percent of the women had had one or more episodes of recurrent urinary tract infection by the age of 70 years and the diagnosis became more prevalent during the follow-up. Twenty-seven percent, 28% and 29% of the 80, 85 and 90 years old participants had a history of recurrent urinary tract infection, respectively. None of the females reported having urological diseases. 3.2. Recurrent urinary tract infection, morbidity and mortality Urinary incontinence was strongly associated with urinary tract infection. Nineteen to 38 percent of the females without urinary tract infection had incontinence whereas 48–68% of the participants with recurrent infections were incontinent. A history of recurrent urinary tract infection was neither associated with the development of hypertension or kidney dysfunction nor increased mortality.
2.2. Diagnosis of recurrent urinary tract infection and hypertension 4. Discussion In mailed questionnaires, we asked the participants whether recurrent urinary tract infections have ever been diagnosed. We also asked detailed information about previous and current diseases. Hypertension was defined either as a clinical diagnosis or the use of antihypertensive medication. Hypertensive participants were referred to a physician at the baseline examination in 1991 ensuring the diagnosis and treatment of high blood pressure. 2.3. Determination of kidney function Serum creatinine of the 70, 80, 85 and 90 years old participants was measured immediately after the samples were drawn. The original enzymatic creatinine values measured 1991 were recalibrated providing isotope dilution mass spectrometry traceable values. Glomerular filtration rate was estimated using an equation developed by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) [7]. 2.4. Mortality Time and cause of death of deceased participants were ascertained from the national Death Register kept by Statistics Finland. The register covers information on all death certificates of Finnish citizens, and assures complete coverage. A unique national personal identification number assigned to every permanent resident of the country was used in the computerised record linkage.
In mailed questionnaires, we asked the participants whether a recurrent urinary tract infection has ever been diagnosed. In this study, recurrent urinary tract infection refers to recurrent cystitis because recurrent pyelonephritis is very rare in a population that has no urological disorders. We found that in our study, the prevalence of recurrent urinary tract infection increased with age and was comparable to other cohorts [2]. Our data on the association between urinary tract infection and urinary incontinence is consistent with previous reports [2,3]. The basis of this association is poorly understood. The etiology of urinary incontinence in older females is often multifactorial and urge and mixed types of urinary incontinence become the most prevalent types of incontinence [8,9]. These types of urinary incontinence are not typically complicated with chronic retention. It is possible that incontinent females receive antimicrobial treatment to asymptomatic bacteriuria more often than those without this problem. There is some data on asymptomatic kidney inflammation in patients with urinary tract infection. Chronic pyelonephritis is an uncommon cause of chronic tubulointerstitial disease and kidney dysfunction due to recurrent infection. Autopsy studies have revealed the presence of kidney inflammation in some patients with long-term catheterization even without symptoms of urinary tract infection [4]. There is no data on asymptomatic kidney inflammation without predisposing factors. Our study shows that
Please cite this article in press as: Wuorela M, et al. Recurrent urinary tract infection in females is a benign disease. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.02.006
G Model
EURGER-739; No. of Pages 4 M. Wuorela et al. / European Geriatric Medicine xxx (2016) xxx–xxx
3
Fig. 2. Kaplan-Meier survival curve (A), mean estimated glomerular filtration rate (eGFR) values standard deviation (SD) (B), prevalence of hypertension (C) and prevalence of urinary incontinence (D) of the participants with or without urinary tract infections (UTI). n: number of the participants.
appropriately treated recurrent episodes of symptomatic cystitis do not increase mortality or impair kidney function or increase the prevalence of hypertension. The strength of this study is the birth cohort design that ensured that there was no risk of selection bias that may be a potential limitation in cohort studies. The 20-year follow-up to the age of 90 years ensured that the potential effects on recurrent urinary tract infection on kidney function, development of hypertension and mortality were detected. The present study is limited by the use of mailed questionnaire in the assessment of recurrent urinary tract infection. Cognitive functioning of the participants remained quite stable during the 20-year follow-up time excluding the possibility that progressive cognitive decline might have been detrimental in our analysis. Also, the symptoms of an acute urinary tract infection are so obvious to the patient that we believe our data is accurate. We used of creatinine-based estimates of GFR as a marker for kidney function. We acknowledge that there are several other factors that affect plasma creatinine level in addition to kidney function such as variations in diet and creatinine generation as a result of differences in muscle mass and turnover [10]. There were, however, no differences in kidney function between the participants with or without urinary tract infection. Our results show that recurrent cystitis in females is a benign disease in the absence of abnormalities of the urinary tract even in the oldest old. This suggests that it is safe to treat recurrent cystitis in females according to the current guidelines of acute sporadic uncomplicated cystitis [11].
Ethical statement The work described has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans.
All eligible participants signed a written informed consent and the study protocol was approved by the ethical committee of the Hospital District of Southwest Finland. Disclosure of interest The authors declare that they have no competing interest. Acknowledgments The authors are grateful to the volunteers of the study for their participation. Funding: this work was supported by following institutions: Evo grants to the Turku City Hospital and by the Uula Arhio Foundation and Pa¨ivikki and Sakari Sohlberg Foundation. The financial sponsors had no role in the study design, data collection, analysis and interpretation of data, or writing of the study. References [1] Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643–54. [2] Nicolle LE. Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis. Urol Clin North Am 2008;35:1–12. [3] Raz R, Gennesin Y, Wasser J, et al. Recurrent urinary tract infections in postmenopausal women. Clin Infect Dis 2000;30:152–6. [4] Smeeth L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med 2004;351:2611–8. [5] Matthews SJ, Lancaster JW. Urinary tract infections in the elderly population. Am J Geriatr Pharmacother 2011;9:286–309. [6] Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–98. [7] Levey AS, Stevens LA, Schmid CH, CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009;150:604–12.
Please cite this article in press as: Wuorela M, et al. Recurrent urinary tract infection in females is a benign disease. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.02.006
G Model
EURGER-739; No. of Pages 4 4
M. Wuorela et al. / European Geriatric Medicine xxx (2016) xxx–xxx
[8] Minassian VA, Stewart WF, Wood GC. Urinary incontinence in women: variation in prevalence estimates and risk factors. Obstet Gynecol 2008;111:324–31. [9] Nygaard I, Barber MD, Burgio KL, Pelvic Floor Disorders Network. et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311–6. [10] Stevens LA, Schmid CH, Greene T, et al. Comparative performance of the CKD Epidemiology Collaboration (CKD-EPI) and the Modification of Diet in Renal
Disease (MDRD) Study equations for estimating GFR levels above 60 mL/min/ 1.73 m2. Am J Kidney Dis 2010;56:486–95. [11] Grabe M, Bartoletti R, Bjerklund TE, et al. Guidelines on urological infections. European Association of Urology; 2015 [accessed 27.10.2015]http://uroweb. org/guideline/urological-infections/.
Please cite this article in press as: Wuorela M, et al. Recurrent urinary tract infection in females is a benign disease. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.02.006
EURGER-739; No. of Pages 4 European Geriatric Medicine xxx (2016) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Research paper
Recurrent urinary tract infection in females is a benign disease M. Wuorela a,*, H. Isoaho b, S. Arve a,c, A. Lehtonen a, M. Viitanen a,d a
Department of Geriatrics, Turku City Hospital and University of Turku, Kunnallissairaalantie 20, 20700 Turku, Finland Statcon Ltd, Paltankatu 10 B, 24260 Salo, Finland c Department of Nursing Science, University of Turku, Turku, Finland d Department of Geriatrics, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1st November 2015 Accepted 18 February 2016 Available online xxx
Background: Little is known about long-term consequences of recurrent urinary tract infections although 60% of women develop urinary tract infection during their lifetime and 20–40% of them have a recurrence. Objective: To study the role of recurrent urinary tract infections in mortality or development of kidney dysfunction or hypertension in women. Design: Retrospective analysis of prospective, population-based 20-year follow-up study. Setting: Community. Subjects: A birth cohort of 764 older females living in the defined geographical area in Southwestern Finland who were 70 years old at baseline. Methods: The participants were examined and interviewed to assess health history, health behaviors, cardiovascular risk factors, morbidity and physical, social and psychocognitive functioning at the age of 70, 80, 85 and 90 years between 1991–2011. Results: Recurrent urinary tract infections in females were not associated with increased mortality, development of hypertension or kidney dysfunction. Urinary incontinence predisposed females to receive antimicrobial treatment for recurrent urinary tract infections. Conclusions: The results indicate that recurrent urinary tract infection in females is a benign disease in the absence of abnormalities of the urinary tract even in the older population. ß 2016 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Urinary tract infection Female Kidney failure
1. Introduction Recurrent urinary tract infection refers to at least 2 infections in 6 months or 3 or more infections in one year. Most recurrences are thought to represent reinfection rather than relapse [1]. The pathogenesis of recurrent urinary tract infection in females is assumed to be the same as with sporadic infection. However, several host genetic, biologic, and behavioural factors appear to predispose young healthy women to uncomplicated urinary tract infections [2]. The strongest and most consistent risk factor of urinary tract infection for postmenopausal women is a history of urinary tract infection at a younger age. Urinary tract infections in postmenopausal women are also consistently associated with chronic incontinence [2,3]. A single acute cystitis is benign from the perspective of longterm outcomes. Acute infections including urinary tract infections
* Corresponding author. Tel.: +358 40 8372507; fax: +358 2 2662107. E-mail address: maarit.wuorela@turku.fi (M. Wuorela).
are, however, associated with a transient increase in the risk of vascular events in outpatients [4]. Nosocomial urinary tract infections increase morbidity in nursing homes [5]. We investigated if recurrent urinary tract infections have a role in mortality or in the development of kidney dysfunction or hypertension in women.
2. Methods 2.1. Study design and population All community-living older females at the specified age and living in the defined geographical area (n = 764), were offered the possibility to participate a survey investigating the health of older people in the city of Turku, Southwest Finland. The participants were 70 years old at baseline and the follow-up time was 20 years (1991–2011). Eighty-six percent of them returned the questionnaire and participated in clinical examination. They were considered eligible for the follow-up (Fig. 1). To investigate the
http://dx.doi.org/10.1016/j.eurger.2016.02.006 1878-7649/ß 2016 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Please cite this article in press as: Wuorela M, et al. Recurrent urinary tract infection in females is a benign disease. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.02.006
G Model
EURGER-739; No. of Pages 4 M. Wuorela et al. / European Geriatric Medicine xxx (2016) xxx–xxx
2
2.5. Statistical analysis In statistical analysis we used descriptive statistics, cross tabulation with Fisher’s exact test, analysis of variance and KaplanMeier survival curves with log-rank test. Our statistical packages were NCSS 2007 NCSS 8 (Hintze, J. 2012, Kaysville, UT, USA) and SPSS 16.0 (SPSS Inc., Chicago, IL, USA). 3. Results Cognitive function of the participants was relatively stable during the 20-year follow-up time. The mean MMSE ( SD) values of the 70, 80, 85 and 90-year old females were 26.9 2.5, 25.7 3.0, 25.3 3.3 and 27.2 2.9 respectively. Fig. 2 shows that the mean estimated glomerular filtration rate was about 60 mL/min/1.73 m2 corresponding to a moderately reduced kidney function. The prevalence of hypertension increased from 36% to about 70% during the 20-year follow-up time. 3.1. Prevalence of recurrent urinary tract infection
Fig. 1. Flow chart of the participants.
determinants of successful aging, the participants were examined and interviewed at the age of 70 (n = 660), 80 (n = 381), 85 (n = 202) and 90 (n = 91) years to assess health history, health behaviors, cardiovascular risk factors, and physical, social and psychocognitive functioning. Incident cognitive impairment was ascertained on clinical interviews with the Mini-Mental State Examination (MMSE) as a screening instrument [6]. All eligible participants signed a written informed consent and the study protocol was approved by the ethical committee of the Hospital District of Southwest Finland.
Twenty-two percent of the women had had one or more episodes of recurrent urinary tract infection by the age of 70 years and the diagnosis became more prevalent during the follow-up. Twenty-seven percent, 28% and 29% of the 80, 85 and 90 years old participants had a history of recurrent urinary tract infection, respectively. None of the females reported having urological diseases. 3.2. Recurrent urinary tract infection, morbidity and mortality Urinary incontinence was strongly associated with urinary tract infection. Nineteen to 38 percent of the females without urinary tract infection had incontinence whereas 48–68% of the participants with recurrent infections were incontinent. A history of recurrent urinary tract infection was neither associated with the development of hypertension or kidney dysfunction nor increased mortality.
2.2. Diagnosis of recurrent urinary tract infection and hypertension 4. Discussion In mailed questionnaires, we asked the participants whether recurrent urinary tract infections have ever been diagnosed. We also asked detailed information about previous and current diseases. Hypertension was defined either as a clinical diagnosis or the use of antihypertensive medication. Hypertensive participants were referred to a physician at the baseline examination in 1991 ensuring the diagnosis and treatment of high blood pressure. 2.3. Determination of kidney function Serum creatinine of the 70, 80, 85 and 90 years old participants was measured immediately after the samples were drawn. The original enzymatic creatinine values measured 1991 were recalibrated providing isotope dilution mass spectrometry traceable values. Glomerular filtration rate was estimated using an equation developed by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) [7]. 2.4. Mortality Time and cause of death of deceased participants were ascertained from the national Death Register kept by Statistics Finland. The register covers information on all death certificates of Finnish citizens, and assures complete coverage. A unique national personal identification number assigned to every permanent resident of the country was used in the computerised record linkage.
In mailed questionnaires, we asked the participants whether a recurrent urinary tract infection has ever been diagnosed. In this study, recurrent urinary tract infection refers to recurrent cystitis because recurrent pyelonephritis is very rare in a population that has no urological disorders. We found that in our study, the prevalence of recurrent urinary tract infection increased with age and was comparable to other cohorts [2]. Our data on the association between urinary tract infection and urinary incontinence is consistent with previous reports [2,3]. The basis of this association is poorly understood. The etiology of urinary incontinence in older females is often multifactorial and urge and mixed types of urinary incontinence become the most prevalent types of incontinence [8,9]. These types of urinary incontinence are not typically complicated with chronic retention. It is possible that incontinent females receive antimicrobial treatment to asymptomatic bacteriuria more often than those without this problem. There is some data on asymptomatic kidney inflammation in patients with urinary tract infection. Chronic pyelonephritis is an uncommon cause of chronic tubulointerstitial disease and kidney dysfunction due to recurrent infection. Autopsy studies have revealed the presence of kidney inflammation in some patients with long-term catheterization even without symptoms of urinary tract infection [4]. There is no data on asymptomatic kidney inflammation without predisposing factors. Our study shows that
Please cite this article in press as: Wuorela M, et al. Recurrent urinary tract infection in females is a benign disease. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.02.006
G Model
EURGER-739; No. of Pages 4 M. Wuorela et al. / European Geriatric Medicine xxx (2016) xxx–xxx
3
Fig. 2. Kaplan-Meier survival curve (A), mean estimated glomerular filtration rate (eGFR) values standard deviation (SD) (B), prevalence of hypertension (C) and prevalence of urinary incontinence (D) of the participants with or without urinary tract infections (UTI). n: number of the participants.
appropriately treated recurrent episodes of symptomatic cystitis do not increase mortality or impair kidney function or increase the prevalence of hypertension. The strength of this study is the birth cohort design that ensured that there was no risk of selection bias that may be a potential limitation in cohort studies. The 20-year follow-up to the age of 90 years ensured that the potential effects on recurrent urinary tract infection on kidney function, development of hypertension and mortality were detected. The present study is limited by the use of mailed questionnaire in the assessment of recurrent urinary tract infection. Cognitive functioning of the participants remained quite stable during the 20-year follow-up time excluding the possibility that progressive cognitive decline might have been detrimental in our analysis. Also, the symptoms of an acute urinary tract infection are so obvious to the patient that we believe our data is accurate. We used of creatinine-based estimates of GFR as a marker for kidney function. We acknowledge that there are several other factors that affect plasma creatinine level in addition to kidney function such as variations in diet and creatinine generation as a result of differences in muscle mass and turnover [10]. There were, however, no differences in kidney function between the participants with or without urinary tract infection. Our results show that recurrent cystitis in females is a benign disease in the absence of abnormalities of the urinary tract even in the oldest old. This suggests that it is safe to treat recurrent cystitis in females according to the current guidelines of acute sporadic uncomplicated cystitis [11].
Ethical statement The work described has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans.
All eligible participants signed a written informed consent and the study protocol was approved by the ethical committee of the Hospital District of Southwest Finland. Disclosure of interest The authors declare that they have no competing interest. Acknowledgments The authors are grateful to the volunteers of the study for their participation. Funding: this work was supported by following institutions: Evo grants to the Turku City Hospital and by the Uula Arhio Foundation and Pa¨ivikki and Sakari Sohlberg Foundation. The financial sponsors had no role in the study design, data collection, analysis and interpretation of data, or writing of the study. References [1] Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643–54. [2] Nicolle LE. Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis. Urol Clin North Am 2008;35:1–12. [3] Raz R, Gennesin Y, Wasser J, et al. Recurrent urinary tract infections in postmenopausal women. Clin Infect Dis 2000;30:152–6. [4] Smeeth L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med 2004;351:2611–8. [5] Matthews SJ, Lancaster JW. Urinary tract infections in the elderly population. Am J Geriatr Pharmacother 2011;9:286–309. [6] Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–98. [7] Levey AS, Stevens LA, Schmid CH, CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009;150:604–12.
Please cite this article in press as: Wuorela M, et al. Recurrent urinary tract infection in females is a benign disease. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.02.006
G Model
EURGER-739; No. of Pages 4 4
M. Wuorela et al. / European Geriatric Medicine xxx (2016) xxx–xxx
[8] Minassian VA, Stewart WF, Wood GC. Urinary incontinence in women: variation in prevalence estimates and risk factors. Obstet Gynecol 2008;111:324–31. [9] Nygaard I, Barber MD, Burgio KL, Pelvic Floor Disorders Network. et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311–6. [10] Stevens LA, Schmid CH, Greene T, et al. Comparative performance of the CKD Epidemiology Collaboration (CKD-EPI) and the Modification of Diet in Renal
Disease (MDRD) Study equations for estimating GFR levels above 60 mL/min/ 1.73 m2. Am J Kidney Dis 2010;56:486–95. [11] Grabe M, Bartoletti R, Bjerklund TE, et al. Guidelines on urological infections. European Association of Urology; 2015 [accessed 27.10.2015]http://uroweb. org/guideline/urological-infections/.
Please cite this article in press as: Wuorela M, et al. Recurrent urinary tract infection in females is a benign disease. Eur Geriatr Med (2016), http://dx.doi.org/10.1016/j.eurger.2016.02.006