There is no clear consensus on the definition of frailty; however, it is proposed that frailty comprises a collection of biomedical factors which influences an individual's physiological state in a way that reduces his or her capacity to withstand environmental stresses. Only a subset of older people are at risk of becoming frail; these are vulnerable, prone to dependency and have reduced life expectancy. These health outcomes contribute to an increased demand for medical and social care, and are associated with increased economic costs (1). 
In urology, antimicrobial stewardship programmes should include a series of measures to ensure rational, evidence based use of antimicrobials in the prevention and treatment of infections of the urinary tract and male accessory glands, as well as non-antimicrobial strategies (2).
The objectives of this study are: 
1. To know factors related to the presence of urinary tract infections in frail institutionalized older adults.
2.To propose improved measures in the management of recurrent urinary tract infections avoiding antimicrobial prophylaxis.

Multicentric prospective study in institutionalized people diagnosed with recurrent urinary tract infections. 
Intervention: alternative random assignment 1/1 successive to each group. 
Study groups: 
   - Group A (n = 50): patients receiving continuous low-dose antibiotic prophylaxis;
   - Group B (n = 50): patients receiving prophylaxis with a polybacterial vaccine (Uromune ®). 
Age, gender, number of urinary tract infections, secondary diagnoses, concomitant treatments, health-related quality of life relative to UTI measured with a visual analogue scale (VAS: 0 = worst, 10 = best) were analysed. 
Descriptive statistics, ANOVA, Student's t test, Fisher's exact test, Pearson's correlation test were performed; p <0.05 was considered significant.

Patients in the sample were 56 women (56%) and 44 men, which were equally distributed in both groups (Group A: 28 women and 22 men; Group B: 28 women and 22 men).
Regarding average age, no differences were found in the whole sample (women: 83.71 years; men: 80.17 years; p = 0.3112).  Mean number of urinary tract infections per year before prophylactic treatment: 8 (SD: 5.31). 
At follow-up, the average number of urinary tract infection per month was higher in Group A (mean: 0.66, SD: 0.31) than in Group B (mean: 0.212, SD: 0.14) (p <0.0213).
There was no difference in the guiding symptom between groups (p = 1.0000): agitation (24.5%), dysuria (24.5%), disorientation/confusion (15.5%), haematuria (12.5%), malodorous urine (8.5%), general deterioration (4.5 %), decrease in consciousness (4.5%), oligosymptomatic (5.5%). 
No differences between Group A and Group B were found regarding Combur test results, urine culture or pre-intervention secondary diagnoses (p = 1.0000). 
The number of urinary tract infections was related to constipation, urinary incontinence's severity, neurological disorders and renal failure. 
 Average VAS was higher in Group B (mean: 7.1 SD: 0.55) with respect to Group A (mean 2.31, SD 0.87) (p <0.0001). The VAS was lower in cases of severe urinary incontinence / greater number of absorbents compared to other secondary diagnoses.

Developed countries' populations tends to ageing. Antibiotic treatment may cause gastrointestinal disorders in elderly patients, in addition to increasing antibiotic-resistant microorganisms. This study shows the efficacy and benefit of the use of the polybacterial vaccine (Uromune ®) in this specific population. This vaccine favours immunoactive prophylaxis using a suspension of inactivated complete cells of differents strains of Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis and Enterococcus faecalis. It is worth underlining that the sublingual administration of this vaccine is easy and comfortable, being practical for its use in institutionalised and dependent patients.

The polyvalent bacterial vaccine is effective in the reduction of UTI against continuous low-dose antibiotic prophylaxis in frail institutionalized older adults and provides improvement in the quality of life. Severe urinary incontinence, that requires the use of absorbents to a greater degree, worsens the management of UTIs in the frail institutionalized elderly.

Lally F, Crome P. Understanding frailty. Postgraduate Medical Journal. 2007;83(975):16-20. doi:10.1136/pgmj.2006.048587.
G. Bonkat (Co-chair), R. Pickard (Co-chair), R. Bartoletti, F. Bruyère, S.E. Geerlings, F. Wagenlehner, B. Wullt Guidelines Associates: T. Cai, B. Köves, A. Pilatz, B. Pradere, R. Veeratterapillay. EAU Guidelines on Urological Infections, 2018. Available at: http://uroweb.org/guideline/urological-infections/