UTIs are common in older adults and can be difficult to diagnose due to atypical symptoms. It is important to distinguish UTIs from asymptomatic bacteriuria to avoid unnecessary antibiotic treatment. Age, female anatomy, and medical conditions increase risk. Proper diagnosis using symptoms, urinalysis and culture along with prevention strategies and guidelines can help reduce inappropriate antibiotic use and antibiotic resistance.
2. ◦ UTI is a common infection in older adults and can affect the kidneys, bladder, or urethra.
◦ Asymptomatic bacteriuria (ASB) is often confused with UTI, leading to unnecessary antibiotic
treatment. Therefore, it is important to distinguish between the two conditions.
◦ Older adults are more vulnerable to UTI due to changes in their immune system, reduced mobility,
and other age-related factors.
◦ Antibiotic overuse in treating UTI can lead to the emergence of antibiotic-resistant bacteria, which is
a growing public health concern.
◦ Healthcare providers should use evidence-based guidelines for the diagnosis and management of
UTI in older adults to avoid inappropriate antibiotic use.
◦ Prevention strategies such as good hygiene practices and staying well-hydrated can help reduce the
risk of UTI in older adults.
◦ Patients and caregivers should be educated on the signs and symptoms of UTI, and encouraged to
seek medical attention promptly if they suspect an infection.
◦ Monitoring and surveillance of antimicrobial use in hospitals is important to ensure appropriate use
of antibiotics and prevent the emergence of antibiotic resistance.
Journal of Pharmacy Practice and Research (2020) 50, 276–283
3. EPIDEMIOLOGY, RISK FACTORS AND PATHOPHYSIOLOGY OF UTI
◦ UTIs cause 15.5% of hospitalizations and 6.2% of deaths attributable to infectious diseases in patients
over the age of 65 in the USA.
◦ Although a weak association, increasing age is a risk factor for UTI due to disruption of acquired
immunity and normal defense mechanisms.
◦ Women are more prone to UTIs due to their shorter urethral length and frequent vaginal colonization,
and older women may be more affected due to loss of pelvic floor muscle tone and associated
prolapse.
◦ Other risk factors for UTIs include anatomical abnormalities, sexual activity (at any age), anal
intercourse, diabetes, urinary incontinence, and physical limitations.
◦ Proper diagnosis and management of UTIs in older adults are crucial to avoid inappropriate antibiotic
use and prevent the emergence of antibiotic resistance.
◦ Prevention strategies such as good hygiene practices, staying well-hydrated, and regular voiding can
help reduce the risk of UTI in older adults.
◦ Healthcare providers should use evidence-based guidelines for the diagnosis and management of UTI
in older adults, taking into consideration individual patient factors and avoiding unnecessary antibiotic
treatment.
◦ Patients and caregivers should be educated on the signs and symptoms of UTI, and encouraged to
seek medical attention promptly if they suspect an infection.
4. ◦ UTIs are a significant cause of hospitalizations and deaths attributable to infectious diseases in older
adults in the USA.
◦ Age is a risk factor for UTI due to the disruption of acquired immunity and normal defense
mechanisms.
◦ Women are more prone to UTIs due to their anatomy, and older women may be more affected due to
loss of pelvic floor muscle tone.
◦ Other risk factors for UTIs include anatomical abnormalities, sexual activity, diabetes, urinary
incontinence, and physical limitations.
◦ Proper diagnosis and management of UTIs in older adults are crucial to avoid inappropriate antibiotic
use and prevent antibiotic resistance.
◦ Prevention strategies such as good hygiene practices, staying well-hydrated, and regular voiding can
help reduce the risk of UTI in older adults.
◦ Healthcare providers should use evidence-based guidelines and avoid unnecessary antibiotic
treatment.
◦ Patients and caregivers should be educated on the signs and symptoms of UTI and seek prompt
medical attention if they suspect an infection.
5. EPIDEMIOLOGY OF ASYMPTOMATIC BACTERIURIA (ASB)
◦ ASB is rare in younger people but is found in 7-10% of men and 17-20% of women over the age
of 75.
◦ Among nursing home residents, up to 25%-50% have ASB at any given time.
◦ The prevalence of ASB is 100% in patients with long-term indwelling catheters (IDC).
◦ The prevalence of ASB is about 3% to 5% in patients with short-term use of catheters.
◦ ASB is often confused with UTI, leading to unnecessary antibiotic treatment, especially in older
adults.
◦ Guidelines recommend against routine screening or treatment of ASB in most populations,
including older adults and nursing home residents, unless they are undergoing urologic
procedures or are pregnant.
◦ Proper catheter care and early removal when possible can help reduce the risk of ASB and
related complications.
8. Asymptomatic Bacteriuria (ASB)
◦ The definition of ASB in patients without IDC is a urine specimen with ≥105 colony-forming units
(CFU)/mL (≥108 CFU/L) without any signs or symptoms attributable to UTI.
◦ ASB is associated with white blood cells (WBC) in urine (pyuria) in over 90% of cases, making it difficult
to distinguish from UTI.
◦ Patients with symptoms unrelated to UTI who have ASB may be misdiagnosed with UTI, which can
lead to unnecessary antibiotic treatment.
◦ Screening for and treating ASB is not recommended, except in pregnant women or immediately before
a urologic procedure likely to involve mucosal injury, as it does not reduce morbidity or mortality but
increases the risk of antimicrobial-related adverse effects and resistance.
◦ Proper diagnosis and management of UTI in older adults are crucial to avoid inappropriate antibiotic
use and prevent antibiotic resistance.
◦ Guidelines recommend using a combination of symptoms, urinalysis, and urine culture to diagnose UTI
in older adults and avoiding routine urine culture in asymptomatic patients.
◦ Education of healthcare providers, patients, and caregivers about the appropriate diagnosis and
management of UTI and ASB can help reduce unnecessary antibiotic use and prevent complications.
9. Symptomatology of UTI
◦ Asymptomatic bacteriuria (ASB) can be challenging to diagnose in older individuals
as they may not exhibit typical UTI symptoms.
◦ Symptoms of UTI include lower urinary tract symptoms such as dysuria, urinary
frequency and urgency (cystitis), back/flank pain, and costovertebral angle
tenderness (pyelonephritis).
◦ Urine turbidity, sediment colour and odour are not reliable indicators of infection.
◦ Diagnosis based solely on mental state changes can be inaccurate, and obtaining
collateral history from family members or nursing staff may be useful.
◦ The diagnosis of UTI requires clinical symptoms of infection, laboratory evidence of
pyuria and bacteriuria, systemic inflammation, and the absence of another infection
or non-infectious process.
◦ In patients with functional and/or cognitive impairment with bacteriuria and delirium,
without local genitourinary symptoms or systemic signs of infection, it is
recommended to assess for other causes and carefully observe patients rather than
start antimicrobial treatment.
10. Role Of Urine Dipstick Testing
◦ Dipstick testing of urine is a common and fast method for ruling out UTI as
a cause of symptoms.
◦ The test detects the presence of leucocyte esterase (a marker for pyuria)
and nitrites (a marker for gram-negative bacteriuria).
◦ However, dipstick testing may not be reliable for detecting UTI caused by
Gram-positive bacteria and other organisms such as Enterococci and
Pseudomonas species that do not reduce urinary nitrates to nitrites.
◦ A study conducted in nursing home residents suggests that a negative
dipstick test result for both leukocyte esterase and nitrite can effectively
exclude the diagnosis of UTI, but the positive predictive value is low.
◦ Urine dipstick testing is similar to the D-dimer test for pulmonary embolism
diagnosis, where a negative result is useful for ruling out the disease, but a
positive result alone is not enough to establish the diagnosis.
11. Urine and Blood Culture
◦ Urine culture is done to identify bacteriuria and determine antibiotic
sensitivity.
◦ Bacterial count of 105 CFU/mL is considered significant, but lower counts
may also be relevant in symptomatic patients.
◦ UTI cannot be diagnosed solely based on urine culture as bacteriuria can
be present in asymptomatic patients, especially in older adults.
◦ Requests for urine culture in older people should be limited to patients with
acute urinary symptoms and those with features of systemic inflammation
and no other explanation for their acute illness.
◦ Positive blood culture in the absence of other sources of infection is
consistent with UTI, especially if urine culture also grows the same
organism.
◦ Taking blood cultures is appropriate in patients with suspected sepsis and
can help determine further investigations such as CT scan.
12. OTHER INVESTIGATIONS
◦ Imaging of the urinary tract is not necessary for routine UTI management.
◦ Imaging should be reserved for patients who have not improved despite 48-
72 hours of antibiotic therapy, those with known history of obstruction, or
those with a decline in renal function from baseline.
◦ Ultrasound is a safe and non-invasive imaging option that can provide
clinical information.
◦ CT scans may be necessary for certain patients who present acutely and
can identify issues such as renal calculi, pyelonephritis, haemorrhage, and
cortical abscesses.
◦ Specialised studies such as CT intravenous pyelography and urodynamic
evaluation of the bladder may be required for chronic obstruction or urinary
incontinence, but are not necessary for routine UTI management.
Consultation with a urologist may be helpful in such cases.
13. Future Research In Laboratory Confirmation
◦ Biomarkers like interleukins 8 and 6, lactoferrin, and
procalcitonin are being used to identify UTI in children and
young adults after surgery.
◦ However, the evidence supporting their accuracy in older
adults is moderate, and further research is needed.
◦ Public Health England published a guideline in 2018 for the
diagnosis of UTIs in primary care settings.
◦ The guideline provides a practical and empirical approach to
diagnose UTIs, reduce antibiotic misuse, and minimize
emerging resistance.
14. MANAGEMENT OF UTI
◦ Limited guidelines available for the diagnosis, treatment, and
management of UTIs in older adults
◦ Australian antibiotic guidelines provide empirical treatment
recommendations for UTI in older adults
◦ Prior to antibiotic treatment, review history of any antibiotic
allergy and consider modifying antibiotic doses based on the
patient's renal function
◦ Empirical therapy for patients over 65 should provide
antimicrobial cover against E. coli, Proteus mirabilis, Klebsiella
pneumoniae, and other Gram-negative bacteria
◦ UTI in men is uncommon and treatment is extrapolated from
recommendations in women
◦ It is crucial to obtain a urine sample before commencing
15. Complicated Urinary Tract Infection
◦ UTIs in patients with renal calculi, pyelonephritis, prostatitis or epididymo-
orchitis, and in those with long-standing indwelling catheters or those using
intermittent self-catheterisation are likely to be complicated
◦ Complicated UTIs may involve other parts of the urinary tract apart from the
bladder and often require hospitalisation and surgical interventions such as
nephrostomy tubes or ureteric stents
◦ Intravenous antibiotics are usually prescribed for these patients
◦ Treatment can be modified based on known multi-drug resistant organism
colonisation or previous (within last 6 months) urine culture result
◦ Usually, patients with complicated UTIs require a 10-14 day course of
antibiotic treatment.
16. Management of Catheter-Associated UTI (CAUTI)
◦ For patients with CAUTI, catheter removal or changing should
be considered as soon as possible, especially if the catheter
has been in place for more than 7 days.
◦ The microbiology of CAUTI is more diverse, with higher rates
of infection with Candida spp and Pseudomonas aeruginosa.
◦ Empirical treatment for CAUTI is not recommended, and it is
suggested to obtain a urine sample before antibiotics are
prescribed.
◦ If the catheter has been removed, obtain a midstream
specimen of urine for a better clinical outcome.
◦ Review of choice of antimicrobial therapy is highly
recommended, as in the case of non-catheter associated UTIs.
17. Residential Aged Care Setting
◦ UTI is the second most common indication for antimicrobial
prescription in aged care facilities in Australia.
◦ Cystitis is the most commonly reported indication for
antimicrobial prophylaxis in 2016-2018.
◦ Prescriptions for antimicrobial therapy for ASB have decreased
from 46% in 2016 to 2.1% in 2018.
◦ ASB should not be treated with antibiotics for either treatment
or prophylaxis as it does not reduce complications and can
increase the risk of subsequent UTI.
◦ Unnecessary antimicrobial treatment can lead to the
development and progression of antimicrobial resistance,
adverse drug events, and Clostridiodes difficile infection.
18. MANAGEMENT OF RECURRENT UTI
◦ Antibiotic Prophylaxis
◦ Non Antibiotic Strategies
◦ Emerging Treatments for Recurrent UTI
19. Antibiotic Prophylaxis
◦ Prophylactic antimicrobials can be used in selected cases to reduce the incidence
and severity of recurrent UTIs.
◦ Evidence from a Cochrane review shows reduced clinical and microbiological
recurrences with prophylaxis versus placebo.
◦ Recurrent UTI is defined as more than four episodes of UTI in a 12 month period
and differs from recurrent ASB.
◦ Prophylaxis for recurrent UTI may reduce the risk of UTI recurrence in post-
menopausal women but longer term outcomes such as adverse effects, recurrence
rates following cessation of prophylaxis and impacts on antimicrobial resistance are
yet to be established.
◦ Increased rates of resistance to trimethoprim-sulfamethoxazole were demonstrated
in one trial with over 90% of urinary and faecal E. coli isolates developing resistance
to this medication following 1 month of prophylactic treatment.
◦ The Australian Therapeutic Guidelines recommend either intermittent post-coital or
continuous prophylaxis for up to 6 months with a single agent.
◦ There is currently no published evidence available to support the use of prolonged
continuous prophylaxis (>6 months duration) with ‘cycling’ of antimicrobials.
20. Non Antibiotic Strategies
◦ Intra-vaginal oestrogens can reduce the risk of vaginal
colonisation by E. coli in post-menopausal women.
◦ D-Mannose, probiotics, urinary acidification compounds and
cranberry products have been used with variable reported
improvements in symptoms for recurrent UTIs.
◦ Intravesical instillation of hyaluronic acid or a non-pathogenic
strain of E coli has shown benefit in a small number of
patients.
21. Emerging Treatments for Recurrent UTI
◦ Emerging treatments for recurrent UTI include
photoantimicrobials, an antimicrobial vaccine and bladder
instillation of antimicrobial agents.
◦ Photoantimicrobials utilise light-activated compounds or
photosensitisers to kill bacteria, and an immunomodulation
vaccine utilises the patient's immune system to prevent
recurrent UTI.
◦ A systematic review showed that intravesical bladder
installations of antimicrobials are a safe and effective method
for the prophylaxis and treatment of recurrent UTIs.
