Pearl: In the absence of localizing signs/symptoms, the likelihood of a true UTI is low.

If there are no localizing signs/symptoms of a UTI, the likelihood of a true UTI is probably low

Remember that frail older adults are increasingly vulnerable to ANY stress/illness (homestenosis) and often manifest with nonspecific signs and symptoms. Those signs/symptoms overlap with what has traditionally been associated with UTIs.

There is mounting evidence to not attribute certain sign/symptoms to UTIs:

1. “Dark, cloudy, or foul-smelling urine is not sufficient to indicate a UTI and may instead reflect mild dehydration or changes to diet or medications” (JAMDA consensus – Diagnosis of UTI)
   
   Consider medication side effect, poor oral intake, dehydration, constipation, pain, or other underlying medical etiology, etc.
   
2. “Nonspecific symptoms — including change in cognition, agitation [or aggression], decreased appetite, [nausea +/- vomiting, syncope] and falls – are not symptoms of UTI, especially when genitourinary tract specific signs and symptoms are absent” (JAMDA consensus – Role of Behavioral Change; emphasis added)
   
   In older patients with functional and/or cognitive impairments with bacteriuria and without local genitourinary symptoms or other signs of infection (fever, hemodynamic instability) who experience delirium or a fall, we recommend assessment for other causes and careful observation rather than antimicrobial treatment.” (IDSA Asymptomatic Bacteriuria Guidelines 2019 – Recommendations V1 and V2)