Pearl: The diagnosis of UTI in older adults is challenging because of high rates of asymptomatic bacteriuria and misattribution of non specific signs and symptoms to the urinary tract.

Diagnosing UTIs in older adults is challenging!

UTIs are diagnosed based on the presence of (1) signs and symptoms attributable to the urinary tract and (2) the presence of significant bacteriuria.

Urinary tract infections are common with aging and frailty. However, asymptomatic bacteriuria (ASB; the presence of bacteriuria or 100,000+ CFU in the absence of symptoms) becomes increasingly common as well (see table below)! In long-term care, rates of ASB approach 50% in women and men! ASB does not benefit from treatment.

The traditional paradigm that urine is sterile is wrong have been proven wrong

Urine is NOT sterile!

There is even a human urine virome suggesting the possibility of viral urinary infections

Older patients may present atypically

The ability to communicate may be limited by cognitive impairment and dementia. In addition, frail, older adults are increasingly vulnerable to stress/illness (homeo-stenosis) and can manifest with nonspecific signs and symptoms. Those signs/symptoms may overlap with those thought to be due to UTIs For example, simple dehydration may induce delirium or falls

UTIs are over-diagnosed and over-treated

Up to 50% of antibiotics prescribed in long-term care were inappropriate! (JAMDA UTI consensus page 13). Antibiotic use leads to adverse events such as drug hypersensitivities, drug intolerance (nausea, diarrhea, malaise, headache, drug interactions, and more), multidrug resistance, clostridium difficile infection, potential disruption of the urinary microbiome, more even frequent urinary tract infections (JAGS Urinary Tract Infection – Requiem for a Heavyweight)

Potential incorrect attribution of signs and symptoms to a UTI interferes with a timely, accurate evaluation:

Over 8 years, 25.4 million US adults visited the ED and were diagnosed with a UTI, but only 32% had urinary symptoms (Caterino et al). Given the high rates of asymptomatic bacteriuria, this raises concerns of overtreatment and iatrogenic harm in addition to missing the real underlying reason that prompted medical attention.

For further commentary about UTI and older adults, consider:

• Dr. Tom Finucane’s “Urinary Tract Infection – Requiem for a Heavyweight”
• Following commentary by Dr. Crnich et al’s “Improving Management of Urinary Tract Infections in Older Adults: A Paradigm Shift or Therapeutic Nihilism?”

NOTE: This guide is does not include pregnant women (this is GeriGuides after all…), certain clinical situations such as plans for urologic instrumentation, or other scenarios that call for screening of asymptomatic bacteriuria. For indications to screen ASB, see IDSA 2019 ASB Guidelines