Urinary Tract Infections in Older Patients

  • Roberta PetrinoEmail author
  • Aldo Tua
  • Fabio Salvi


Urinary tract infections (UTIs) are the most common infection in older patients, above all when living in a long-term care facility. UTIs are caused by the presence and multiplication of microorganisms in the urinary tract. A UTI can result in several clinical syndromes, including acute and chronic pyelonephritis (infection of the kidney and renal pelvis), cystitis (infection of the bladder), urethritis (infection of the urethra), epididymitis (infection of the epididymis), and prostatitis (infection of the prostate gland). A urinary tract infection is defined by a combination of clinical features and the presence of bacteria in the urine. The diagnosis of UTI is particularly difficult in older patients, who may present with atypical symptoms such as delirium and without a fever.

Older institutionalised patients frequently receive unnecessary antibiotic treatment for asymptomatic bacteriuria (ASB), despite compelling evidence of no clinical benefit. The high prevalence of bacteriuria in long-term care facility patients makes it difficult for providers to distinguish a clinically relevant UTI from ASB, with a consequent overtreatment of ASB, which leads to the development of multidrug-resistant organisms (MDROs). In older patients who have nonspecific symptoms, a holistic assessment should be performed, specifically looking for alternative explanations for the presentation before assuming UTI is the issue. Urine dipstick testing is not useful other than to exclude UTI (high negative predictive value) as it has poor positive predictive value. It is important to know the epidemiology and local resistance patterns, to ensure the correct use of antibiotics.


  1. 1.
    Foxman B (2003) Epidemiology of urinary tract infections. Dis Mon 49(2):53–70CrossRefGoogle Scholar
  2. 2.
    Mody L, Juthani-Metha M (2014) Urinary tract infections in older woman. A clinical review. JAMA 311(8):844–854CrossRefGoogle Scholar
  3. 3.
    Nicolle LE, Bradley S, Colgan R et al (2005) Infectious diseases society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 40(5):643–654CrossRefGoogle Scholar
  4. 4.
    Ninan S, Walton C, Barlow G (2014) Investigation of suspected urinary tract infection in older people. BMJ 348:g4070CrossRefGoogle Scholar
  5. 5.
    Das R, Perrelli E, Towle V et al (2009) Antimicrobial susceptibility of bacteria isolated from urine samples obtained from nursing home residents. Infect Control Hosp Epidemiol 30(11):1116–1119CrossRefGoogle Scholar
  6. 6.
    Liang SY (2016) Sepsis and other infectious disease emergencies in the elderly. Emerg Med Clin N Am 34:501–522CrossRefGoogle Scholar
  7. 7.
    Limpawattana P, Phungoen P, Mitsungnern T et al (2016) Atypical presentations of older adults at the emergency department and associated factors. Arch Gerontol Geriatr 62:97–102CrossRefGoogle Scholar
  8. 8.
    Adedipe A, Lowenstein R (2006) Infectious emergencies in the elderly. Emerg Med Clin N Am 24(2):433–448CrossRefGoogle Scholar
  9. 9.
    Grabe M, Bartoletti R, Bjerklund-Johansen TE, Çek HM, Pickard RS, Tenke P, Wagenlehner F, Wullt B (2014) Guidelines on urological infections. European Association of UrologyGoogle Scholar
  10. 10.
    Nicolle LE (1997) Asymptomatic bacteriuria in the elderly. Infect Dis Clin N Am 11(3):647–662CrossRefGoogle Scholar
  11. 11.
    Scottish Intercollegiate Guidelines Network (2012) SIGN guideline 88. Management of suspected bacterial urinary tract infection in adults.
  12. 12.
    Caljouw MA, Den Elzen WP, Cools HJ et al (2011) Predictive factors of urinary tract infections among the oldest old in the general population. A population-based prospective follow-up study. BMC Med 9:57CrossRefGoogle Scholar
  13. 13.
    Hu KK, Boyko EJ, Scholes D et al (2004) Risk factors for urinary tract infections in postmenopausal women. Arch Intern Med 164(9):989–993CrossRefGoogle Scholar
  14. 14.
    Rao GG, Patel M (2009) Urinary tract infection in hospitalized elderly patients in the United Kingdom: the importance of making an accurate diagnosis in the post broad-spectrum antibiotic era. J Antimicrob Chemother 63:5–6Google Scholar
  15. 15.
    Swami SK, Liesinger JT, Shah N et al (2012) Incidence of antibiotic-resistant Adv PSA337 bacteriuria according to age and location of onset: a population-based study from Olmsted County, Minnesota. Mayo Clin Proc 87(8):753–759CrossRefGoogle Scholar
  16. 16.
    Juthani-Mehta M, Quagliarello VJ (2010) Infectious diseases in the nursing home setting: challenges and opportunities for clinical investigation. Clin Infect Dis 51(8):931–936CrossRefGoogle Scholar
  17. 17.
    Loeb M, Bentley DW, Bradley S et al (2001) Infect Control Hosp Epidemiol 22:120–124CrossRefGoogle Scholar
  18. 18.
    Stone ND, Ashraf MS, Calder J et al (2012) Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 33(10):965–977CrossRefGoogle Scholar
  19. 19.
    Schulz L, Hoffman RJ, Pothof J, Fox B (2016) Top ten myths regarding the diagnosis and treatment of urinary tract infections. J Emerg Med 51:25–30CrossRefGoogle Scholar
  20. 20.
    Hooton TM (2012) Clinical practice. Uncomplicated urinary tract infection. N Engl J Med 366(11):1028–1037CrossRefGoogle Scholar
  21. 21.
    Jepson RG, Craig JC (2009) Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 1:CD001321Google Scholar
  22. 22.
    Cove-Smith A, Almond M (2007) Management of urinary tract infections in the elderly. Trends Urol Gynaecol Sexual Health:30–35Google Scholar
  23. 23.
    Mckinnell JA, Stollenwerk NS, Jung CW et al (2011) Nitrofurantoin compares favourably to recommended agents as empirical treatment of uncomplicated urinary tract infections in a decision and cost analysis. Mayo Clin Proc 86(6):480–488CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2018

Authors and Affiliations

  1. 1.Emergency Medicine UnitS. Andrea HospitalVercelliItaly
  2. 2.Department of Geriatrics and Geriatric Emergency CareINRCA-IRCCSAnconaItaly

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