Urinary Tract Infections in Older Adults: Current Issues and New Therapeutic Options

Sophie Robichaud, MD, FRCP(C); Joseph M. Blondeau, MSc, PhD, RSM(CCM), SM(AAM), SM(ASCP), FCCP

Disclosures

Geriatrics and Aging. 2008;11(10):582-588. 

In This Article

Symptomatic Urinary Tract Infection

The fact that both asymptomatic bacteriuria and pyuria are so prevalent among older adults is problematic for the clinician. Although the absence of bacteriuria may exclude a UTI in an older patient, the presence of a positive culture does not confirm it. Classic symptoms and signs for UTI include dysuria, incontinence, increased frequency, urgency, hematuria, and suprapubic pain; when pyelonephritis is present, flank tenderness and fever are usually encountered.[20] In older adults, though, one should look for other signs also, such as delirium or falls (this is different than the nonspecific symptoms of weakness and fatigue discussed below). Nicolle, in two excellent reviews on UTI among older adults,[7,21] points out that a diagnosis of UTI should be based on a very thorough clinical evaluation, the exclusion of other possible diagnoses, and the presence of new signs and symptoms localized to the genitourinary tract. A new onset of urinary tract symptoms can indicate the presence of a UTI, although attention should be given to differentiating these symptoms from chronic symptoms.

A good clinical evaluation is frequently impaired by the difficulty in obtaining a reliable history from patients who are often unable to communicate their symptoms adequately. However, nonspecific symptoms such as general weakness, fatigue, and malaise cannot be relied upon to make the difference between asymptomatic and symptomatic infections, especially if the patient is afebrile.[3,7,22] The presence of fever, while directing the clinician in the direction of an infectious process, cannot identify with certainty the origin of its focus: a study by Orr et al.[23] shows that a urine culture, even in the presence of fever, has a low predictive value[3,4]—serological criteria actually showed that only 10% of significant fever episodes among older adults in LTC facilities can be attributed to UTI. Since UTI is a common source of bacteremia in residents of LTC facilities, especially if an indwelling catheter is present,[24] a blood culture can be done. A positive culture with a known uropathogen or the same species found in the urine culture helps in substantiating the diagnosis. A prudent approach, the exclusion of other possible focuses of infection, and the follow-up of the patient's symptoms is probably the most appropriate course to follow before a treatment for UTI is started, recognizing that, in some instances, no other focus will be found or that the severity of the illness will warrant empirical antibiotic therapy.

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