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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #29, #32, #42, #71


Learning Objectives

  • Differentiate asymptomatic bacteriuria (ASB) and symptomatic urinary tract infection (UTI) in older adults.

  • Apply specific considerations and guidelines for evaluation of UTI in older adults residing in long-term care facilities.

  • Recognize the limitations of current guidelines for diagnosis and treatment of UTI in both community-dwelling older adults and residents of long-term care facilities.

  • Identify which older adults are at greatest risk for developing a UTI with a resistant organism.

  • Utilize strategies to limit unnecessary antibiotic use in older adults with suspected UTI.

Key Clinical Points

  1. ASB and UTI are the most common reasons antibiotics are prescribed for older adults in both the community and health care settings.

  2. Distinguishing ASB and symptomatic UTI is problematic. Many older adults do not present with localized genitourinary symptoms required by guidelines to diagnose a symptomatic infection and the baseline prevalence of bacteriuria is high.

    1. Clinicians should NOT screen older adults for ASB and those with ASB should NOT be treated with antibiotics. Only in older adults undergoing invasive urologic procedures should ASB screening be considered.

    2. In either community-dwelling or long-term care resident older adults with vague, nonspecific symptoms (eg, periods of altered perception, disorganized speech, lethargy, change in odor or color of urine), observation for 24 to 48 hours for the evolution of symptoms with hydration and alternative diagnoses should be considered and does NOT lead to worse outcomes in those eventually proven to have UTI when compared to empiric, immediate antibiotic therapy. If symptoms persist and no other identifiable cause is found, urinary dipstick testing for the presence of leukocyte esterase and nitrite should be performed and if positive, culture and treatment considered. A urinary dipstick negative for both leukocyte esterase and nitrate has been shown to have a negative predictive value of 88% to 100%.

  3. Clinicians in outpatient and inpatient settings do not often use guidelines aimed at reducing unnecessary antibiotic prescriptions.

  4. Use of antibiotics to treat UTI is associated with the development of uropathogens with resistance to commonly used antibiotics.


Urinary tract infection (UTI) is the most frequently encountered bacterial infection in older adults. While the presence of bacteria in the urine in older adults is usually asymptomatic and considered a colonization state, symptomatic infection is associated with morbidity and, rarely, mortality. Optimal management of UTI in this population is challenging in the face of diagnostic uncertainty, concerns with excess antimicrobial use, and increasing antimicrobial resistance in both the community and long-term care (LTC) setting. In addition, the heterogeneity of the older adult population means approaches may vary for different groups. The impact and management of urinary infection differs for older adults in the community and in those residing in long-term care facilities (LTCFs). There are also unique considerations for the subgroup of older adults with chronic indwelling ...

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