Urinary tract infection (UTI) is the most frequent bacterial infection in elderly populations. While urinary infection in the elderly person is usually asymptomatic, symptomatic infection occurs frequently with associated serious morbidity and, rarely, mortality. Optimal management of urinary infection in the elderly patient is challenging in the face of diagnostic uncertainty, concerns with excess antimicrobial use, and increasing antimicrobial resistance in both the community and nursing home. Current limitations in knowledge and optimal management strategies for this problem must be appreciated. In addition, the heterogeneity of the elderly populations means approaches may vary for different groups. The impact and management of urinary infection differs for women and men, and for the institutionalized and noninstitutionalized elderly person. There are also unique considerations for the subgroup of institutionalized elderly persons with chronic indwelling catheters. The discussion in this chapter is relevant to individuals without long-term indwelling catheters, unless otherwise stated.
The bladder is normally sterile. While bacteriuria is always abnormal, it is not necessarily detrimental. “Bacteriuria”, a positive urine culture without attributable signs or symptoms, is used interchangeably with “asymptomatic UTI” in this chapter. The majority of the elderly individuals with bacteriuria have evidence for a local host response. Some authors use the term “bladder colonization” in discussing asymptomatic bacteriuria. This term has not been shown to have clinical or biological relevance in elderly populations, and is not used in this discussion.
UTI encompasses a spectrum of presentations (Table 127-1). Acute uncomplicated urinary infection, also known as acute cystitis, is usually considered relevant only for premenopausal women. However, women who experience recurrent acute uncomplicated urinary infection prior to menopause often continue to experience these episodes after menopause. Complicated UTI occurs in either sex in the setting of a structurally or functionally abnormal urinary tract. A wide variety of genitourinary abnormalities are associated with infection, from prostatic hypertrophy and cystoceles to chronic renal failure and chronic indwelling catheters. A characteristic of complicated UTI is frequent and early post-therapy recurrence if the underlying genitourinary abnormality persists. These infections are also characterized by a wider variety of infecting organisms. The majority of functionally impaired older women and all men with urinary infection should be considered to have complicated infection.
Table 127-1 Potential Clinical Presentations of UTI ||Download (.pdf)
Table 127-1 Potential Clinical Presentations of UTI
Acute, uncomplicated urinary infection
Bladder infection in women with a normal genitourinary tract
Acute, nonobstructive pyelonephritis
Acute renal infection in women with a normal genitourinary tract
Bladder or renal infection in men and women with functional or structural genitourinary abnormalities
Asymptomatic bacteriuria (asymptomatic UTI)
Positive urine culture meeting standard quantitative criteria for significant bacteriuria with no signs or symptoms referable to the urinary tract, irrespective of the presence or absence of pyuria
Febrile illness, usually with bacteremia and severe voiding symptoms associate with acute bacterial infection of the prostate
Chronic bacterial prostatitis