Urinary Tract Infections

Urinary tract infections (UTIs) are the most common bacterial infections in the elderly. They are also a leading cause of admission to the hospital from the nursing home and a leading cause of death due to blood infections (sepsis).

What are risk factors for urinary tract infections?

• Increased age
• Neurogenic bladder (damage to nerves around the bladder)
• History of urinary tract infections
• Dehydration
• Constipation
• Poor catheter care

Can there be bacteria present in the urinary tract without having a UTI?

Yes. According to the Association for Practitioners in Infection Control and the Society for Healthcare in Epidemiology of America, a laboratory confirmation of >100,000 colony-forming units (CFU)/mL is the usual standard to confirm a positive urine culture.

But a positive culture without any symptoms of painful urination, urinary frequency, incontinence of recent onset or increase, back, suprapubic, or flank pain, fever, decline in mental function, changes in urine color and consistency, or other signs of infection should not be treated for a UTI. If there are no accompanying symptoms, an antibiotic should not be prescribed to treat an infection. Overuse of antibiotics can cause the person to develop resistance. If the person develops such resistance, the antibiotics will not work when there is a significant infection that needs to be treated, which can result in death. Again, when there are bacteria in the urine without symptoms, it is termed asymptomatic bacteruria, which is NOT a UTI.

What if my loved one’s urine is dark or cloudy? Does that mean there is an infection?

No, not without other symptoms. Dark, cloudy urine may be a sign of dehydration. Increasing fluids is the treatment of choice in this situation.

How frequent do UTIs occur in residents who have catheters?

Frequently. That is one reason why federal regulations limit the use of indwelling catheters. Residents with catheters are more susceptible to UTIs, and they are also more susceptible to inappropriate treatment. Asymptomatic bacteruria can be identified in 95%-100% of patients who have indwelling catheters for over 30 days and for most residents who have a catheter for over two weeks. If an infection is suspected in a resident with a catheter, the catheter should be changed prior to obtaining a urine specimen.

Should the doctor wait to obtain a urine culture result before treating my loved one if he or she is very sick and a UTI is suspected?

No, due to frail conditions of most nursing home residents, treatment for a suspected symptomatic UTI should not be delayed while waiting the usual 2-3 days to receive culture and sensitivity results. A broad spectrum antibiotic that covers many bacteria can be ordered, and then when the culture and antibiotic sensitivity is returned, the physician can make sure that the appropriate antibiotic is being prescribed.

Is it necessary for my loved one to have another urine sample taken after a course of antibiotics for a UTI?

It is not necessary to reculture after a course of antibiotics if the resident appears to be responding to the therapy. Bacteria often persist after a course of antibiotics. This does not mean the treatment has failed.

Questions you can ask the nursing home about UTIs:

• How does the nursing home determine when to test residents for urinary tract infections?
• How does the nursing home determine whether to treat incontinent residents who have positive test results for UTIs but have no symptoms?
• How does the nursing home try to prevent urinary tract infections?
• How are residents with recurrent urinary tract infections evaluated?

Resources

Urinary tract infections. In: Beuben D, Herr K, Pacala J, et al, eds. Geriatrics at Your Fingertips. New York: American Geriatrics Society; 2000:70-73.

Association for Practitioners in Infection Control

Society for Healthcare in Epidemiology of America

Managing Urinary Tract Infections: Guide for Nursing Home Practitioners