Urinary tract infections in the elderly

Urinary tract infections

Urinary tract infections (UTI’s) are the most frequently encountered infections in aged care facilities, accounting for at least 30% of all infections. UTI’s are also often a reason for client hospitalisation and also are responsible for considerable antibiotic use at the aged care facility where I work as an Infection Control Coordinator.

In a healthy person, the upper urethra, the urinary bladder and the regions of the upper urinary tract are sterile. In contrast, the lower urethra has a normal flora that includes, Staphylococcus epidermidis, Enterococcus faecalis, Ecoli and Proteus to name a few. The upper regions of the urinary tract are normally kept free of microorganisms by a variety of defence mechanisms. One of the more critical of these is the normal flow of urine that washes over the surface of the urethral epithelium, flushing away micro-organisms. The lower urethra is also cleaned by this mechanism. but re-colonisation there occurs much more quickly.





E coli is the most common cause of Urinary tract infection. Many of the micro-organisms that we see causing UTI’s have increased antimicrobial resistance patterns.  Factors that may contribute to antibiotic resistance include repeated exposure to antibiotics due to treatment of recurring infections, increased use of antibiotics in aged care, and increased opportunities for transmission of micro-organisms among clients due to multiple contacts with healthcare workers.

Clinical Presentation of a Urinary tract infection

The diagnosis of a UTI in an elderly client is often difficult because cognitively impaired clients may not be able to recall or communicate their symptoms. Various illnesses may present with non-specific symptoms similar to a UTI, (for example fever or altered mental status) making diagnosis challenging, and clients may not present with classic genitourinary symptoms.  Sometimes frail elderly clients may not present with a classic febrile response, they may be afebrile or even hypothermic. Despite the potential for atypical presentation, most serious UTI’s will nevertheless be associated with fever and classic genitourinary symptoms.

Symptoms of a UTI (as per the McGeer definitions)

To be classified as a UTI the following criteria are to be present:

Both criteria 1 and 2 must be met:

Criteria 1

The client has at least one of the following signs and symptoms

    1. Acute dysuria (difficult or paintful passing of urine) or acute pain, swelling or tenderness of the testes, epididymis, or prostate


    1. Fever and at least 1 of the following
  1. Acute pain or tenderness
  2. Suprapubic pain
  • Gross hematuria
  1. New or marked increase in incontinence
  2. New or marked increase in urgency
  3. New or marked increase in frequency


    1. In the absence of fever, then 2 or more of the following
  1. Suprapubic pain
  2. Gross hematuria
  • New or marked increase in incontinence
  1. New or marked increase in urgency
  2. New or marked increase in frequency

Criteria 2  

Positive urine culture

Care should be taken to rule out other causes of these symptoms.

Signs and Symptoms not specific for UTI

The following signs and symptoms may indicate an illness or an infection at another site, or even dehydration, and therefore are not necessarily indicative of a UTI:

  • Worsening of functional status
  • Worsening of mental status, increased confusion, delirium or agitation
  • Increased falls (new or more often)

At the facility I work at, unless the clients medical status is declining rapidly or the client is on a fluid restriction, we encourage fluids for 24 hours and then reassess. (In consultation with the residents doctor)

After 24 hours if typical symptoms for a UTI develop, we treat as for a UTI.

If non-specific symptoms continue without development or typical symptoms of a UTI consider an alternative diagnosis or infection at other site.(In consultation with the residents doctor).

If symptoms resolve after 24 hours of fluids, no further work up is required.

*It is important to note that cloudy and turbid urine can occur in normal urine and is not considered an indicator of a UTI.

*Malodorous or smelly urine may be caused by poor diet or hygiene.


Laboratory diagnosis:

Urine culture – A urine culture should always be obtained to confirm a diagnosis of UTI whenever signs and symptoms suggestive of a UTI are present. In addition to providing confirmation of diagnosis, a urine culture will identify the causative organism and provide information required for the appropriate selection of an antibiotic.

Significant bacteriuria is usually defined as a count of 105 cfu/mL in a properly collected MSU.

A positive urine culture without accompanying symptoms in the client is not considered a UTI. The client must have symptoms plus a positive urine culture.


A number of laboratory findings can indicate improper specimen collection. One or more of the following in a MSU would cast doubt on the quality of the collected urine:

  • Greater than normal numbers of epithelial cells
  • Culture of more than one type of bacterium (since most UTI’s are caused by a single organism)
  • The presence of organisms without white cells (in some cases)
  • The presence of gram-positive rods (ie lactobacilli from vaginal flora).


Treatment and Management

Ensure proper hydration and nutrition

Dehydration results in concentrated urine and less frequent urinating, both these conditions support bacterial growth in the bladder. Dehydration is a concern for clients who may also be on medications that increase diuresis or who have a disease such as diabetes that may cause excessive urination. Adequate hydration is indicated by pale-coloured urine, moist mucous membranes, and/or normal specific gravity of the urine.

Provide good perineal hygiene

Ensure that personal hygiene is performed correctly to prevent prolonged contact with urine or faceces

Antibiotic therapy

The choice of antimicrobial therapy should be based on culture and sensitivity results. This is particularly important in nosocomial or recurrent infections, which may be caused by antibiotic resistant organisms.


Supportive measures such as raising of the pH of the urine with urinary alkanisers ( to slow bacterial growth) and high fluid intake (to help flush out organisms) may also be instituted

*Disclaimer: Any and all treatment and management should be done in consultation with the residents doctor. This post should not be taken as recommendations for treatment.

So are Urinary tract infections the most common type of infection you are seeing in aged care? What are you doing to manage the infections in your facility? It would be great to hear what others are doing and get your feedback.

The next post will be on Respiratory tract infections, so until next time take care,




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Royal Australian College of General Practitioners, Medical care of older persons in residential aged care facilities, Silver Book, 4th edition, 2006.

American society of Nephrology, Juthani-Mehta, M, Chapter 32: Urinary tract infections in Elderly Persons

Brightwater Nurse practitioner clinical protocol, Managing urinary tract infections:


Blair, K, Evidence-based management of Urinary tract Infections across the lifespan: current update, Journal for Nurse Practitioners, 2007, 3(() 629-632

Beveridge, L, Davey, P, Phillips, G, McMurdo, M, Optimal management of Urinary tract infections in older people, Clinical Interventions in Ageing, 2011, 6, 173-180:


Toward Optimized Practice (TOP), “Guideline for the Diagnosis and Management of Urinary Tract Infections in Long Term Care,” (Edmonton, Alberta: TOP, 2010). [http://www.topalbertadoctors.org/cpgs.php?sid=15&cpg_cats=66 – retrieved March 2012]

Nicolle LE and Society for Healthcare Epidemiology of America (SHEA) LongTermCare Committee, “Urinary tract infections in LongTermCare Facilities (SHEA Position Paper),” Infection Control and Hospital Epidemiology 22, no. 3 (2001): 167175.

Beier MT, “Management of urinary tract infections in the nursing home elderly: a proposed algorithmic approach,” International Journal of Antimicrobial Agents 11 (1999): 275284. [http://download.journals.elsevierhealth.com/pdfs/journals/09248579/PIIS0924857999000308.pdf – retrieved April 2012]

Mentes J, “Oral hydration in Older Adults: Greater awareness is needed in preventing, recognizing and treating dehydration,” American Journal of Nursing 106, no. 6 (2006): 4049. [http://journals.lww.com/ajnonline/Fulltext/2006/06000/Oral_Hydration_in_Older_Adults__Greater_awareness.23.aspx – retrieved March 2012]

National Healthcare and Medical Research Council (NHMRC), “Australian Guidelines for the Prevention and Control of Infection in Healthcare,”. (Canberra, AU, NHMRC, 2010). [http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cd33_complete.pdf – retrieved December 2012]


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