Urinary Tract Infections in Older Women

Abstract

IMPORTANCE Asymptomatic bacteriuria and symptomatic urinary tract infections (UTIs) in older women are commonly encountered in outpatient practice. OBJECTIVE To review management of asymptomatic bacteriuria and symptomatic UTI and review prevention of recurrent UTIs in older community-dwelling women. EVIDENCE REVIEW A search of Ovid (Medline, PsycINFO, Embase) for English-language human studies conducted among adults aged 65 years and older and published in peer-reviewed journals from 1946 to November 20, 2013. RESULTS The clinical spectrum of UTIs ranges from asymptomatic bacteriuria, to symptomatic and recurrent UTIs, to sepsis associated with UTI requiring hospitalization. Recent evidence helps differentiate asymptomatic bacteriuria from symptomatic UTI. Asymptomatic bacteriuria is transient in older women, often resolves without any treatment, and is not associated with morbidity or mortality. The diagnosis of symptomatic UTI is made when a patient has both clinical features and laboratory evidence of a urinary infection. Absent other causes, patients presenting with any 2 of the following meet the clinical diagnostic criteria for symptomatic UTI: fever, worsened urinary urgency or frequency, acute dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness. A positive urine culture (≥105 CFU/mL) with no more than 2 uropathogens and pyuria confirms the diagnosis of UTI. Risk factors for recurrent symptomatic UTI include diabetes, functional disability, recent sexual intercourse, prior history of urogynecologic surgery, urinary retention, and urinary incontinence. Testing for UTI is easily performed in the clinic using dipstick tests. When there is a low pretest probability of UTI, a negative dipstick result for leukocyte esterase and nitrites excludes infection. Antibiotics are selected by identifying the uropathogen, knowing local resistance rates, and considering adverse effect profiles. Chronic suppressive antibiotics for 6 to 12 months and vaginal estrogen therapy effectively reduce symptomatic UTI episodes and should be considered in patients with recurrent UTIs. CONCLUSIONS AND RELEVANCE Establishing a diagnosis of symptomatic UTI in older women requires careful clinical evaluation with possible laboratory assessment using urinalysis and urine culture. Asymptomatic bacteriuria should be differentiated from symptomatic UTI. Asymptomatic bacteriuria in older women should not be treated.

Impact of Extended-Spectrum β-Lactamase Production on Treatment Outcomes of Acute Pyelonephritis Caused by Escherichia coli in Patients without Health Care-Associated Risk Factors

“…However, this study demonstrates that more concern should be directed toward diabetic patients with previous APN. Diabetes increases the risk of UTIs (17,18) and their recurrence (19), which might place diabetic patients at risk of acquiring ESBL-EC as a result of repeated antibiotic exposure (1,(20)(21)(22). In this study, we found that the risk of acquiring ESBL-EC was markedly increased in diabetic patients with a history of APN, whereas either factor alone was not an independent risk factor.…”

Antibiotic Resistance among Urinary Isolates from Female Outpatients in the United States in 2003 and 2012

“…Although cost-benefit analyses and clinical practice guidelines discourage treatment of asymptomatic bacteriuria in older adults, this practice frequently occurs in ambulatory care (15). Once a diagnosis is established, antibiotic selection for UTIs among older outpatients should be based on previous uropathogen susceptibility profiles, when available, and be weighed carefully against potential adverse drug events, comorbidities, and medication interactions (15).…”

Urinary Tract Infection and Asymptomatic Bacteriuria in Older Adults

“…Fortunately, dysuria is identified reliably. The presence of dysuria appears to be one of the strongest predictors of bacteriuria plus pyuria in nursing home residents, and new dysuria is the most helpful clinical finding in identifying UTI in older adults [52–53]. …”