Urinary tract infections (UTIs) are one of the most common infections among adults and elderly patients, impacting their health and quality of life. As people age, physiological changes can lead to unique challenges in how UTIs present, are diagnosed, and treated. Recognizing these challenges is critical for healthcare providers and caregivers to ensure older adults receive the best possible care.
Understanding Urinary Tract Infections in the Non-Pediatric Population, the Adult and Elderly
UTIs occur when bacteria infiltrate the urinary tract, which encompasses the bladder, urethra, kidneys, and ureters. In elderly individuals, symptoms often diverge from the typical presentation seen in younger adults.
NOTE: It is Never normal to have bacteria in the urinary tract. A low intensity infection can persist in the background, and when the conditions are right, it can blossom into a life-threatening event.
In the presence of a low grade infection, one that you may not even know exists, something may occur. You may take a medication, undergo a procedure or develop an illness, and the next thing you know, you have a florid UTI.
Recently, I have found a series of patients that became ill following the use of Jardiance. Because this medication increases the amount of sugar dumped into the urine, it feeds the bacteria and they can grow very, very quickly and aggressively.
Medications that inhibit bladder emptying, such as oxybutynin, anti-histamines and opiods can worsen the situation due to incomplete bladder discharge.
Symptoms in the Non-Pediatric (Geriatric) Population
For instance, rather than experiencing the common signs of burning during urination, older adults might display confusion, increased incontinence, or vague abdominal pain. It's estimated that about 30% of older adults in nursing homes experience atypical UTI symptoms, which can complicate diagnosis and treatment.
Older adults face an elevated risk of UTIs due to various factors. For example, studies show that those with diabetes have up to a 40% higher incidence of UTI compared to their non-diabetic peers. Other contributing elements include weakened immune systems and anatomical changes in the urinary tract with age. Additionally, mobility issues, cognitive decline, and chronic conditions can further exacerbate the situation.

Diagnosis of UTIs in the Older Adult
A correct diagnosis is vital. It relies on understanding that the symptoms in older adults may differ from those found in younger individuals. Factors such as sudden changes in mental status or a decline in daily functioning should increase suspicion for a possible UTI.
Testing Protocols for UTI in Adult and Elderly Populations
A comprehensive diagnostic approach includes taking a thorough patient history, conducting a physical examination, and performing laboratory tests like a urinalysis and urine culture. An important aspect to note is the impact of previous antibiotic use on culture results. Analysis has shown that as many as 50% of older patients may have misleading urine cultures due to recent antibiotic treatment.
The testing begins with the ubiquitous 'Test Strip.' As easy as this would appear, it is shocking how many facilitis, including stand alone clinics, doctor's offices and ER's use these devices, but NEVER calibrate them. If you use the strip without computer-driven analyzers, the interpretation can become questionable, and without the analyzer, standardization and calibration is impossible.
Secondly, the the test strip may be only 30-40% sensitive to the presence of a urinary tract infection. If there is a moderate to high indication of a UTI, the next step is to perform a 'Bacterioscan,' microscopic examination or CATALASE reaction test. This looks for the presence of live bacteria in the urine. If this is possible, you have direct feed back that there is a problem.
The next step is to proceed with culture and sensitivity, often associated with an additional microscopic examination.
If indicated, PCR studies are ordered to look for the presence and speciation of the organism to permit more precise antibiotic selection.
Urinalysis and Culture
Urinalysis can reveal nitrites and leukocyte esterase, indicators of a bacterial infection. However, false positives can arise from contamination or other medical issues. Therefore, urine cultures, which are considered the gold standard, are crucial for confirming UTIs and guiding effective antibiotic therapy.

Management Strategies for UTIs in the Elderly
Prompt and effective management of UTIs is essential to prevent severe complications, such as kidney infections or sepsis. These conditions can pose significant risks, especially among older adults.
Pharmacological Interventions
First-line antibiotic options typically include nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin. Clinicians should be aware of potential drug interactions and the risks associated with polypharmacy in this age group. Research indicates that nearly 80% of elderly patients on multiple medications face significant interaction risks.
Non-Pharmacological Approaches
Beyond antibiotics, several non-drug strategies can help manage UTI symptoms and prevent recurrence. Proper hydration is essential; drinking an adequate amount of fluids daily can help flush out bacteria. Good hygiene practices also play a crucial role in minimizing the risk of reinfection, with studies showing that regular cleansing can lower UTI rates by 20%.
Preventative Measures
For those experiencing recurrent UTIs, preventive strategies may include the use of prophylactic antibiotics, cranberry products, or vaginal estrogen therapy in postmenopausal women, tailored to their individual health profiles and risks. Some evidence suggests that cranberry products can reduce UTI occurrences by as much as 30%.
Special Considerations
Cognitive Impairment
Diagnosing UTIs in patients with cognitive impairments or dementia can be especially challenging. Behavioral changes, such as increased agitation or withdrawal, might be the only indicators of an underlying infection. A more thorough examination of these symptoms is essential to ensure no other medical issues are being overlooked.
Hydration and Nutrition
Proper hydration and nutrition are critical in managing UTIs in older adults. Dehydration can significantly increase the risk of infections and worsen existing symptoms. Research shows that increasing fluid intake can reduce UTI rates in the elderly by approximately 50%, emphasizing the need to monitor hydration levels closely.
Treatment
Treatment approach will differ from patient to patient, influenced by patient age, gender, co-morbidities and physician preference. There are many ways from which to choose, the recommendations, below, are simply my own preferences and are by no means the only approach to this common clinical problem.
Protocol 1: Uncomplicated Cystitis in Women
This applies to non-pregnant women with no structural abnormalities or significant comorbidities.
First-Line Antibiotics:
Nitrofurantoin (Macrobid): 100 mg orally twice daily for 5 days.
Trimethoprim-Sulfamethoxazole (TMP-SMX): 160/800 mg orally twice daily for 3 days (if local resistance is <20%).
Alternative Antibiotics:
Fosfomycin Trometamol: 3 g orally as a single dose.
Pivmecillinam: 400 mg orally twice daily for 5 days (in regions where available).
Non-Antibiotic Adjuncts:
Increased hydration.
Cranberry extract for prophylaxis (limited evidence but widely used).
References:
Gupta K, et al. Infectious Diseases Society of America (IDSA) guidelines for uncomplicated UTI. Clin Infect Dis. 2011;52(5):e103–e120.
Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012;366(11):1028-37.
Protocol 2: Complicated UTIs and Pyelonephritis
Used for patients with structural urinary abnormalities, diabetes, or severe presentations (e.g., pyelonephritis).
First-Line Antibiotics (Outpatient):
Ciprofloxacin: 500 mg orally twice daily for 7 days (or 1 g extended-release once daily).
Levofloxacin: 750 mg orally once daily for 5–7 days.
First-Line Antibiotics (Inpatient):
Ceftriaxone: 1 g IV every 24 hours.
Piperacillin-Tazobactam: 4.5 g IV every 6–8 hours.
Monitoring and Adjustment:
Tailor antibiotics based on urine culture sensitivity results.
Repeat urinalysis after completion of treatment for persistent symptoms.
References:
Nicolle LE, et al. Complicated urinary tract infection in adults. Can J Infect Dis Med Microbiol. 2005;16(6):349–60.
Flores-Mireles AL, et al. Urinary tract infections: epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol. 2015;13(5):269-284.
Smaill FM, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev. 2019;11:CD000490.
Giesen LG, et al. Guidelines on management of urinary tract infections in pregnancy. BMJ. 2010;340:c220.
Lipsky BA, et al. Treatment of bacterial prostatitis and UTIs in men. J Urol. 2010;182(5):2431–41.
Wagenlehner FM, et al. Antimicrobial therapy for UTIs in 2020. Clin Microbiol Infect. 2020;26(8):871-879.
Harding GK, et al. UTI guidelines for adults. Can Med Assoc J. 1991;144(6):721-728.
Bader MS, et al. Risk factors for recurrent UTIs. Postgrad Med. 2020;132(1):26-33.
Final Thoughts
Managing UTIs in elderly patients requires a nuanced approach that prioritizes recognizing atypical symptoms, performing accurate diagnoses, and implementing tailored treatment strategies. Given the complexities associated with this age group, healthcare professionals must conduct thorough assessments and foster open dialogue with both patients and caregivers.
With attention to these details, healthcare providers can improve outcomes and enhance the quality of life for older adults. Continuous education and further research on the best practices for managing UTIs will play a vital role in advancing care for this vulnerable population.
Medical Treatment
References
Hooton, T. M. (2012). Urinary tract infections in the elderly. American Family Physician, 86(12), 1056-1063.
Albrecht, J. S., et al. (2018). The UTI incidence in adults aged ≥65 years; finding the elderly woman and the definitive diagnosis. Infection Control and Hospital Epidemiology, 39(9), 1090-1096.
Foxman, B. (2014). Urinary tract infection in adults: A Western perspective. Disease-a-Month, 60(12), 748-782.
Nicolle, L. E. (2005). Urinary tract infections in the elderly. Clinical Geriatrics, 13(1), 39-49.
Gumba, A., et al. (2021). A review of urinary tract infection in older adults. Geriatrics, 6(2), Article 16.
Ouslander, J. G., & Schnelle, J. F. (2000). Diagnosis and treatment of urinary tract infections in long-term care: Too little and too late. Journal of the American Geriatrics Society, 48(3), 218-222.
Schaeffer, A. J., & Schaeffer, E. M. (2005). The role of microbiology in the diagnosis of urinary tract infections. Urology, 66(5), 922-927.
Mody, L., et al. (2012). Recurrent urinary tract infections in older women: A qualitative study of patient and provider perspectives. Journal of the American Geriatrics Society, 60(12), 2308-2313.
Loeb, M., et al. (2005). Effect of a brief intervention on antibiotic prescribing for lower respiratory tract infections in older adults: A randomized controlled trial. Archives of Internal Medicine, 165(18), 2190-2197.
10. Kauffman, S. S. (2002). Urinary tract infections in the elderly: Principles of diagnosis and treatment. Current Opinion in Urology, 12(1), 75-78.
11. Ontiveros, B., et al. (2020). Management of urinary tract infections in older adults: A practical guide. Geriatric Nursing, 41(3), 364-367.
12. Magill, S. S., et al. (2014). Multistate Point-Prevalence Survey of Health Care–Associated Infections. New England Journal of Medicine, 370(13), 1198-1208.
13. Wang, C. H., et al. (2015). The impact of urinary tract infections on the quality of life for elderly patients. Annals of Long-Term Care: Clinical Care and Aging, 23(3), 20-25.
14. Sullivan, J. E., et al. (2016). Clinical guideline for the management of urinary tract infections. Canadian Journal of Urology, 23(4), 8676-8689.
15. Hossain, K. M., et al. (2021). Antibiotic management for urinary tract infections. American Family Physician, 104(3), 213-220.
David S. Klein, MD, FACA, FACPM
1917 Boothe Circle, Suite 171
Longwood, Florida 32750
Tel: 407-679-3337
Fax: 407-678-7246