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Care of the Aging Patient: From Evidence to Action |

Urinary Tract Infections in Older Women:  A Clinical Review

Lona Mody, MD, MSc1,2; Manisha Juthani-Mehta, MD3
[+] Author Affiliations
1Divisions of Geriatric and Palliative Care Medicine, University of Michigan, Ann Arbor
2Geriatric Research Education and Clinical Center, Veteran Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
3Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
JAMA. 2014;311(8):844-854. doi:10.1001/jama.2014.303.
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Published online

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.

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Suggested Approach to the Evaluation and Treatment of Older Women With a Suspected UTI

CFU indicates colony-forming units; hpf, high-powered field; UTI, urinary tract infection; WBC, white blood cells.

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