U r i n a r y Tr a c t

Infections
Janice A. Litza, MD*, John R. Brill, MD, MPH

KEYWORDS
 Urinary tract infection  Pyelonephritis
 Asymptomatic bacteriuria

Urinary tract infection (UTI) is the most common urological disorder among men and
women, with most cases presenting to primary care physicians in the outpatient clin-
ical setting.1,2 UTIs represent 4% of all outpatient physician visits.3 Of the total number
of visits for UTI, 52% of patients present to primary care clinics, and 23% present to
emergency departments.4 UTIs are also the most common nosocomial infections of
hospitalized patients. As men and women become older, UTI becomes more likely,
and UTIs lead to more hospital-based care.1,2
A woman’s lifetime risk of UTI is greater than 50%.2 Women develop four times
more urinary tract infections than men because of anatomic differences including
a shorter urethra and because of normal vaginal flora that colonize the external
urethra.5,6 Infection in women most often results from perineal or periurethral bacteria
that enter the urethra and ascend into the bladder, often in association with sexual
activity, or due to mechanical instrumentation such as catheterization.5,6

ASYMPTOMATIC BACTERIURIA

Asymptomatic bacteriuria (ASB) is the presence of 100,000 microorganisms per milli-

liter of urine without clinical symptoms.5 Usually no treatment is needed. Screening for
ASB is not recommended for nonpregnant women,6 elderly living in the community,7
diabetic women,8 institutionalized elderly,9 or persons with spinal cord injuries.9
However, screening with treatment of positive cultures is recommended for pregnant
women in the first trimester.5–7

UNCOMPLICATED UTIS

An uncomplicated UTI is diagnosed in patients with cystitis symptoms who have

normal urinary tract anatomy, no fever, no kidney disease, and no contributing medical

Department of Family Medicine, University of Wisconsin School of Medicine and Public Health,
Milwaukee Academic Campus, 2801 West Kinnickinnic River Parkway, #250, Milwaukee,
WI 53215, USA
* Corresponding author.
E-mail address: [email protected]

Prim Care Clin Office Pract 37 (2010) 491–507

doi:10.1016/j.pop.2010.04.001 primarycare.theclinics.com
0095-4543/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
492 Litza & Brill

problems such as diabetes, neurogenic bladder, or renal stones.5,10,11 Characteristic

symptoms of cystitis include dysuria, urgency, increased frequency, pyuria, and
bacteriuria on urinalysis, and sometimes suprapubic pain, fullness, and hematuria.5,6
No long-term adverse effects have been seen on renal function or increased mortality
with acute uncomplicated UTI in the nonpregnant female population; therefore, treat-
ment goals are aimed at symptom resolution.10
The differential diagnosis for uncomplicated UTI includes
Acute urethritis caused by sexually transmitted infections (STIs), often Neisseria
gonorrhea or Chlamydia trachomatis.
Irritative voiding symptoms due to urethral syndrome, interstitial cystitis, recurrent
UTI,12 vaginitis, vulvovaginitis, or dysmenorrhea.7

Using Clinical Predictors

Helpful positive predictors include symptom onset with recent sexual intercourse,
history of pyelonephritis, and resolution of symptoms within 48 hours of starting anti-
biotic treatment.12 Negative predictors include nocturia more than twice per evening,
and persistent symptoms between acute episodes; these patients should undergo
work-up for other causes. Neutral predictors, neither favoring nor disfavoring the diag-
nosis of UTI, include hematuria and dyspareunia.12 Patients with unsure pregnancy
status should be tested,7 as diagnostic criteria and treatment options differ.

Diagnostic Testing
Many studies and organizations refer to urine dipstick testing that is positive for leuko-
cyte esterase or nitrite as confirmatory for uncomplicated UTI.5–7 The European Asso-
ciation of Urology also recommends urine microscopy for white and red blood cells
and nitrites.9 In one study, the absence of four markers (blood, leukocyte esterase,
nitrite, and protein) on urine dipstick at the point of care had a 98% negative predictive
value, with sensitivity of 98.3% and specificity of 19.2%.13 This conflicts with another
study in which patients with clinical symptoms but negative urine dipstick symptom-
atically improved after taking antibiotics.13 If treatment is driven by symptom reduc-
tion, use of empiric antibiotics for a 3-day course in low-risk patients with dysuria,
frequency, and absence of vaginal symptoms can be recommended without use of
dipstick, with 80% accuracy.13,14
Even with clinical predictors indicating greater than 90% probability of UTI, many
physicians also order urine culture and sensitivities,14 which add cost and laboratory
workload and make little difference in the treatment of uncomplicated UTIs.14,15 Urine
culture is defined as positive for bacteriuria when there is isolation of no more than two
microorganisms, each with at least 100,000 cfu/mL, from a clean voided midstream
urine sample.5,16 Changing this criterion to 1,000–10,000 cfu/mL would improve sensi-
tivity to >90% without much loss of specificity,5,9 and has been used by some practices.

Uropathogens
Escherichia coli remains the primary agent responsible for UTIs in both outpatient and
inpatient settings.5,6,17 Other common uropathogens are Enterococcus faecalis,
Enterobacter species, Staphylococcus saprophyticus, Klebsiella pneumoniae, Proteus
mirabilis, and Pseudomonas species.5,6,10,18 Knowing local variations in sensitivity
among the common uropathogens, in both inpatient and outpatient settings, can
help physicians make the best treatment choices. First-line antibiotics may have
better sensitivity rates in the outpatient setting compared with the inpatient setting.18
 Urinary Tract Infections 493

Treatment
Many studies have demonstrated that a 3-day antibiotic course is effective and cost-
effective in 90% of uncomplicated UTIs.2,5,6,19 A 1-day course is ineffective in most
cases.5,10 Treatment for longer than 3 days is reserved for complicated UTIs.9,10
One source suggests symptomatic treatment only until culture results are available,
to reduce unnecessary prescribing of antibiotics.7
Antibiotics for empiric treatment of uncomplicated UTI include

First-line antibiotic: trimethoprim/sulfamethoxazole (co-trimoxazole) in communi-

ties with resistance rates for E coli less than 20%.5,7,9 Avoid in women who
have been treated within 6 months, as they are more likely to have resistant
organisms.7,10
Second-line antibiotics, or first-line in resistant communities: fluoroquinolones,
such as ciprofloxacin, levofloxacin, norfloxacin, and ofloxacin. Their efficacy is
comparable to co-trimoxazole, but increasing resistance rates have been
noted.10
Alternates: third-generation cephalosporins, nitrofurantoin, fosfomycin.
The following should not be used unless indicated by individual patient culture
sensitivities: first- or second-generation cephalosporins,5,10 ampicillin,5,10 and amox-
icillin with clavulate.5,6,10

Follow-Up
Follow up is generally unnecessary for uncomplicated UTI unless there is treatment
failure, or if clinical signs or symptoms suggest involvement of the upper urinary tract.7
Cultures are indicated if symptoms persist after standard therapy,6 or if symptoms
recur 2 to 4 weeks after treatment.7,9

Use of Protocols for Uncomplicated UTIs

Empiric treatment based on suggested guidelines and protocols appears to be cost-
effective, although some groups still advocate use of urine dipstick and culture to
confirm diagnosis and allow accurate antimicrobial choices. Protocols that include
nurse-directed triage and phone triage have not shown adverse clinical
consequences.18
If the following criteria are met, then empiric antibiotics can be prescribed using
a first-line agent for a 3-day course without further evaluation7,18:

Women younger than 55

No other comorbidities
Not postmenopausal
Not pregnant
No recent UTI
No vaginitis or cervicitis symptoms
Presence of increased urinary frequency
Presence of dysuria.
One outpatient family medicine study evaluated the use of standard guidelines
using risk stratification and empiric therapy and found that use of electronic health
record (EHR) templates increased compliance with protocols, reducing variability in
use of urine dipstick, culture, and antibiotics.18
494 Litza & Brill

ACUTE PYELONEPHRITIS

Acute pyelonephritis is an infection of the kidney that starts either from ASB or from an
ascending bladder infection.6 Pyelonephritis can develop from an uncomplicated UTI;
however, it is more commonly seen in the setting of obstruction, urinary tract malfor-
mations, urolithiasis, or pregnancy.6 Typical symptoms include flank pain, chills, fever
(>38 C), nausea or vomiting, and costovertebral angle tenderness. Common symp-
toms of cystitis also can be present, especially dysuria, increased frequency, and
urgency.5–7 Uncomplicated pyelonephritis can be treated as an outpatient with
empiric therapy if only mild symptoms are present and the patient does not have
significant nausea or vomiting to interfere with oral antibiotics.10 Urine culture should
be obtained at the initial evaluation. First-line antibiotic choices are the same as for
uncomplicated UTIs, and the duration of therapy is typically 10 to 14 days. Hospital-
ization is appropriate if complicating factors cannot be ruled out, the patient clinically
appears septic, or is unable to tolerate oral medication.6,7 A clinical response is
expected in 48 to 72 hours. If there is no improvement at that time, it is appropriate
to evaluate for stones and obstruction.5,6,9

RECURRENT UTI

Recurrent UTI is defined as at least three episodes of symptomatic uncomplicated UTI

with one or more documented positive cultures in 12 months,6,12 without complicating
factors. A relapse is infection with the same organism as the previous UTI.5 A reinfec-
tion is when the initial UTI is treated, the patient becomes asymptomatic with a nega-
tive culture in between, and then develops symptoms again, or when the second
infection is caused by a second organism.5,6 American College of Obstetricians and
Gynecologists (ACOG) data show reinfection occurs in 25% to 50% of women within
the first year of an initial uncomplicated UTI, and recurrent UTI occurs in 3% to 5% of
women.5
Patient education on the following behaviors has not been shown to reduce recur-
rent UTIs: wiping techniques, hygiene, postcoital voiding, douching, use of hot tubs,
wearing of pantyhose, or timing of voiding.6,7
Age-based initial evaluation of recurrent UTI might include assessment for
Adolescent women (undiagnosed congenital abnormalities and onset of sexual
activity)
Premenopausal women (frequent/recent sexual activity, diaphragm use, spermi-
cide use, increasing parity, diabetes, obesity, sickle cell trait, and renal
stones5,7)
Postmenopausal women (tumors, obstructive problems, detrusor failure, genital
infection,9 vaginal atrophy, incontinence, incomplete bladder emptying,
prolaps5,7).
After ruling out complicating factors and changing modifiable factors, the following
are possible treatment regimens:
Antimicrobial prophylaxis with first-line agent (reduced dose daily9; after sexual
intercourse6,7,9; three times a week for 6 months, after infection clearance is
documented by a negative culture7).
Patient initiated treatment at an early symptom stage.5,7,9,10 Patients can usually
accurately self diagnose after the first infection.7
Food additive prophylaxis (Cranberry extract6,9 inhibits adhesion of certain
bacteria, decreasing subsequent infection.19 Improvement is seen only in young
 Urinary Tract Infections 495

and middle-aged women with recurrent UTI.19 Further studies are needed to
determine the optimal dosage and administration.20 Cranberry extract is not
indicated for treatment of UTI. Lactobacilli probiotics can restore the urogenital
flora and decrease uropathogens.21).
Methenamine hippurate, a nonspecific antibacterial agent, may be effective for pre-
venting UTI when no renal abnormalities are present. In one trial, it resulted in
symptom reduction after 1 week of therapy.22
Local hormonal treatment in postmenopausal women.10 In a Cochrane review,
vaginal estrogens were more effective than placebo at preventing recurrent
UTIs. Oral estrogens offered no benefit in reduction of recurrent UTI. More
studies are needed to determine the best type of estrogen and most effective
duration of therapy.23

MEN

Only 20% of UTIs occur in men. Male UTI rates increase dramatically with age, and most
are complicated by prostate pathology.1 Men at low risk with a first UTI may be treated
using a 3-day course with a first-line agent.14 Low-risk men are defined as under age of
45, with no prostatitis, urethritis, obstructive symptoms, or hematuria.14 Urological
evaluation is recommended in adolescents, men with febrile UTI, pyelonephritis, recur-
rent infections, or when complicating factors are suspected.9 The European Associa-
tion of Urology recommends a 7-day course with fluoroquinolones even in
uncomplicated male UTI.9 If fever is present, then a 2-week course of therapy is recom-
mended, since prostatic involvement is common.9 In contrast to uncomplicated UTI in
women, a urine culture is recommended to confirm the diagnosis in all men. No further
evaluation or imaging is needed if there is a positive culture along with resolution of
symptoms in a man’s first uncomplicated UTI. If symptoms persist or culture is negative,
imaging with abdominal ultrasound is a reasonable next step.

NOSOCOMIAL UTIS

There has been a recent interest in prevention of catheter-associated UTI (CAUTI) in

the hospital setting, since the Centers for Medicare and Medicaid Services (CMS)
identified this as one of six unacceptable diagnoses for payment if UTI was not present
on admission.24,25 As of 2009, a CAUTI is one that occurs in a patient who had an
indwelling urethral catheter at the time of or within 48 hours of the event.26 A previous
definition included those with a catheter within 7 days of the event.16 CAUTIs account
for 80% of nosocomial UTIs and 40% of all nosocomial infections.24,26–29 Currently,
the mechanism for infection is thought to be bacterial biofilm formation on the cath-
eter; the longer the catheter is in place, the greater the risk of symptomatic
CAUTI.24,30–35
The initial recommended strategy for patients who become symptomatic with
a urinary catheter is to assess for catheter removal or replacement,36 obtain urine
and blood cultures,36 begin treatment with first-line antibiotic agents based on local
susceptibility patterns, and change to a specific antibiotic when sensitivities are avail-
able.36 The source of urine for urine cultures should ideally be from a newly- placed
catheter or urine obtained after removal.37 Prevention of nosocomial UTIs involves
using protocols for nursing, emergency rooms,38 and physician order sets39 to cath-
eterize only for specific indications, removing the catheter as soon as possible, using
sufficient lubricant with insertion, and inserting the smallest caliber catheter in
a closed, gravity-dependent system.36–38,40,41 Routine urinalysis and cultures are
not recommended for patients who have been catheterized unless they develop
496 Litza & Brill

symptoms suggestive of a UTI.37 Likewise, treatment of ASB in this clinical situation is

not recommended. The short-term use of silver- and antibiotic-coated catheters
reduced UTI rate, but longer-term use of these catheters and maintenance of this
reduction has yet to be assessed.36,42,43 Application of topical antiseptics or antibi-
otics to the meatal opening is not currently recommended.36,44,45 Currently, prophy-
lactic antibiotics in patients with short-term catheters are not routinely
recommended.36 However, studies continue to show mixed results from various
prophylactic regimens just before or immediately following catheter removal.46,47

PEDIATRIC PATIENTS

Infants and children diagnosed with UTIs more often present to emergency rooms
than outpatient clinics.48 In any setting, prompt identification, treatment, and follow-
up of pediatric UTIs are key to preventing long-term complications.
When considering whether a UTI is the cause of unexplained fever in infants or chil-
dren, physicians should assess pretest probability, using prevalence data by age,
gender, race, and for male patients, circumcision status. A meta-analysis by Shaikh
and colleagues49 in 2008 showed that demographic and clinical characteristics are
useful to help determine whether further testing is needed.49 Cincinnati Children’s
Hospital Medical Center50 and a recent review in Journal of the American Medical
Assocation51 have algorithms and worksheets for determining the pretest probability
of a child having a UTI. The overall risk for all children with unexplained fever having
a urinary tract infection is 7% to 9%.52,53

Initial Evaluation
If the pretest probability of UTI is less than 2%, observation with close follow-up in 24
hours can be considered.51 If the pretest probability is greater than 2%, or if other risk
factors are present, such as a history of UTI, temperature greater than 39 C, ill appear-
ance, suprapubic tenderness, or fever greater than 24 hours, then testing and imme-
diate treatment might be warranted.51,54,55 The 2007 National Institute for Health and
Clinical Excellence (NICE) guidelines suggest obtaining a clean urine specimen
(bagged or midstream).54 A negative dipstick is helpful in ruling out a UTI, while
a test positive for leukocyte esterase, nitrite, or bacteriuria can guide treatment51
and can help determine if catheterization or suprapubic aspiration is necessary.54
Any positive urinalysis in children should be followed by a urine culture.52 Imaging
considerations are made based on risk factors, initial presentation, and response to
treatment in the first 48hours. Hospitalization typically is recommended for infants
younger than 1 year, ill-appearing children, and patients for whom follow-up might
be difficult.50,56,57

Initial Antibiotic Treatment

Standard treatment for a first pediatric UTI includes a 7 to 14 day course of antibi-
otics,50,51,54,58 selected based on local resistance patterns. The antibiotics most often
used include parenteral ceftriaxone, cefotaxime, ampicillin, and gentamicin, and oral
co-trimoxazole, cefixime, and cephalexin.50,53,56 A Cochrane review in 2005 recom-
mended a 3-day antibiotic course in well-appearing children over 3 months of age,
but this does not appear to be widely accepted in the clinical protocols reviewed.59,60

Prophylactic Antibiotics
Recommendations for prophylactic antibiotics in children with renal scarring or vesi-
coureteral reflux have undergone significant changes.50,53,54,58,61 Routine prophylaxis
 Urinary Tract Infections 497

may not be indicated after an uncomplicated first UTI, or with absent/mild grade 1 to 3
vesicoureteral reflux.55,61–64

Imaging
The main goal of imaging is to evaluate for obstruction, pyelonephritis, previously
undetected anomalies, vesicoureteral reflux, and renal scarring.50,53,58 These findings
may be important in deciding which children require antibiotic prophylaxis. Infants and
children up to the age of 24 months with UTI have a 20% to 24% incidence of
vesicoureteral reflux of all grades, with 8% to 9% showing other urinary tract abnor-
malities.65 Imaging recommendations vary by institution, as more evidence-based,
cost-effective, and patient-centered approaches are sought.

Imaging Studies
Renal ultrasound
This is helpful for anatomic variations, obstruction, pyelonephritis, and changes
such as hydronephrosis that may suggest vesicoureteral reflux.
It is the least invasive, has no radiation exposure; therefore renal ultrasound is the
most common initial test.66,67

Cystogram
The voiding cystourethrogram (VCUG) is the most invasive, requiring urethral cath-
eterization and radiation exposure with fluoroscopy. It is used to detect pyelo-
nephritis and to grade vesicoureteral reflux.
The radionuclide cystogram (RNC) is less invasive and less detailed compared with
traditional VCUG. It requires radionuclide exposure.

Tc 99 m dimercaptosuccinic acid renal scanning

This is useful for detecting renal scarring and acute renal abnormalities. It can be
used initially or as a follow-up study.68
Tc 99 m dimercaptosuccinic acid renal scanning (DMSA) involves intravenous
injection and radiation exposure.58
The cost is higher cost and it requires radionuclide exposure.
Neonates and children with recurrent or atypical UTI (seriously ill, poor urine flow,
abdominal or bladder mass on examination, elevated creatinine, septicemia, no
response within 48 hours of antibiotics, or non-E coli infection) should have renal ultra-
sound during the acute infection and VCUG on follow-up, with possible
DMSA.53,54,58,69

Imaging Guideline Highlights

The American Academy of Pediatrics 1999 guidelines highlight the following: 2
months to 2 years—renal ultrasound and either VCUG or RNC.53
NICE 2007 guidelines emphasize

Younger than 6 months with good response: renal ultrasound in 6 weeks, no further
imaging54
6 months to 3 years with good response: no imaging
Greater than 3 years with good response: no imaging
Cincinnati Children’s Hospital evidence-based guidelines from 2006 emphasize50
498 Litza & Brill

All males, females younger than 3 years, and females from age 3 to 7 years with
fever of at least 38.5 C: ultrasound and cystogram
Females older than 3 years without fever: may not need imaging after first UTI.

Guidelines from the Albany Medical Center58 include

All children younger than 5 years with febrile UTI: ultrasound and VCUG
All males with UTI: ultrasound and VCUG
Females younger than 2 years: ultrasound and VCUG
Females 2 to 3 years: ultrasound
Newborns with reflux: DMSA scan, possibly additional testing.

One additional tool is serum procalcitonin, used as an indicator of systemic upper

UTI.58,70 It is potentially a less invasive clinical predictor of infants at low risk. Procal-
citonin becomes elevated within 2 to 6 hours of initial significant bacterial infection.
Levels higher than 0.5 ng/mL are associated with renal parenchymal damage.70 Newer
guidelines might include this marker if further studies confirm its usefulness.

IMMUNOSUPPRESSED PATIENTS

There is sparse literature on UTIs in immunosuppressed hosts, perhaps because

opportunistic infections are more likely to manifest in other organ systems.71 Viruses
such as BK virus, adenovirus, and cytomegalovirus are a relatively commonly cause of
UTIs, particularly hemorrhagic cystitis, in the immunocompromised.72 UTIs are
common in renal transplant patients, particularly in the first 3 months after transplan-
tation.73 An international guideline includes the following recommendations for
prevention and treatment of UTIs in renal transplant patients:
Treat infection in the recipient before transplantation.
Culture both the donor tissue sample and perfusate.
Use perioperative antibiotic prophylaxis.
Continue low-dose co-trimoxazole for 6 months.
Treat overt infection with a quinolone or co-trimoxazole for 10 to 14 days.74

PATIENTS WITH SPINAL CORD INJURY

Urologic complications are a primary source of morbidity and until recently were the
leading cause of death for the estimated 260,000 Americans living with spinal cord
injury (SCI).75 Factors leading to UTIs in SCI patients are impaired voiding, stone
formation secondary to acute bone loss, and altered sensation and symptoms. Vari-
ables linked to development of UTI in spinal cord injured patients are prior history of
UTI, higher degree of functional impairment, and lack of exercise.76 Table 1 summa-
rizes methods used to decrease the incidence of UTIs in SCI patients. For those using
intermittent catheterization, a Cochrane review concluded that various alternative
approaches are no better than clean technique with a simple catheter. Although
most guidelines recommend intermittent catheterization,84 indwelling suprapubic
catheters may be preferred by patients and caregivers. A recent review by Sugimura
found a relatively low rate of infection or other complications with this approach.85
Darouiche observed that using an antimicrobial securing device (Stat-Lock TM) with
indwelling catheters reduced UTI rates.86
Screening for UTIs in SCI patients is not recommended, as there is a high rate of
ASB and no demonstrable benefit to treatment without symptoms.87 Observation
of a high rate of UTIs following bladder testing and manipulation suggests use of
 Table 1
Strategies for reducing UTI in patients with spinal cord injury

Strategy Subject Characteristics Comparison Effect Comment

Hydrophilic catheter77 Self-intermittent catheterization Noncoated catheters 20% reduction in total UTIs Small sample (45 total)
Hydrophilic catheter78 123 male patients, > or 5 16 y Noncoated catheters 18% reduction in percentage
and SCI within 6 months of patients without UTI
Escherichia coli Intermittent Catheterization Historical 62% achieved colonization with Small sample (13 subjects)
83,972-coated catheters79 protective strain; these historic controls, only E coli
patients had 66% reduction UTIs reported
in E coli UTIs
Clean technique80 Tetraplegic patients requiring Sterile technique No difference in number of UTIs Small sample size (36 subjects)
assisted intermittent or time to develop UTI
catheterization
Weekly oral cyclic Clean intermittent Historical controls 81% reduction in symptomatic Small sample size (38 subjects)
antibiotic (WOCA)81 catheterization, frequent UTIs UTI
Cranberry tablets82 Documented neurogenic Placebo 70% relative reduction of UTIs Small sample size (47 total)
bladder

Urinary Tract Infections

Methenamine hippurate Neurogenic bladder, mostly Placebo No difference in UTI-free period 345 total subjects
or cranberry tablets83 community-dwelling

Abbreviation: SCI, spinal cord injury.

499
500 Litza & Brill

antibiotic prophylaxis for SCI patients undergoing procedures.88 A trial of a formal

patient education program did not reduce UTI recurrence, but did enhance the SCI
patients’ sense of control.89 UTIs may present as increased spasticity or autonomic
dysreflexia in quadriplegic patients.90 Treatment consists of 10 to 14 days of a fluoro-
quinolone antibiotic, guided by culture and sensitivity.

SENIORS

UTIs occur frequently in the elderly, and contribute significantly to morbidity and
mortality. UTIs are a principal cause of falls in nursing home patients,91 especially
those with dementia.92 UTIs frequently complicate acute medical conditions such
as stroke.93 A clear association exists between UTI and acute coronary syndrome,
suggesting that systemic inflammation may even precipitate coronary ischemia.94
Several factors make the diagnosis of UTIs in the elderly challenging. ASB is highly
prevalent. In a community-based study, increasing age, incontinence, and impaired
mobility increased ASB prevalence; a woman over 80 with urinary incontinence and
needing support to walk had a risk of nearly 50% of ASB.95 Neither screening for
ASB nor treatment of this condition in the elderly is recommended.8,87 Diagnosis of
UTI in nursing home residents is often difficult because of atypical symptoms. One
study found the most useful signs and symptoms to be dysuria (relative risk [RR] 5
1.58), change in character of urine (RR 5 1.42), and change in mental status (RR 5
1.38).96 In patients with comorbidities, especially pulmonary disease, even diagnostic
experts frequently cannot agree whether a patient has bacteriuria or a UTI.97
Several studies note the connection between impaired mobility and UTI develop-
ment. Mobile nursing home patients had nearly a 70% less likelihood of being hospi-
talized for UTI than immobile counterparts, and maintaining or improving mobility
reduced this risk by 39% to 76%.98 Other strategies effective at reducing UTIs include
avoiding catheterization and having a physician visit at the time of nursing home
admission.98 In older women with recurrent UTIs, daily cranberry extract was as effec-
tive as and safer than trimethoprim for prophylaxis.99 Postmenopausal women with
recurrent UTI treated with intravaginal estrogen have significantly reduced rates of
recurrence.9
CAUTIs are a particular problem for the elderly. In 2004, Gokula found that less than
half of urinary catheters placed in hospitalized seniors were indicated.100 In addition to
general guidelines for prevention of CAUTIs, recommendations for the elderly include
Avoid use of urinary catheters in nursing home residents for management of incon-
tinence (category 1b)
Consider using external catheters (eg, condom catheters) as an alternative to
indwelling urethral catheters in cooperative male patients without urinary reten-
tion or bladder outlet obstruction (category 2)
Appropriate indications for use of indwelling catheters in seniors include

To assist in healing of open sacral or perineal wounds in incontinent patients

To allow prolonged immobilization of potentially unstable thoracic or lumbar spine
injuries or pelvic fractures
To improve comfort for end-of-life care.84
Recent studies have challenged the traditional notion that age alone constitutes
a complicated UTI. Grover studied older women seen for UTI in a family practice
center and concluded that treatment employed with co-trimoxazole and without the
use of culture and sensitivity may be effective for appropriately selected older
 Urinary Tract Infections 501

women.101 A Cochrane review found that otherwise healthy elderly patients given
longer than 3 days of antibiotics had significantly higher rates of adverse drug reac-
tions, with no improvement in efficacy.102 Thus, evidence suggests that the type
and duration of treatment should be based on comorbidities and complications, not
age.

DIABETIC PATIENTS

ASB is common in diabetic patients. Although diabetics with ASB have higher rates of
developing symptomatic UTIs, there is no good evidence that antibiotic treatment of
ASB reduces UTI rates, as recolonization occurs rapidly.103 Nicolle states succinctly:
‘‘Bacteriuria is benign, and seldom permanently eradicable.’’104 The United States
Preventive Services Task Force does not recommend screening for ASB in diabetic
patients.8
However, a UTI in a diabetic patient is considered a complicated UTI. Diabetic
patients have more frequent and severe UTIs, and often have asymptomatic upper
tract involvement. Insulin therapy and a history of prior cystitis are associated with
a higher risk of UTI.105 Well-controlled studies of optimal type and duration of therapy
for UTIs in diabetes are lacking, but expert recommendations suggest a 10- to 14-day
course of antibiotics with an antimicrobial agent that achieves high levels both in the
urine and in urinary tract tissues.77 Diabetics have a higher risk of recurrence than
nondiabetics.78 Funguria is also found more frequently in diabetics. It should not be
routinely treated, but an indwelling catheter, if present, should be changed.36

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