Urinary Tract Infection (UTI) Tool Kit for Improving Evaluation of UTIs in the Elderly

Asymptomatic bacteriuria is common among the elderly. Asymptomatic bacteriuria is the isolation of bacteria in an appropriately collected urine sample from an individual not experiencing symptoms of UTI. The presence of bacteria without symptoms indicates bacterial colonization of the urinary system, a condition for which treatment is not recommended.

Unfortunately, colonized long-term care residents still receive unnecessary antibiotic treatment, increasing their risk of antibiotic resistant infections and other adverse events.

The clinical decision support tools below will help guide laboratory test ordering and therapy decisions for suspected UTI in long-term care.

These tools will also help long-term care facilities educate staff, residents, and families on the most up- to-date guidance for the evaluation and treatment of suspected UTIs and asymptomatic bacteriuria.

The quality improvement tools below aim to:

  • Improve evaluation of urinary tract infection.
  • Decrease treatment for asymptomatic bacteriuria.
  • Increase use of clinical quality improvement tools for decision support.
  • Communicate with patients and their loved ones for safer care.

Treating Asymptomatic Bacteriuria: All Harm, No Benefit

Up to 50% of seniors over 70 years old living in long-term care facilities have asymptomatic bacteriuria; that is their urinary systems are colonized with bacteria, but they do not experience any UTI symptoms.

Treatment of asymptomatic bacteriuria is not recommended.

In fact, unnecessary treatment of residents with asymptomatic bacteriuria can be harmful.

Unfortunately, prevalent colonization and habitual urine testing can lead to unnecessary prescriptions in
long-term care and across the healthcare continuum.

Providers and families may think that an antibiotics prescription is taking the “better safe than sorry”
approach, but unnecessary antibiotic use is not without harm.

Unnecessary Treatment with Antibiotics Harms Patients

  • Drug-drug interaction
  • Renal and other complications
  • Increase of multi-drug resistant bacteria
  • C. difficile infection
  • Nausea and vomiting
  • Drug allergies
Cloudy or malodorous urine is always diagnostic
of a urinary tract infection.
These changes may be seen in asymptomatic bacteriuria. Other causes can include dehydration, certain medications, and diet.
A positive urine culture and abnormal urinalysis (positive nitrates or leukocytes, increased white blood cells or pyuria) always indicates a urinary
tract infection and requires antibiotics.
Positive urine culture and abnormal urinalysis in a resident without symptoms are consistent with asymptomatic bacteriuria – that is, colonization –
not infection. Treatment with antibiotics is not indicated.
A positive urine culture in a resident with a chronic indwelling catheter always indicates a urinary tract infection and requires antibiotics.A chronic indwelling catheter is associated with
bacteriuria 100% of the time. There is no need to
treat unless the resident has symptoms of a UTI.
Elderly residents often have urinary tract
infections with no symptoms except a change in
mental status or delirium, or other nonspecific
symptoms such as falls.
Urinary tract infection is much less likely without
specific symptoms. Non-specific symptoms, such
as a change in mental status, delirium, fatigue, or
a fall may be due to a variety of causes, including
pain, depression, constipation, dehydration, poor
sleep, or medication side effects. It is important
to consider a range of possible causes to prevent
missing the real diagnosis.
A follow-up urine culture is indicated to confirm
successful treatment of UTI.
Even when a UTI is successfully treated, a urine
culture may still be positive due to asymptomatic

Don’t Test, Don’t Treat Without Specific Signs and Symptoms

Consensus is growing among leading medical organizations: don’t order a urine culture and don’t treat with antibiotics unless the patient is displaying UTI signs and symptoms.

“Don’t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract.”

The American Medical Directors Association

“Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.”

The American Geriatric Society

Criteria for Urine Testing

Resident without indwelling catheter

Acute dysuria alone OR

Fever + at least one of the symptoms below (new or increased) OR if no fever, at least two of the symptoms below (new or increased)

  • Gross hematuria
  • Urinary incontinence
  • Urgency
  • Suprapubic
  • Costovertebral angle tenderness
  • Frequency

Resident with indwelling catheter

At least one of the symptoms below (new or increased)

  • Fever
  • Pelvic discomfort
  • Flank pain (back, side pain)
  • Malaise or lethargy no other cause
  • Costovertebral angle (CVA) tenderness
  • Rigors (shaking chills)
  • New onset delirium
  • Acute hematuria

Suspect UTI Traffic Light

Red: No symptoms of UTI.

  • Do not test urine
  • Do not treat if urine test was done by someone else or for “routine”

Yellow: Weakness, delirium, or fever without a focus.

  • Individualized care
  • Be mindful of prevalence of asymptomatic bacteriuria
  • Seek other causes

Green: Specific UTI symptoms.

  • Test or treat as usual

Challenges Evaluating and Managing Suspect UTI vs. Asymptomatic Bacteriuria

ChallengeStrategies for Practice Change
The resident’s family wants a urine test and
antibiotic treatment in the setting of
asymptomatic bacteriuria.
Educate the family about the prevalence of
asymptomatic bacteriuria and tell them you do
not suspect UTI on clinical grounds. Emphasize
the dangers of antibiotic overuse.
We’ve always ordered urine cultures for
nonspecific problems in residents with dementia.
There are many potential causes for nonspecific
changes in status and thorough evaluation is
needed. Residents in long-term care frequently
have positive urine cultures, even when they are
It is okay to give an antibiotic even if it may not
be needed. Better safe than sorry.
Antibiotics can cause adverse drug reactions, C.
infection, and promote the emergence of
Antibiotics can cause adverse drug reactions, C.
infection, and promote the emergence of
multi-drug resistant organisms. They should not
be administered unless clinically indicated.
It is hard to ignore a positive urine test even
when done for no clearly apparent reason.
Treatment decisions should not be made based
on test results alone. Evaluate the resident
clinically and consider a period of observation for
development of specific signs or symptoms of a

Practice Support and Education Tools for Clinicians in Long-Term Care

UTI Protocol: ABCs for Diagnosing Urinary Tract Infection in Long Term Care

A checklist-based worksheet to guide decisions and communication about testing urine and treating
UTIs in long-term care.

Assessing Change in Mental Status Mnemonic Poster

A poster using the acronym DELIRIUMS to remind clinicians of the many potential causes for altered
mental status in the residential elderly.

AMDA – The Society for Post-Acute and Long-Term Care Medicine: Fifteen
Things Physicians and Patients Should Question

3. Don’t obtain urine tests until clinical criteria are met.

Don’t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract.

6. Don’t place an indwelling urinary catheter to manage urinary incontinence.

Don’t use a catheter to manage urinary incontinence in the long-term care setting.

Education Tools for Long-Term Care Residents and their Families

Suspect a Urinary Tract Infection? How Taking Antibiotics When You Don’t Need Them Can Cause More Harm Than Good

Helps long-term care facility residents and their families learn about the hazards of unnecessary
antibiotic prescribing for asymptomatic bacteriuria.

When Do You Need an Antibiotic?

Supports conversations with long-term care facility residents and their families to avoid harm from
unnecessary use of antibiotics.

Consumer Reports Health and the American Geriatric Society “Choosing Wisely”

Describes to older patients when antibiotics may be indicated, why they should avoid unnecessary antibiotic use, and how to prevent UTIs.