Q: An older friend, who is in her 90s, has been having bacteria in her urine, but no symptoms. Despite treatment with antibiotics, she was still having urine in the bacteria, so the doctor recommended chronic antibiotics and a referral to urology.
What can be done when an elderly woman has bacteria in her urine but no symptoms? Can a urology consultation help?
A: This is a great question. You are describing something called asymptomatic bacteriuria, which means having urine bacteria without symptoms.
Every older person and family caregiver should know about asymptomatic bacteriuria. Here’s why:
- It’s very common in older adults. This condition is found in an estimated 20% of women aged 80 or older, and also affects older men. The older the person, the more common it is.
- It’s often confused with a urinary tract infection (UTI). This can lead to unnecessary — and potentially harmful — treatment with antibiotics.
- It usually does NOT need to be treated with antibiotics. As I’ll explain below, research shows that people don’t live better or longer when asymptomatic bacteriuria is treated. In fact, such treatment can be harmful: one study found that treatment increased the risk of future (real) UTIs, and increased the risk of infection with antibiotic-resistant bacteria.
- It’s common for seniors to inappropriately be given antibiotics to treat this condition. Part of why this happens is that distinguishing this condition from a real UTI cannot just be done with a urine test. Instead, health providers must take the time to talk to the patient — or family caregiver — and ask about whether symptoms are present. In a busy clinical environment, this step is all-too-often neglected.
In short, this is another one of those common aging health issues that can easily be mismanaged, unless older adults and family caregivers know to ask extra questions.
Because it’s so common for antibiotics to be inappropriately prescribed for this condition, “Don’t treat asymptomatic bacteriuria with antibiotics” is the number one “Choosing Wisely” recommendation from the Infectious Disease Society of America. The American Geriatrics Society also includes this recommendation on its Choosing Wisely list.
Now, let’s try to equip you to understand this common condition. This will help you — and your older loved ones — avoid unnecessary testing and antibiotic treatment. Specifically, in this article I’ll cover:
- What is asymptomatic bacteriuria?
- How common is asymptomatic bacteriuria?
- How to tell the difference between asymptomatic bacteriuria and a UTI
- Why asymptomatic bacteriuria usually doesn’t warrant antibiotics
I’ll close with some practical tips for older adults and family caregivers concerned about UTIs and/or bacteria in the urine.
What is asymptomatic bacteriuria?
Asymptomatic bacteriuria means having significant quantities of bacteria in the urine, but no clinical signs of inflammation or infection.
In other words, in asymptomatic bacteriuria, a urine culture will be positive. (This means that if your healthcare provider takes a sample of urine and a clinical laboratory incubates it, within 1-2 days, a sizeable quantity of bacteria will grow.)
When bacteria are present in the bladder but not provoking an inflammatory reaction, this can also be called bacterial “colonization” of the bladder.
How common is asymptomatic bacteriuria?
Asymptomatic bacteriuria is more common in older adults than many people — including practicing clinicians — may realize:
- In women aged 80 or older, 20% or more may have this condition.
- In healthy men aged 75 or older, 6-15% have been found to have bacteria with no UTI symptoms.
- Studies of nursing home residents have found that up to 50% may have asymptomatic bacteriuria.
This condition also affects 2-7% of premenopausal women, and is more common in people with diabetes.
Asymptomatic bacteriuria becomes more common as people get older, in part because it is related to changes in the immune system, which tends to become less vigorous as people age or become frailer.
Studies have found that in older adults, asymptomatic bacteriuria does sometimes go away on its own, but it also often comes back or persists.
How to tell the difference between asymptomatic bacteriuria and a UTI
By definition, in asymptomatic bacteriuria, there should be no UTI symptoms present.
The following signs and symptoms can be caused by UTI:
- Burning or pain with urination
- Increased frequency or urgency of urination
- Bloody urine
- Pain in the low abdomen, flank, or even back
- Fever
(What about “cloudy” or “foul-smelling” urine? In the absence of other symptoms, there’s no good reason to believe this is a good way to detect a possible UTI. See here: Cloudy, Foul-Smelling Urine Not a Criteria for Diagnosis of Urinary Tract Infection in Older Adults.”)
Whether or not an older person has a clinical UTI, the urine dipstick may be abnormal, in part because certain abnormal results suggestive of UTI may in fact only reflect bacterial colonization of the bladder. So one should not rely on urine dipsticks or related urine analysis tests (which measure the number of white blood cells in the urine, among other things) as the sole justification for diagnosing a UTI. Symptoms are necessary!
The thing is, some older adults may only show vague or non-specific symptoms when they get a UTI, such as confusion or weakness. (That “confusion” would be delirium.) This is especially true of seniors who are frail, or are quite old, or have Alzheimer’s or another dementia.
For this reason, it can be difficult to determine whether a frail or cognitively impaired older person is having UTI symptoms that warrant treatment.
Experts are currently debating whether it’s justified to treat for possible UTI, for those cases in which an older person with asymptomatic bacteriuria shows signs of delirium, but no other UTI symptoms.
Why asymptomatic bacteriuria usually doesn’t warrant antibiotics
Clinical studies overwhelming find that in most people, treating asymptomatic bacteriuria with antibiotics does not improve health outcomes.
(The exceptions: pregnant women and men about to undergo urological procedures do benefit from screening for and treatment of asymptomatic bacteriuria.)
A 2015 clinical research study found that treatment of asymptomatic bacteriuria in women was associated with a much higher chance of developing a UTI later on, and that these UTIs were more likely to involve antibiotic-resistant bacteria.
Even for frail nursing home residents, there is no proof that treating asymptomatic bacteriuria improves outcomes, but it does increase the presence of antibiotic-resistant bacteria.
Despite the expert consensus that this condition doesn’t warrant antibiotics, inappropriate treatment remains very common. A 2014 review article on this topic notes overtreatment rates of up to 83% in nursing homes.
Is there a role for cranberry to treat or manage urine bacteria?
The use of cranberry juice or extract to prevent UTIs has been promoted by certain advocates over the years, and many patients do prefer a “natural” approach when one is possible.
However, top quality clinical research has not been able to prove that cranberry is effective for this purpose. In a 2016 study of older women in nursing homes, half were given cranberry capsules daily. But this made no difference in the amount of bacteria or white blood cells in their urine.
In a related editorial titled “Cranberry for the Prevention of Urinary Tract Infection? Time to Move On,” which summarized many other studies of cranberry for the prevention of UTI, the author concluded:
The evidence is convincing that cranberry products should not be recommended as a medical intervention for the prevention of UTI. A person may, of course, choose to use cranberry juice or capsules for whatever reason she or he wishes. However, clinicians should not be promoting cranberry use by suggesting that there is proven, or even possible, benefit. Clinicians who encourage such use are doing their patients a disservice.”
A 2012 systematic review of high-quality research studies of cranberry for UTI prevention also concluded that cranberry products did not appear to be effective.
That said, many people really feel that cranberry supplements make a difference.
As cranberry is unlikely to cause harm to older adults, I don’t object when an older person or family caregiver wants to use them. But I don’t particularly encourage it either.
Practical tips on urine bacteria and possible UTIs in older adults
Given all this, what should you do if you are worried about bacteria in the urine, or a possible UTI?
Here are my tips for older adults and families:
- Realize that asymptomatic bacteriuria is common in older adults.
- If you keep having positive urine cultures despite feeling fine, you may have asymptomatic bacteriuria.
- Know that treatment of asymptomatic bacteriuria is not going to help, and might lead to harm.
- Unless you are having symptoms, it’s pointless to try to “eradicate” bacteria from the bladder. Studies show that this increases your risk of getting a real UTI later on, and that you’ll be more likely to be infected with bacteria that are resistant to antibiotics.
- Antibiotic treatment also affects the “good bacteria” in your gut and elsewhere in the body. Research to help us understand the role of the body’s usual bacteria (the “microbiota”) is ongoing, but suggests there can be real downsides to disrupting the body’s bacteria. So you don’t want to use antibiotics unless there’s a good reason to do so.
- Avoid getting a urine culture unless you’re experiencing symptoms of likely UTI, such as pain with urination or low belly pain.
- Some healthcare providers will do a urine culture “just to check” for UTI. Or sometimes patients and family members request this. But this is a bad idea, since all you might do is uncover signs of asymptomatic bacteriuria (which then has a tendency to be inappropriately treated with antibiotics).
- Experts strongly recommend that urine tests for possible UTI only be done if an older person is experiencing symptoms.
- If a health provider suggests a urine test and you aren’t having UTI symptoms, inquire as to the purpose of the test.
If you’re caring for an older adult who has dementia or is otherwise prone to delirium:
- Realize that it can be tricky to determine whether the person is experiencing UTI symptoms.
- The doctors should still attempt to do so before checking a urine culture or treating any bacteria found in the urine.
- Realize that some experts believe that increased confusion alone (meaning no fever or other signs of UTI) may not be a good reason to treat a nursing home resident for a presumed UTI.
- A geriatrician explains this debate in this very interesting article: “Urinary Tract Infection”—Requiem for a Heavyweight
In short: I’d summarize the benefits and burdens of treating asymptomatic bacteriuria in a 90 woman as follows:
Benefits: No proven benefit to antibiotic treatment in someone who doesn’t have clinical signs of a UTI.
Burdens: Antibiotics cost money, and increase pill burden. There is a risk of side-effects, of interactions with other medications, of harming your body’s “good bacteria,” and of developing an infection resistant to antibiotics. Also, the overuse of antibiotics in society means we are developing more resistant bugs all around us.
So there you have it. If an older person has a positive urine culture but no symptoms, think long and hard before agreeing to treatment. And ask extra questions before spending time pursuing a urology consultation.
Remember, bacteria in the urine does NOT equal a UTI.
So, ask your clinicians if this could be asymptomatic bacteriuria. Tell them you’ve heard that the Infectious Disease Society of America, the American Geriatrics Society, and other experts say that this condition should not be treated in older adults. (Unless you’re about to undergo a urological procedure.)
You can even share these peer-reviewed articles:
- Approach to a Positive Urine Culture in a Patient Without Urinary Symptoms
- Diagnosis and Management of Urinary Tract Infection in Older Adults
- “Urinary Tract Infection”—Requiem for a Heavyweight
Do you have questions about bacteria in the urine of older adults? Have you been treated for a questionable UTI? Please post your questions and comments below!
Oh wow. That’s very informative blog posted. Thank you for sharing it.
Very informative and very appreciated!!!
As a chronic UTI sufferer, I was desperate for a solution. I’ve been using the Lady Soma cranberry pills for not too long, but can already feel the difference. They DO NOT aggravate the stomach, as some people have said about cranberries. I do feel a slight difference in regards to stomach, though, but I can’t say if it’s these supplements or something else. But please don’t let that deter you – the Lady Soma Cranberry pills are an absolute godsend. I recommend them full-heartedly. I will be taking these on a daily basis for a very very very long time.
Great that you have found something that seems to help. Cranberry has been studied clinically, but the verdict is mixed. Although one 2012 review concluded that there is evidence that it can reduce UTIs, another 2012 review came to more skeptical conclusion.
Cranberry-Containing Products for Prevention of Urinary Tract Infections in Susceptible Populations
Cranberries for preventing urinary tract infections
Of note, the 2016 study of cranberry extract in nursing home residents did not find any benefit.
That said, many people really feel that cranberry supplements make a difference, and they are unlikely to cause harm. So it’s fine to use them if one prefers.
I use cranberry pills for my mother who suffers from lots of things including UTI’s. When she takes these, that problem is one less.
In your article, you stated that asymptomatic bacteriuria is common in older adults and in women aged 80 or older, 20% or more may have this condition. Last night my son and I were eating dinner at my mom’s house and she started saying that she was having a really hard time using the bathroom. I wonder what older people can do to prevent UTIs.
An older woman complaining of a “hard time using the bathroom” does not necessarily sound like a UTI symptom to me. I would encourage you to ask her to elaborate. Is she having pain with urination? Or is she referring to constipation?
Unfortunately, almost nothing has been proven to prevent UTIs in older adults who are not hospitalized. There is some evidence that remaining mobile helps prevent UTIs.
Mom has dementia and though consistently has bacteria in her urine and dark urine, she is becoming resistant to antibiotics. She frequently has the foul smell and becomes even more confused than she already is. The elderly home where she lives has a geriatric physician. Is there any advantage to taking her to an urologist?
Well, as I explain above, chronic bacteria in the urine is quite common in older adults. So the question is, is she showing other signs suggesting a clinically significant UTI. Foul smell probably doesn’t count, but if she definitely gets more confused, that could be a sign of a UTI. She should also at that time be evaluated for other causes of delirium and/or increased confusion. These include constipation, untreated pain, medication side-effects, electrolyte imbalances, other new illness, and much more.
Regarding the question of a urologist: if you are feeling stuck, then sometimes getting a second opinion from a specialist can help. However, a urologist probably won’t evaluate your mom for other problems that might be causing increased confusion; that is really the job of a generalist or geriatrician.
So you could try seeing a urologist, but I would also encourage you to ask more questions of the geriatrics physician at her living facility. Good luck!
What are the causes of excessive amounts of bacterium in urine?
I mean, is there anything more specific than a general weakening on the immune system as a person ages that would cause this? Or maybe the question should be: How does one go about strengthening the immune system as a person ages? Would regular exercise help, certain changes in diet? Does wearing adult diapers contribute to causes of this problem?
The aging of the immune system is called “immunosenescence.” Researchers are currently working to piece together exactly how it happens, and how we might be able to influence this process.
Causes, consequences, and reversal of immune system aging
I don’t think anyone knows for sure how to counter or delay immunosenescence. Presumably exercise, enough sleep, a healthy diet, social relationships, and all the other things we know are good for older people can help maintain the immune system. But we don’t yet know of specific regimens proven to work.
Regarding diapers: people with incontinence are at higher risk for developing UTIs. But this in part will reflect the fact that adults wearing diapers are often older or frailer, which in of itself puts one at risk for developing infections. Otherwise, some studies have suggested that nursing homes with better staffing and better care practices have fewer UTIs among their residents. Presumably keeping someone reasonably clean helps reduce the risk of UTIs.
While you’re at it – why not tell us what generally CAUSES asymp. bac and UTI?
Most parts of the human body are frequently exposed to bacteria. Whether the bacteria settle in to “colonize” (i.e. establish a presence without causing significant inflammation and illness), or to “infect” (establish a presence that does cause inflammation or illness) depends on factors related to the specific bacteria in question, as well as on the state of the person and their immune system.
In fact, scientists are increasingly realizing that whether new bacteria can gain a foothold is partly dependent on the presence and activity of other colonizing bacteria. This may be why using antibiotics can increase the risk of infections later on; antibiotics weaken your “good” or “usual” bacteria, which can make it easier for “new” or potentially “bad” bacteria to settle in.
Thank you for passing this information on to your subscribers Dr. Kernisan. My 94 year old mother is prone to UTI’s and her doctor recently prescribed a course of antibiotics that really did nothing but give mom stomach pains. As her full time 24/7 caregiver I usually try to ply her daily with some cranberry juice. I’m fortunate if my mom takes in 12oz of liquid in a day.
Question: Would an insufficient daily intake of liquids invite and/or exacerbate UTI’s and asymptomatic bacteriuria?
My understanding is that to potentially benefit from cranberry juice, one has to drink quite a lot of it…as in, an amount that isn’t feasible or palatable for most older adults. Hence many studies have tried cranberry extracts instead, but as I mention in the article, it’s not clear that these work well.
Re your question about dehydration and UTI risk, I addressed this here: How to Prevent, Detect, & Treat Dehydration in Aging Adults.
Basically, it’s plausible that mild dehydration might increase UTI risk or otherwise impair the body’s ability to repel bacteria. But it hasn’t been proven definitively.
12 ounces of fluid per day is not very much, and probably not enough for most older adults. There are suggestions in the dehydration article on how to help an older person take in the fluids they need. Good luck!
I’ve been reading today about UTIs and acidic urine, that cranberries seem to work when the urine isn’t overly acidic and the gut flora is good. (Of course, the gut flora is often bad after repeated antibiotics!) My mother (90yo) has reoccurring UTIs with confusion and more frequent falls often before pain is noted.
http://urologytimes.modernmedicine.com/urology-times/news/diet-urine-ph-may-affect-urinary-tract-bacterial-growth
Yes, it seems plausible that urine pH would influence bacterial growth.
Recurrent UTIs can be challenging to control, especially in people like your mother. Some studies have found that vaginal estrogen cream can help. Good luck!
Can you talk about dangers of antibiotics for urinary tract problems? We get the ‘Worse Pill Best Pills’ newsletter and they were saying that some antibiotics given for UTI could make the dementia considerable worse and even cause psychosis.
Also does l mannose work? This is what my mother has been taking sometimes.
As noted in the linked article above (Diagnosis & Management of UTIs in older adults), the recommended first line antibiotics for UTI treatment are nitrofurantoin and trimethoprim/sulfamethoxazole (TMP/SMX). As far as I know, both are usually well tolerated by most people, including people with dementia. However, it’s always possible for someone to experience a side-effect or adverse reaction. Also, it’s not uncommon for bacteria to be resistant to TMP/SMX.
D-mannose is a natural sugar and it’s been studied in recent years for prevention of recurrent UTIs. It interferes with some types of bacteria establishing a foothold in the bladder. Some of the studies of D-mannose are promising, but according to UptoDate (the peer-reviewed clinical reference that I and most doctors use), it’s not yet clear what dose is effective. As D-mannose is unlikely to be harmful, it’s certainly something that could be tried.
Because of the newer thinking as outlined in your article, I’m having a hard time getting my Mom treated for UTI’s. She is frequently written off because she has dementia. She cannot tell us it burns or that she has unusual pains. We know she has a UTI because her behavior is off the charts when she gets one. By then, it’s nearly impossible to get a sample from her. I’m not exaggerating. I spent 30 minutes w/ my hand between her legs with her screaming and hitting at me in the doctor’s office the last time this happened. Of course, I also can’t explain to her that we need a sample so she feels violated. I wish doctors would pay more attention to the individual and realize that the guidelines don’t fit everyone. My Mom hurts people when she has a UTI. We have lost help and have difficulty getting new people oriented to her.
Thanks for sharing your story and bringing up this important issue. Yes, although many older adults are being given too much treatment for possible UTI, it’s certainly possible that some are being undertreated.
The guidelines don’t fit everyone, but they are a good starting place. From there, evaluation and treatment needs to be adapted to the individual circumstances, and also to the preferences of the patient and family.
Unfortunately, your situation is particularly tricky because it’s especially important to check a urine culture in people who have had previous treatments for UTIs…because they are especially likely to be resistant to certain antibiotics. If she won’t cooperate with a sample when she’s symptomatic, then you are in a pickle…and with such dilemmas there is usually no good solution; the family and clinicians have to carefully consider all the possible options with their associated trade-offs, and then just try to muddle through together. Good luck!
WHY don’t you use a ‘hat’ to collect the urine and let her sit on a stool with arms???
The trouble with letting an older adult pee into a “hat” (a container placed in the toilet) is that this doesn’t allow for a “clean-catch” sample. When we culture urine due to concern for a UTI, the goal is to have urine that has not been contaminated by bacteria outside the body.
A hat is useful if you are tracking how much an older person urinates.
Excellent and timely article. As a clinical laboratory director for forty years, I applaud your clarification on the treatment of bacteriuria vs. UTI. As a son caring for his 92 year old Mom, I found your explanation invaluable. Thank you! Can you tell us what the likely complications are of an untreated, bona fide UTI?
I’m glad you find the article helpful.
Untreated UTIs can turn into pyelonephritis (infection of the kidney) or sepsis (bacteria in the bloodstream and severe generalized illness). These are both serious infections that require hospitalization, and sepsis (which is sometimes referred to as “urosepsis” if it seems the bacteria originated in the bladder) in particular can be life-threatening, as the generalized infection causes dangerously low blood pressure, and sometimes organ damage.
In this article I describe the true story of one of my 93 year old patients, who almost died of urosepsis: A Trial of ICU Care: a true end-of-life story.
Now how likely is it that an untreated UTI will turn into pyelonephritis or urosepsis? We don’t really know the answer to this question, as we’re generally unwilling to leave true UTIs untreated in older adults.
In younger women, delayed treatment of antibiotics for UTI has been studied. For women who delayed treatment by a week, many of them experienced improvement or resolution of their UTI symptoms. So we do know it’s possible for the body to heal itself from UTIs, but again, such studies have been done in women who are younger (average age 40s) and otherwise healthy.
For older adults, we generally treat what appears to be a “bona fide” UTI with antibiotics, unless a patient or family has decided they no longer want medical care that prolongs life. (This is a choice that some people prefer when they are quite impaired by a terminal illness, such as dementia or end-stage lung disease, for instance.) If the goals of care are no longer to prolong life, then we might not treat a UTI (unless it appears to be quite painful), and in this case, some patients will recover and others will get worse.
Can bacteria form or multiply in urine samples several days old prior to being analyzed? How important is freshness in a sample?
Hm, I have never heard of the lab culturing a sample that is several days old. Presumably the sample should be fresh, because otherwise there is increased risk of contamination from outside sources.
This irritates me, I had a “asymptomatic” uti, the male urologist poo pooed it and said it was due to hormones or lack of , the sensitivity showed a very antibiotic resistant ecoli, I am only 49, and was having back pain in between my shoulder blades, I could feel my heart beating through my ribs when I put my hand there, night sweats and a foul cloudy urine and he wouldnt treat me, I found another urologist who put me on ceftin for 3 months and I no longer show any signs of bacteria in my urine, no longer feel my heart coming out of my chest, no night sweats or back pain, My question is , If left untreated these “asymptomatic” utis, doesnt the person become sepsis?
It’s always frustrating to feel that a doctor is not taking one’s concerns seriously. Back pain can be a symptom of a UTI, although it’s usually lower than the shoulder blades. So perhaps you were having symptoms and hence a real UTI, as opposed to asymptomatic bacteriuria.
In terms of the possibility of developing sepsis: asymptomatic bacteriuria can turn into a UTI, and that can lead to sepsis. However, studies have found that treating asymptomatic bacteriuria doesn’t lead to fewer UTIs, or other complications overall.
Part of this is probably because the body is designed to either live with or fight off bacteria. It’s probably good to give the body a chance to do this, and then intervene with antibiotics only if things seem to be getting worse.
Your information was helpful on bacteria in the urine. However you did not give any symptoms . I have been dealing with constant urination, to the point where it gushes out. I at times have pain. Have had culters and nothing grows. Was told there is bacteria but that’s it. Am taking d-mannose, cranberry pills and it is good one day and back the next . Have had meds for uti until it continued and the tests were run.
Actually, this article does describe symptoms of a UTI, in the section titled “How to tell the difference between asymptomatic bacteriuria and a UTI.”
It sounds like you have some pretty significant urinary symptoms but your urine culture is negative, so you have neither a UTI nor asymptomatic bacteriuria.
I would encourage you to be persistent in asking your doctors to explain what they think is the cause of your urinary frequency and pain. You may want to see a urologist for a second opinion, or better yet, a gynecologist specialized in women’s urological issues. There are many non-bacterial problems that can cause frequency and pain. Normally a good pelvic exam would be indicated in this situation, to see if your symptoms might be related to the position or condition of your uterus.
There is no evidence that it’s helpful to take UTI antibiotics, in the absence of a positive culture AND symptoms.
Good luck!
So i just got a full body check up and my doctor did some blood tests and a urine test also. My doctor told me that there was a little bit of bacteria in my urine test and she told me that she will do a pap smear on the next visit before looking into the bacteria in my urine( since at that time i was on my menstral cycle) . So I did a pap smear and got a respond on the results three weeks later saying that everything was fine and that they prescribed something for the bacteria. well i havent went to pick my medicine because i dont want to take antibiotics .. i feel fine and dont want to take something that may not useful. Im 37 years old and since my pregnancy (2 years ago) i been having weird menstrual cycles. 4 months i will go with no cycle and when i do have my cycle its very lite and lasts a couple days. my mom had a early menopause at the age of 35.Not sure if thats useful information but there it is. Im not sure what to do. i need advice
If you feel fine and aren’t having symptoms, then you may not need antibiotic treatment for any bacteria that were found in your urine.
In fact, even in women with UTI symptoms, a certain number of them get better without antibiotics, see here: Women with symptoms of uncomplicated urinary tract infection are often willing to delay antibiotic treatment: a prospective cohort study
I would recommend that you talk more with your doctor about this issue. Let your doctor know that you’d prefer to only take antibiotics if it’s absolutely necessary. What you are describing sounds like it might be asymptomatic bacteriuria, so it would be reasonable to ask the doctor why he or she feels antibiotic treatment is necessary. It may not have been clear to the doctor that you aren’t having symptoms, or the doctor may not have remembered that asymptomatic bacteriuria usually doesn’t require antibiotic treatment.
Hello-my mom is a resident in a nursing facility and has had several UTI’s in the past several years. In the past month, there have been changes in her behavior, such as screaming, hollering for help, agression toward the aides who are trying to clean or toilet her, refusing meds and pushing away things that come close to her face, constantly holding her lower abdomen and drawing her legs toward her body. She does have dementia, but in the past few days doesn’t understand a word that i am saying. Ie TV, laundry, lunch. This behavior is similar to the other times when she had UTI’s, so i requested a urine test. They also did labs. Her BUN was high. Urine had bacteria but they said it was not enough for antibiotic and some was from her skin. I saw the sample which looked like it had clouds of a darker color. I feel so helpless. She appears to be in pain and very distressed. What can i do to help her?
Sorry to hear that your mother seems to be in pain and distressed. It sounds like it might be related to her belly, since you say she’s holding her abdomen and drawing her legs up.
There are many problems that can cause belly pain in an older adult, so it’s important for her health providers to start investigating for those. Constipation is a very common problem that can cause terrible belly pain if it’s severe. Other problems to consider include diverticulitis, gallstones, a tumor or other mass, blockages in the arteries that nourish the bowels, and much more.
What you can do is keep pressing your mother’s doctors to evaluate her distress and treat it. Do make sure they have ruled out constipation as a cause. Ask them what abnormalities were seen on the labs, and what they think might be causing her belly pain. If they drew a complete blood cell count, ask if it’s showing signs of anemia, or of infection. For belly pain we also often draw tests related to liver function and sometimes pancreas function, as this can help us determine whether the person might be suffering from gallstones or pancreatitis.
For some people with dementia in nursing homes, the care plan is to minimize hospitalization and procedures, because the goal is to prioritize comfort and avoid medical care that is often burdensome to people with dementia. But even in such cases, that doesn’t mean doctors should just stand by if she’s distressed; normally even when the goal is comfort, we pursue labs and simpler tests that can help us figure out why a person is in pain.
Regarding a high BUN, this is often associated with decreased kidney function. It’s always important to know whether such a finding is new or worse than usual (in which case it might reflect dehydration or some other problem affecting the kidneys) versus chronic.
In short, if her urine culture is negative, then she doesn’t need treatment for a UTI. What she does need is a careful evaluation to figure out what might be causing her pain, and then treatment tailored to that cause.
If they can’t figure out what is causing her pain, they should still try to treat her pain. In my own practice, I consider low doses of opioid painkillers when an older person is having a lot of pain, but this usually requires adding or increasing any laxative treatment, to avoid worsening any constipation. Good luck!
Hello,
My mother-in-law is 93 and has re-occurring diagnosis of UTI. She also has early symptoms of dementia which makes her reporting suspect.
For 2-3 years her doctor prescribed daily low-level antibiotics. In the past year with a new doctor, that was stopped and now she reports symptoms, a urine sample is taken and she is diagnosed with e-coli in the sample so another round of antibiotics is prescribed.
I can’t say for sure how many UTIs were reported/diagnosed under the low-level plan.
Now with a new doctor, he is prescribing continuoius low-level antibiotics again.
Her daughters have talked to her about hygiene , drinking water, etc…
I was confused by the term asymptomatic bacteriuria. Does that include e-coli?
What is your opinion about continuous low-level anti-biotics?
Thank you in advance,
Mark
Given her age and what you describe, it’s quite likely that your mother-in-law’s bladder is “colonized.” So she is likely to have a positive urine culture whenever you check. Given that she has dementia and is perhaps frail as well, her doctors will have trouble determining whether she is having a clinically significant UTI or not.
The term asymptomatic bacteriuria certainly encompasses E. coli. Pretty much any bacteria that shows up on a positive urine culture can colonize the bladder of an older person.
In terms of continuous low-level antibiotics: they can reduce recurrent UTIs in younger women, but this has not been confirmed in women aged 80s or 90s. Most research done on this age group is done in nursing homes, and those studies tend to suggest that antibiotic treatment doesn’t help much.
So in geriatrics, we would usually not use continuous antibiotics in someone like your mother-in-law, but of course it depends on the particular circumstances and also on what’s important to the family.
The practice of many geriatricians is to not check a urine culture, once a person has shown signs of having a colonized bladder. Instead, we would only check if there were true UTI symptoms (e.g. belly pain, definite pain with urination) or signs of infection spreading in the body (e.g. fever, low blood pressure, high pulse, much less responsive than usual).
My husband is quite compromised w/Parkinson’s, MultiSystem Atrophy (MSA), Progressive SupraNuclear Palsy (PSP), Axonal Polyneuropathy and Lewy Body Dementia. He’s had numerous UTI’s, kidney infections and prostatitis through his younger years. Since May 2017: on sterile cath specimens: he has had Enterococcus Faecalis, Dipthheroid-like Gram Positive (NOT Corynabact.), Citrobacter Youngae and in August: Serratia Marcescens and again in September: Serratia Marcescens. These are sterile specimens. He has had fever, increased altered mental status, back pain, abdominal pain, testicular pain, dysuria. In August he was treated w/Cefepime IM inj. BID x 7 days. In September: Gentamycin 80 mg. q 8 hours. I am so sad; as I am concerned the infection will come back.
So sorry for your situation, it sounds like your husband has had to deal with a lot of illness.
It’s impossible for me to say whether his urine infections will come back. It does sounds like he has a lot of risk factors and his immune system is probably weakened, so that does put him at risk for future infections.
If he keeps getting infections, you may want to consider talking to a doctor about the big picture of his health, and what to expect over the coming year. If he is declining overall, sometimes it’s helpful to reconsider the goals of his medical care and make sure you are addressing everything possible to maintain his quality of life. Palliative care doctors are especially good at this. We are not always able to cure or fix every medical problem, but it’s often possible to help people feel better. Good luck!
When you have asymptomatic bacteruiria in urine test right after antibiotic treatment 14 days for a previous kblesia pneumatia bacteria (another with no symptoms at all) , if bacteria colonizes in bladder can it spread to kidneys or cause sepsis. I now have citrobacter freundii and prescribed nitrofurantoin antibiotics but have not taken yet. Waiting to see if I have any symptoms. Just concerned about the colonizing. Culture has not come back yet. Most all antibiotics really hard for me to take. I am so glad I found your site, so interesting. Wish I could get these post in print to review without searching on computer. Thanks so much for what you are doing for older adults.
Mary Hill October 16, 2017
Yes, if the bladder is colonized with bacteria, then this is associated with a slightly higher chance of developing sepsis or a clinically important infection in the kidneys. The thing is, antibiotic treatment of asymptomatic bacteriuria has NOT been shown to reduce one’s chances of developing sepsis.
So if you have asymptomatic bacteriuria — and it sounds like you might, since your urine cultures remain positive despite antibiotic treatment — I would say it’s important to take some deep breaths and try to not worry too much about the colonization. It’s there, you can’t get rid of it with antibiotics.
Probably a better approach is to get lots of rest and try to take a holistic approach to health that can cultivate a stronger immune system. In truth, we don’t really know exactly how people can do this, but we do know that stress and sleep deprivation weaken the immune system. Probably adequate rest, social support, exercise, good nutrition, and other basics of good health can support the body and make it a little less likely that a person develops sepsis.
Antibiotics do affect the body’s “good bacteria” in the gut, and those play a role in regulating the immune system. It’s possible that by stopping antibiotics for a while, you’ll allow your body’s usual bacteria to recover and help protect you.
When to use antibiotics? You will have to discuss with your doctor to find what’s right for you, but in general, older adults with colonized bladders are most likely to benefit from antibiotics when they have a very clear, significant infection that is causing pain or seems to be spreading in the body.
Otherwise, I’m glad you’re finding the articles helpful. FYI, you should be able to see a small printer icon at the end of each article. If you click this, you should be able to easily print a copy of the article.
Good luck!
Thank you so much for our your answer. I have not heard from the culture and still do not have any symptoms. I feel fine today, just getting over the 14 days of other antibiotics I took. No symptoms then either. I am going to stop worrying over this and get on with my life. Again I appreciate your answer. God bless. Mary Hill
How should a uti in an 87 year old woman that shows citrobacter fruendii complex be treated?
What happens if it is left untreated?
If it’s a true clinically significant urinary tract infection (meaning, the person is having UTI symptoms as described in the article, versus having a positive urine culture but no clear signs of symptomatic infection), then usually the treatment is a course of antibiotics. Which antibiotic depends on many things, including the result of antibiotic resistance testing, whether it looks like the UTI is spreading beyond the bladder, the person’s past medical history, and the goals of care.
Because many urine bacteria are resistant to commonly used antibiotics, it’s common for laboratories to test urine bacteria for their susceptibility to antibiotics. Sometimes the person will have been started on an antibiotic at the time they are seen for symptoms, but the urine culture results and the antibiotic susceptibility results usually take an additional 1-2 days to come in. So doctors and families should follow-up on those results, to be sure they use an antibiotic that will work against the bacteria.
If a UTI is left untreated, it may eventually resolve on its own. The symptoms might go away given some time, as the body manages to fight the infection. Especially in someone who is 87, the bacteria will probably persist in the bladder for a while, but this is colonization, not an active infection.
It’s also possible for a UTI to worsen and for the infection to spread to the kidney or bloodstream. In this case, the person’s symptoms will get worse, or they will show signs of systemic infection. These might include signs such as fever, elevated heart rate, lower blood pressure, or weakness.
A study found that in women with UTI symptoms (they were mainly in their late 30s and 40s), a certain number of them get better without antibiotics: Women with symptoms of uncomplicated urinary tract infection are often willing to delay antibiotic treatment: a prospective cohort study.
Is there a greater risk for people to develop bladder cancer when they have a history of colonized bacteria in the urinary tract?
I am not aware of any data suggesting that asymptomatic bacteriuria is a risk factor for bladder cancer.
Hi Dr Kernisan,
Thank you so much for your very informative article on asymtomatic bacteriuria vs. UTI. My mum has this condition (asymptomatic bacteriuria). After several rounds of antibiotics this summer for what they were calling a UTI, we were sent to urology. They explained everything as you have, and placed Mum on Hiprex 500mg, and Vitamin C 500mg per day. The vitamin C is used to create an acidic bladder, and the Hiprex, as it enters this acidic environment, converts to formeldahyde which suppresses bacterial growth. Learning about this action this gives me cause for concern, since my association with formaldehyde (I’m a nurse) is thinking it should not be in the human body at all! Our pharmacist said as long as a doctor is monitoring my mum it should be ok. I would love to hear your thoughts on this medication. Mum is 90 years old.
I recently looked up the research on these medications for one of my own consultation patients (also aged 90s), who was put on them by urology.
There has been interest in methenamine (Hiprex), but the main problem, from my perspective, is that it’s an unproven treatment, when it comes to women in their 80s and 90s. In 2012, a Cochrane review on methenamine for “preventing UTIs” found that it might be effective in some groups of people, but the vast majority of participants in the studies were younger.
On the flip side, methenamine seems to be well-tolerated, as best we can tell, and I’m not aware of any connection to worrisome side-effects or new health problems.
If your mother doesn’t mind taking these medications, one option would be to try it for a few months and see if things seem to be better.
For my own patient, she really hated taking the pills and wanted to be on fewer medications. In this case, a small chance of benefit didn’t seem worth the definite burden of taking the pills every day. So we discontinued them, and she seems to be doing the same as before.
I think that many doctors feel a bit compelled to offer their patients something for the urinary concerns. But as best I can tell, there is not yet good scientific evidence that this is likely to help women like your mom. Hope this helps!
Hi Dr K!
I had asked a question a while ago re: asymptomatic bacteriuria and the use of Hiprex and Vitamin C for treatment. I did get your answer, but hadn’t responded to you! Anyway, my Mum went to the urologist for a 3 month check up, and Dr. N was pleased with her progress. They apparently do not repeat a culture, because it’s a colonized situation. They just ask if she’s having symptoms; fever, burning, frequency. I told him I had a concern about her being on Hiprex long term, and he said it was actually safer than using antibiotics. I think he was surprised I had looked up the action, and agreed it does sound scary, so he doesn’t usually disclose the action to his patients (I disagree with this-everyone should be informed of what they’re taking). Me being a nurse of course I had to look it up! Mum seems to be tolerating it well, but the odor of the urine hasn’t changed, and since I’m sensitive to odors, cleaning her commode isn’t pleasant, but it’s short-lived! Thanks again for your input!
Thanks for sharing this update. I’m glad your mom is doing ok.
Hi, appreciate your article. I am concerned about my otherwise healthy 90-year-old mom who frequently has positive cultures. Problem is, she had completely asymptomatic infection so we did not treat, and soon she almost died of sepsis—all with no symptoms. Even the sepsis had few symptoms until she was quite far along with it. Would you please explain how, in elderly who feel few or no symptoms, one can safely not treat —when there is always a possibility of progression to bacteremia and sepsis?
Sorry to hear of your mother’s sepsis, that must have been scary for her and for your family.
To answer your question: I don’t know that there’s an entirely safe way to not treat her asymptomatic bacteriuria. Older adults of your mother’s age are at higher risk of infection overall, because their bodies and immune systems are weaker. And having asymptomatic bacteriuria is associated with a higher risk; on one hand, it’s often related to a less vigorous immune system, and on the other hand, it may in of itself facilitate sepsis.
So the issue isn’t really “is safe to not treat?” The issue is, which approach is more likely to do more good than harm: to treat her repeatedly, or to go with watchful waiting?
People who are treated repeatedly for their positive urine cultures can also develop sepsis. Once an older adult has developed chronic bacteriuria, it tends to persist for a while no matter what you do. Continuous antibiotics for UTI prophylaxis has been tried in younger adults, but as far as I know, has not been studied in people like your mom, so whether it actually is likely to improve outcomes is unknown.
The truth is that when it comes to older adults, all the options come with risks and uncertainties. I think there’s something to be said for a “less is more” approach, it does seem to benefit many of our patients in geriatrics. And it might be better for nurturing the overall health of one’s body and immune system. But sure, there is risk. Some people feel more comfortable doing more, especially if they’ve had an experience like sepsis.
What is most important is that they be informed of the uncertainty as to whether they’ll benefit, before proceeding with repeated antibiotics for positive urine cultures.
Antibiotics aside, you may want to look into factors affecting your mother’s overall physical wellbeing, like nutrition, exercise, social activity, and all the other non-medical things that we know promote better function of the body.
Hope this helps, good luck!
i am 80, my husband 85… he seems to have that untreatable bacteria… i have clear urine, but sometimes it smells awful.. showering helps for a few hours… if it continues it will limit my small social activities… Church and Bible study… we are both doing well ‘for our age’ we are told…. can you tell me something i can do to get rid of the rotten smell/?? i had a hysterectomy and rectum repair in ’06…. i do have diverticulitis occasionally…we take vit. C, D, and B12 and flaxseed oil pills along with BP meds and sml dose hydrochlorot….
Hm, hard to say what might be causing the smell in your urine. It can be caused by certain foods and medications. I also wonder if perhaps the smell isn’t related to something else going on in your pelvic area, given your history of past surgeries in this area. I would recommend talking to your doctor about what might be the cause. Also if you are experiencing any continence issues that are impacting your social activities, be sure to bring that up to the doctor as well.
If your PCP isn’t helpful, consider a consultation with a gynecologist specialized in urinary issues for older women. Such doctors do the most thorough pelvic exams, and have lots of experience helping older women manage continence and urinary issues. Good luck!
I find this article very useful. I was searching for atypical UTI and UTI without fever and did not reach this site. I feel info given here presents my father’s case. My father is reaching 89 and was partly paralysed with stroke. Last month he had low fever (around 99 degree Fahrenheit) that subsided with paracetamol. Once he was out of fever, we noticed clouded dark yellow urine. He was treated initially with Ceftriaxone (I/V) and then maintained with nitrofurans and trimethoprim. After he was back from hospital, the clouded urine was back. Now it is three weeks since he is without fever or pain. He appears OK . Though nitrofurans and trimethoprim are still continuing, there is no change in clouded urine condition. He has serious issues with oral antibiotics but we have been pushing them with physicians advice. This article has bettered my understanding of the situation.
Glad you found this helpful and hope your father feels better soon.
I’m a 74 year old female with a history of recurrent UTI from e coli. In 2014, I ended up in the hospital with severe kidney infection and dehydration. I’ve been thoroughly checked out by a urologist who found nothing wrong. I follow the guidelines for preventing infections. My doctor always does a culture before prescribing antibiotics. She is concerned about antibiotic resistance. The last time I had an infection (Aug. 4, 2017) my primary symptom, discomfort at the urethra, did not improve with the antibiotic. The doctor agreed to see if the symptom improved on its own. The discomfort comes and goes but is mostly present. Today I did an AZO Urinary Tract Infection Test at home. The leukocytes test was positive at the 500+++ point. The nitrite test was negative. Because of my past near tragic experience (kidney failure stage 3 was the hospital diagnosis), I don’t know if I can let this go. Since there’s no nitrate I think I don’t need an an antibotic. What might cause the leukocytes? Can I just wait until I have some other symptoms?
Nitrites in the urine are generally caused by “gram-negative” bacteria. (Gram-negative versus gram-positive is a common way to classify bacteria.) Many bacteria which cause commonly cause UTIs are gram-negative (including E. coli) but there are also gram-positive bacteria that can cause UTIs.
So, a lack of nitrites does not mean you can assume you have no significant amounts of bacteria in the urine.
Leukocytes are white blood cells, and their presence in the urine is called “pyuria.” UTI is a cause of pyuria however it’s not uncommon for older women to have pyuria in absence of a UTI or bacterial colonization of the bladder. Possible causes include:
– contamination of the urine sample with vaginal secretions
– non-infectious inflammation of the bladder (e.g. interstitial cystitis) or kidney
– inflammation elsewhere in the abdomen (which can trigger white blood cells in the bladder)
I would recommend asking your doctor to advise you regarding your recent home testing findings. If you aren’t sure you are having symptoms, one reasonable approach might be to repeat the urine test in 3-7 days. However, your doctor will be best positioned to interpret these finding in light of your personal medical history, and your urological evaluation so far. Good luck!
Dr. Kernisan,
Thank you so much for taking the time to write and post this article for us and more importantly taking the time to answer the questions that your readers have posted.
I have but one question for you however, is there ever a point in which the medical community “should” error on the side of prevention rather then taking the wait and see approach?
About 12 years ago my father had prostate cancer and elected to have the seeding procedure done with a very short round of radiation to follow. The cancer thankfully was knocked out and he has been cancer free since that time. One of the side effects from the seeding process was scar tissue in the urethra which has caused many problems over the years. One of which being many UTI’s and at times complete blockages which require surgery to open back up.
He has also had ESRD for the last 8 years and as of April of this year was placed on dialysis. His UTI’s have continued but this last time (about two months ago) he had no symptoms at all until he was on the dialysis machine one night and began shaking really bad. They explained to me that this is signs of sever infection. I immediately took him to the ER and they found that he was in septic shock caused but a UTI that showed no symptoms prior to the Septic Shock.
He spent almost 3 weeks in the hospital/ICU and they did not think he had a very good chance of pulling through because of his other medical conditions and his age (77) but he did. During his stay they did a couple of tests on his heart and he wound up having a double bypass & aortic valve replacement and a pacemaker put in which extended his stay a couple more weeks followed by two weeks of PT/OT.
They just did a urine culture on him a couple of days ago and again he has no symptoms of UTI right now but it came back with “Many Bacteria” Negative Occult Blood, WBC 20, Leukocyte Esterase 1+ and RBC 0-2.
I have read quite a few articles on sepsis – returning sepsis – ESRD & dialysis patients and I know that they are much more prone to a lot of medical issues especially infections and when you include the scar tissue it raises his chances of UTI greatly.
I realize there have been no studies to specifically cover my dad’s case but looking at all of the factors especially the high probability of sepsis returning at his age and ESRD/Dialysis wouldn’t it be prudent to error on the side of caution at some point rather then waiting for the sepsis to return and get him on antibiotics now?
My greatest fear is that it will return again with no signs/symptoms and it will be too late.
Best Regards,
Steve M.
Yes, under certain circumstances, it’s reasonable to treat bacteria in the urine with antibiotics. Whether you will actually be preventing sepsis or progression to a clinically significant UTI is hard to say, but it’s a reasonable approach in someone like your father, who is at higher risk than most for developing a serious infection. Just bear in mind that by treating early, you are probably increasing the risk of infection with resistant bacteria down the line.
But for someone like your father, all the options involve some risks and there is no way to guarantee safety or a perfect outcome. Good luck!
My spouse was septic in August 2016 due to blood contamination from feces bacteria while being cared for at a nursing home. He has had many real UTIs there which were treated with antibiotics, (Septra).
Tests show my spouse currently has two kinds of bacteria in his bladder. Also he has an indwelling catheter. In case it might be relevant, he also has an enlarged prostate.
I spend many hours per day with my spouse at the nursing home and know that he currently has symptoms namely, burning penis and urgency to urinate. I have reported these symptoms to the doctor. However the doctor will not accept my reports because he says he has to see them for himself or hear about them from my spouse. (The doctor is not respecting my Power of Attorney). But my spouse has dementia and can’t remember anything for more than a few minutes; the doctor doesn’t spend more than a few minutes per week with my spouse.
Question 1: Is there a way to tell if the symptoms are caused by the bladder bacteria or by some problem with the catheter?
My spouse (who is 90) was seen recently by a urologist. The urologist has recommended 7 days of Septra DS 2 times daily and 1 Septra DS lifelong. But the doctor refuses to take the advice of the urologist and my spouse is not being treated. The doctor also refuses to authorize changing the catheter ahead of schedule to see if that would make the symptoms go away.
Question 2: Does a doctor assigned to my spouse by the nursing home have the authority to override the recommendation of a specialist?
Question 3: Can the doctor just ignore my PoA? Is he putting the nursing home in any sort of legal jeopardy by doing so?
Question 4: My spouse has just been diagnosed with bacterial pneumonia. Could this have been caused by (or just made more likely because) the bladder bacteria were not treated?
I know this is a complicated situation, but can you provide any insight based on your experience?
Thank you.
Yes, sounds like a complicated situation indeed.
You don’t say how long your spouse has had the indwelling catheter. Do they expect it to remain permanently, or is it supposed to be temporary?
Indwelling catheters do commonly cause chronic bacteriuria (once they are in for over a week or so), and I believe it’s not uncommon for them to cause irritation of the penis as well. This means it will probably be hard to tell if your husband’s symptoms are due to a true UTI or not, unless he also develops symptoms such as fever or lower abdominal pain.
I’m not aware of any research finding that you can reduce infections or improve outcomes by giving chronic antibiotics to someone with an indwelling urinary catheter. Bacterial resistance to Septra is quite common.
So I think the nursing home doctor’s reluctance to start chronic antibiotics sounds reasonable medically. But his job is not just to make a medically reasonable choice, it’s also to partner with you as your husband’s health proxy, and in this, it sounds like he’s not doing a good job at all.
In terms of your specific questions:
– #1: see above. Basically sounds hard to tell what is causing your husband’s symptoms.
– #2: As far as I know, a doctor is generally not required to implement the recommendations of a specialist or anyone else. Usually, it’s the PCP who refers to a specialist, but sometimes patients go see specialists on their own. Specialists do often prescribe directly to patients, but this gets trickier when a patient resides in a nursing home or facility. If a primary doctor and specialist are disagreeing about how to manage a particular problem, it is best for them to talk to each other and resolve the disagreement, or for the patient to stop seeing one of the clinicians. Again, this is harder to do when someone is in a nursing home and has limited options for a primary care provider.
– #3: Patients have rights in relation to their doctors, especially regarding access to their own medical information and privacy. You can learn more about many of those rights on the government’s HIPAA website, see here. Patients also have rights based on state law. As your husband’s proxy, you usually would enjoy similar rights. Honestly, I’m not sure what your options are if the doctor “won’t listen” to you. I doubt that you can truly compel a doctor to provide any specific evaluation or management. Generally, I recommend that people be polite but persistent in requesting more communication with their clinicians, and put things in writing as well. Reference any available rules or standards to bolster your case. You can also raise the possibility of legal action and malpractice, especially if what the doctor is doing is very dangerous or obviously not in line with the standard of care and best available evidence. However, that tends to make the relationship more negative, which is not great for patients and families.
Another option you could explore would be to talk to the nursing home about your concerns and also look into the long-term care ombudsman for your location. Your local Area Agency on Aging might also have ideas as to who can provide more information regarding your legal rights. Last but not least, there are probably elderlaw attorneys with nursing home experience in your area, but this would be a more costly approach.
#4: As far as I know, bacterial pneumonia would not be expected to result from urine bacteria (unless the person first developed full-blown sepsis in the bloodstream). My guess is that the pneumonia is the result of your husband being older, frail, and at generally high risk for infection and illness.
Unfortunately, your husband is likely at somewhat high risk for infection no matter what his doctors prescribe or don’t prescribe. If he has an enlarged prostate and won’t be able to urinate on his own, you could try to find out whether something other than an indwelling catheter is an option, such as intermittent catherization (we used this in the VA nursing home where I once worked).
I do think it’s important to have a decent working relationship with whichever doctors can prescribe medications and provide care in the nursing home. This might take some time and persistence for you to work out. If you can’t work it out with the current doctor, you will have to see if it’s possible to switch to another doctor, or perhaps even another facility.
I’m sorry you are in such a pickle. Do try to step back a bit to see the forest for the trees. I can’t tell from here whether these urine antibiotics are really worth you fighting for or not. I do think it’s a bigger problem that the communication with the doctor sounds difficult. Good luck working that out, and don’t forget to take care of yourself and get some support from other caregivers if you can (many have been in similar situations…)
I came across this article while looking for information to clarify recurring (apparent) UTIs with none of the usual symptoms – no fever, no frequency of urination, no pain when urinating, no pain anywhere. At the time (July, 2017) I just felt awful – no energy, weak – for 2 days. Because I was out of town, I went to an Urgent Care office where I was diagnosed, after UA & blood work, with a UTI and prescribed macrodantin. This seemed to clear the UTI. However, since then, I’ve had a repeat of symptoms 3-4 times and been given antibiotics, though never the same one. Cultures were done 2-3 times and confirmed bacteria in the urine. The latest occurrence was a week ago – same weak feeling, no other symptoms. A clean catch UA was done & confirmed bacteria. This time I was prescribed Keflex 1000mg 2x day which the doctor feels should finally clear the problem. After reading this article & the following questions, I wonder if the issue is actually the asymptomatic bacteriuria (sp?). The doctor had mentioned an ultrasound of the bladder area if the latest culture had shown no bacteria. Would this be a good idea anyway?
You don’t say how old you are, but yes, if you keep having positive urine cultures, then it’s certainly possible that your bladder is colonized.
Feeling weak with little energy is what we would call a “non-specific” symptom, it could be caused by all kinds of things.
You might want to ask your doctor about checking your urine for a culture at a time when you are NOT feeling unwell. Right now they are presumably only checking when you have these non-specific symptoms.
You could also try waiting a few days, next time you have symptoms, especially if it seems you might be colonized. Things often get better with time and non-medical approaches, like getting lots of rest. If you are worried about developing a serious infection, talk to your doctor about what kind of signs/symptoms to look out for.
Whether a bladder ultrasound is likely to help depends on a lot of things, including your past medical history, your other symptoms, and what kinds of problems the doctor has already checked for. Generally, imaging of the urinary tract is not useful, see this study.
Good luck!
I was going to edit my previous post but can find no option, so —
It occurred to me to add that I’m 69, in good health; nothing has particularly changed in my daily habits or my eating/drinking. My doctor reminded me to drink plenty of liquids, be mindful of how I wipe after bathroom visits… Again, nothing different.
Thanks for this additional information. Yes, I would still make the same suggestions as above.
My 87 year old mother had 3 episodes of gross hematuria. After the 2nd one, her doctor prescribed a course of Ciprofloxacin suspension, 5ml twice a day for 7 days. She then had another episode of gross hematuria. A urinalysis was done: Negative for urine culture growth; however, microscopic analysis showed HI bacteria and erythrocytes 1-2. Does this mean she does or does not have a UTI? Could the HI bacteria be caused by contamination in obtaining the sample? (She did not let me wipe her with the wipe provided, plus she is unable to do a true mid-stream) I don’t want to give her more antibiotics since she had a terrible case of diarrhea from the 1st round. Could there be another cause of the gross hematuria?
Yes, having some bacteria visible but a negative culture can be caused by a contaminated sample. It’s certainly often hard to get a clean-catch in an older person.
If her urine culture is negative, then it is often reasonable to look for other causes of hematuria. The Mayo Clinic has a good list here:
Blood in urine (hematuria)
Generally it would not make sense to treat hematuria — or other urinary symptoms — with antibiotics, if the urine culture is negative. Good luck in figuring out your next steps with your mother.
I found your explanations/replys quite informative as I have a family member in a nursing home with persistent “UTI’s that
noone has been able to explain thus far. I have tried to get answers and it goes nowhere, almost like the mefical staff does not understand the dufferences between the problems and antibiotics being given, although they claim the cultures come back positive all the time
And there never seems to be folliw up as to whether or not the original uti cleated up until a medical issue happens and they check for one
Glad you found the article informative.
Well, if your relative is in a nursing home, you may want to ask if the issue might be asymptomatic bacteriuria rather than “persistent UTI” or “recurrent UTI”. It’s extremely common for nursing home residents to have their bladders colonized with bacteria.
Generally doctors will not repeat urine cultures after antibiotic treatment to see if the issue has “cleared up.”
Good luck!
What a relief to find this site. I have had an off again on again UTI since November. It started with cloudy foul smelling urine but no other symptoms. I bought the urine test kit and due to the positive Leukocyte results scheduled a dr visit. They ran a urinalysis and told me there was book in the urine and prescribed amoxycillan for ten days. They also ran a culture. I took the amoxicillan and the cloudiness and smell cleared up, so I thought I was cured. Five days after completing the ten day amoxicillan regime I recieved a clan from the pharmacy that my script was in. I had never been contacted by the dr, so I called and the receptionist told me that the urine culture showed amoxicillan resistant ecoli, to stop taking the amoxicillan and take Bactrim. My mother was allergic to Bactrim and since I was having no symptoms I got the script but did not take it. Then I had the flu, and approx 1 week later the cloudy smelly urine returned. No other symptoms. All my research said you MUST treat it with antibiotics. After three days I decided to take the Bactrim. Immediately the symptoms cleared, but on the fourth day hives appeared on the back of my neck so I stopped taking the Bactrim . Another month and the cloudy smelly returned, then went away after a couple of days. I always “flush” by monitoring my water intake to assure I’m getting approx 64 ozs daily. I am 66 yrs old and weigh 125 lbs. no other health issues, no other meds. I do NOT have a PCP but am scheduled to get one. I want to discuss this with them, for I think I might be an asymptomatic, but if they test and culture I’m sure they’ll freak and prescribe another round of antibiotics, I would prefer a wait and see attitude. Is this a wise choice based on my experience?
Blood. They said there was blood in my urine. Not book. LOL I have since purchased the 10 spots strips and tested posite +, ++’ and +++ occasionally but NEVER positive for blood or anything else.
Microscopic blood in the urine can be associated with UTI but also with other things. If it only happened once and has gone away then it’s much less worrisome, but best to ask your doctor to be sure.
As I explain in the article, if you have no symptoms of UTI but a positive urine culture, you may well have asymptomatic bacteriuria, and in most cases, this does not require treatment with antibiotics. So, what you are suggesting sounds reasonable. If your new PCP recommends treatment, he/she should be able to explain why.
Also, as noted in the article, foul-smelling urine on it’s own is not sufficient to diagnose a UTI.
Last but not least, even in cases of true UTI, delayed treatment has been studied and many women experienced improvement of their symptoms with no antibiotic treatment…so a careful wait and see attitude can certainly be reasonable.
My 90 year old Mom has been more and more confused lately. Urinalysis showed slightly over range WBC, RBC, leukemia esterease and epithelial cells but no bacteria or nitrites. The culture was negative. Could it still be a UTI or does there have to be bacteria? Should we have her tested again?
If the culture is negative, then it is not a UTI. (And it’s not asymptomatic bacteriuria either.) As far as I know, falsely negative urine cultures are not very common.
A much more likely explanation is that your mother’s recent confusion is due to something else affecting her physical health or perhaps her brain function specifically. She needs an evaluation for delirium causes and triggers. Normally we look for signs of new illness, we consider the possibility of medication side-effects, we consider bloodwork to check for electrolyte imbalances, and then we also consider the possibility of pain, constipation, and dehydration.
You don’t say how quickly this confusion has worsened, but sometimes it reflects the progression of vascular (which means small or larger blood vessels) damage to the brain, or even progression of an underlying neurodegenerative condition affecting brain cells.
We would still normally start by looking for delirium causes. You can learn more about them here: 10 Things to Know About Delirium. Good luck!
I have an ileal conduit after my bladder was removed over 3 years ago. Since last Sept I have been treated for 8 positive cultures, but only had symptoms in 3 of those cases. In 7 of the 8 I was given antibiotics. But now, all my doctors, (PCP, Uro, and infectious disease) agree not to treat asymptomatic cultures any longer. I did have kidney damage shown on my last CT scan in Feb. My problem is with identifying kidney pain. I have back pain for 40 years so it is hard to tell my usual back pain from kidney pain. The pain is mild and not constant. I was put on Ellura by my Urologist last month for uti prevention. Have you heard of it? I’ve been taking Dmannose for years prior. Also, if I have a true uti in my upper tract (I have no lower) how bad or constant would the flank or back pain be if it was inflamming my kidney(s)?
Hm, well your situation is quite unusual, with no bladder remaining. I don’t know anything about ileal conduits, any related infection risk, or even asymptomatic bacteriuria in the upper urinary tract.
Generally, based on my experience witnessing people with infections in various parts of the body, I would think that a significant kidney infection will be quite painful and the pain will be fairly constant. But sometimes people have milder or slow-burning infections that can cause milder or vaguer symptoms, I suppose that’s possible for this situation too.
A urologist would probably be better positioned to answer this type of question about kidney infections.
I’m not familiar with Ellura but looks like it’s a supplement based on a cranberry compound. Presumably at best it would be as effective as concentrated cranberry extract, which studies find is generally not very effective. Good luck!
Thank you for your reply. There are many thousands of us out there with urostomys. While not as common as colstomys, there are plenty of us. I’m always surprised how little urologists who do not specialize in bladder cancer know about urostomys or urinary diversions in general. But even with those that do, the depth of knowledge about post cysectomy utis/colonization is strikingly low. I appreciate your input though. Yes I’m in a difficult situation, so I reach out for any info I can find. I believe that your views on asymptomatic uti’s are spot on, and I only wish more urologists and MDs in general would quit treating them with antibiotics at the drop of a hat. Thanks again.
Yes, urostomy is overall not terribly rare, but given that there is so much misunderstanding about UTIs and asymptomatic bacteriuria (conditions that are not at all rare), I’m not surprised to hear you’re noticing a lack of knowledge relevant to infection and urostomy.
If you haven’t already done so, you may want to see if you can find any online communities of other people with urostomy. This can be a better way to find out about the latest research on your situation. Although honestly, it looks like perhaps there hasn’t been much research done on this topic; when I search google scholar, there is an article on Microbial colonization of human ileal conduits, but it is from 1984 and has only been cited 22 times since…but if you dig around, you might find a urologist somewhere who is studying this.
Good luck!
My mother was diagnosed with a UTI in Feb during pre-op checks for a knee replacement surgery. Her right knee joint was replaced last year in May and those tests were clear. From Feb this year, the UTI issue has kept lingering. In March, she was hospitalized for 5 days to administer IV antibiotics since the strain was resistant to oral drugs. Her creatinine came down from 2.4 to 1.1 and other kidney parameters settled. A CT scan of the kidney region had also been done to rule out other reasons for kidney infection. We repeated the test to see if the surgery can now be done and the same Ecoli infection still shows. The drs will not operate until the infection is nullified since it may impact the implant. What is your advise in such situations?
Sorry but I can’t provide any advice. Your mother’s situation sounds particularly complicated and is well beyond a garden variety “UTI vs asymptomatic bacteriuria” question. There is the question of what is surgically safe (which is for orthopedists to answer) and of her kidney health, which is for urology. You may want to consult with both those types of specialists for a second opinion. Alternatively, some medical centers offer special second opinion services during which they extensively review a patient’s chart and consult with their specialists, and then offer an opinion. UCSF’s service is here: UCSF Second Opinion.
Good luck!
I am a 64 yr old female with Lupus/Sjogrens & a multitude of other diagnosis as well as incontinence. I have just gotten home to find the urine test & had earlier today came back with WBC/occ RBC/rare, cast cells/few & Bacteria/occas. it has been sent for culture. This is the 5th time this year & usually the bacteria is too numerous to count. I usually have been treated with Keflex but now a urologist I’ve seen wont prescribe antibiotics. My symptoms start with foul smell/urine, great distress in abdomen & sometimes flu like feeling. My argument with the urologist is that I already have a suppressed immune system & any bacterial infections do not get better, only worse, if not treated. I am requesting that I get a cystoscopy to see what the health of my bladder is. I would appreciate any insight to my dilemma. Thank you, Cindy
Sorry to hear of these concerns. Well, your medical history sounds complicated, as you point out you have autoimmune diseases and are perhaps taking immunesuppressing medications to control your lupus, so special consideration sounds warranted. Also you describe abdominal pain, so you might be meeting criteria for a clinically significant UTI, rather than asymptomatic bacteriuria.
I don’t know that a cystoscopy would particularly help resolve the question of what should be done about recurrent bacteriuria/UTIs, and when/whether to prescribe antibiotics.
Generally I would recommend discussing further with your urologist. It might help to clarify to him what your priorities are regarding your health, and ask for his/her help. If it’s that you’re very worried about an infection getting out of control, tell them that, and ask what they propose to address this concern.
You may also want to consider getting a second opinion.
Hello, I am the caregiver for my mother who was diagnosed with dementia. Within the past week she has been acting extra delusional, seeing and talking to people that aren’t there , ect. I’d heard about UTI’s causing more delusions in the elderly so I took her to get a UTI test . When she gets nervous her bowels get loose and when she urinated in the hat for urine some feces got into the ruins to be tested . I told the Dr. about this and she said she’d take note . She said the dip test came back negative but they would send away to the lab to test for a longer culture . They called a few days later and said she had ecoli bacteria that grew and she needs to start on antibiotics. Do you think that it’s really a UTI or do you think it’s just a tainted result from fecal matter?
Thanks
Hm, this sounds a bit tricky.
Often in a urine culture they can detect contamination because there are several strains of bacteria that grow in the culture. (Feces contain lots of different bacteria, in pretty ample quantities.) They might also see a lot of cells or actual fecal material. You might want to ask your mother’s health provider to explain why they think the positive culture is unlikely to represent contamination of the sample.
Otherwise, if your mother with dementia has become more delusional or otherwise more confused, that sounds like potential delirium. Yes, UTIs are a common cause, however there are a number of other common conditions that can cause this too, such as medication side-effects, metabolic imbalances (e.g. too high/too low levels of sodium or calcium in the blood), kidney or liver problems, etc.
So, I would say it’s important to not be too narrowly focused on UTI, when evaluating an older person with increased confusion. Good luck and hope your mother feels better soon.