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 bacteria in the urine, 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. People often think that your friend is having a “recurring urinary tract infection (UTI)” or even a chronic UTI. But actually, 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. Asymptomatic bacteriuria is even more common in nursing homes, where it’s estimated to affect 30-50% of residents.
- 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 older adults 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.
I also did a two-part interview with colleague and expert Chrissy Kistler, MD, on this very topic.
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, no study has shown that 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!
Guidelines recommend that older adults be treated for UTI with antibiotics only if they are showing clinical signs of UTI.
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 aging adults 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 have debated 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 overwhelmingly find that in most people, treating asymptomatic bacteriuria with antibiotics does not improve health outcomes. Even when it comes to the nursing home population, which is frailer than the general population, a 2022 systematic review found that antibiotic treatment of asymptomatic bacteriuria didn’t improve 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 when it comes to the nursing home population, which is frailer than the general population, a 2022 systematic review found that antibiotic treatment of asymptomatic bacteriuria didn’t improve outcomes.
Despite the expert consensus that this condition doesn’t warrant antibiotics, inappropriate treatment remains very common. A 2014 review article on this topic noted overtreatment rates of up to 83% in nursing homes. To combat this issue, this 2023 BMJ article outlines an approach nursing homes can take: Reducing unnecessary urine culture testing in residents of long term care facilities.
Why older women should consider topical estrogen to prevent UTIs
For older women who might be having recurrent UTIs (or who appear to have asymptomatic bacteriuria), an important option to consider is topical estrogen.
In particular, studies have found that applying estrogen to the vagina reduces UTIs in post-menopausal women.
(Topical estrogen has other benefits as well, such as reducing stress incontinence and making sex more comfortable in later life.)
Topical estrogen can be applied as a cream twice a week, or is also available as a vaginal ring. To explore these options, I recommend seeing a health provider at a uro-gynecology clinic. These are often staffed by nurse practitioners who are very experienced at helping older women with their pelvic health.
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. Specific symptoms to check for include dysuria (painful urination), fever, and lower belly pain.
- 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
If you’re dealing with a positive urine culture:
- If there are definite clinical UTI symptoms:
- Talk to your health provider to get appropriate antibiotic treatment
- If there are vague symptoms (such as increased confusion or fatigue):
- Geriatricians often use a watchful waiting approach. We encourage the person to rest, and we monitor to make sure we don’t miss any increase in illness severity. Most older adults do get better on their own, over a few days. (Or, another cause is found for their vague symptoms.)
- Signs of worsening illness can include developing fever, profound weakness, low blood pressure, and a higher than usual heart rate. Don’t hesitate to get more medical attention if these signs develop.
- Geriatricians often use a watchful waiting approach. We encourage the person to rest, and we monitor to make sure we don’t miss any increase in illness severity. Most older adults do get better on their own, over a few days. (Or, another cause is found for their vague symptoms.)
If you’re dealing with real recurrent UTIs:
- For women, definitely consider topical estrogen.
- Talk to your health provider about possible preventive medication, such as methenamine, or in select cases, prophylactic antibiotics.
In short: I’d summarize the benefits and burdens of treating asymptomatic bacteriuria in a 90-year-old 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. The second part of my two part interview with Chrissy Kistler, MD, focuses on UTIs in older adults with Alzheimer’s and related dementia.
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:
- Reducing unnecessary urine culture testing in residents of long term care facilities
- 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
This article was first published in 2015. It was reviewed and updated by Dr. Kernisan in August 2025. (The basics about asymptomatic bacteriuria and UTIs in aging adults don’t change much!)
Susan says
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.
Leslie Kernisan, MD MPH says
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!
Rebecca Kidder says
Did you hubs get better? You can treat bacteria naturally as well as these bacteria have become more and more resistant to antibiotics.
Mark Blondin says
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
Leslie Kernisan, MD MPH says
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).
Nickiw says
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?
Leslie Kernisan, MD MPH says
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!
Karla Vanessa Zuniga says
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
Leslie Kernisan, MD MPH says
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.
Betty says
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.
Leslie Kernisan, MD MPH says
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!
Lisa says
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?
Leslie Kernisan, MD MPH says
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.
Barbara Rose says
Ok I have MBL OR MANNOSE BINDING LECTIN DEFICIENCY . It’s a problem with my immune system . All of a sudden I can’t hold my urine go to kidney dr he gives me myrbetiq works great /: next visit he does a bladder scope I ask for antibiotics he says he gives them out after this test he then mentioned I have low levels of enterococcus in urine tells me to take pills for 3 days but gives me 5 days nitrofurantoin . My question is ? Do I have a problem ? 2 months ago I though I had a infection cause of bad back pain did 2 prior tests nothing came back? Except mucus and I am totally confused ? 65 years old and just found out my immune system is funky ? Thank
Leslie Kernisan, MD MPH says
I don’t know much about mannose binding lectin deficiency, according to the NIH it seems that it’s of unclear significance in adults: https://ghr.nlm.nih.gov/condition/mannose-binding-lectin-deficiency
I would recommend consulting with a specialist with experience in immune conditions. They would be able to review why you were diagnosed with this condition, and offer a second opinion. Regarding the urinary issues, you may want to get a second opinion for those. good luck!
Fred W Frank says
Can bacteria form or multiply in urine samples several days old prior to being analyzed? How important is freshness in a sample?
Leslie Kernisan, MD MPH says
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.
Lana says
It takes 24 to 36 hrs for a culture
Gerald Arcuri says
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?
Leslie Kernisan, MD MPH says
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.
Victoria Baker says
Maybe u can help me. For yrs I’ve had excruciating pain on r side. DRS WERE convinced it was from bad MESH. NOW it hurts like crazy when I urinate. A culture was done NO UTI. But I got moderate amount of sediment coming thru me. Foul smell dk urine. Macrobid makes the stream better an the frequency of going. When done with Macrobid it all comes back. An now Dr’s say no UTI SO NO ANTIBIOTIC? AN IN PAIN EVERYDAY WITH ALL SYMTOMS ABOVE. FEEL WEAK & TIRED AS WELL.
Leslie Kernisan, MD MPH says
I’m sorry to hear of your pain and unresolved medical issue. It sounds like it might not be clear to your doctors what is causing your pain. Unfortunately I can’t help, you will need to keep working with health providers until you find someone who can help you sort it out. You may want to try seeing a specialist in urology. You may also want to ask if you might have interstitial cystitis, which is a chronic painful bladder syndrome.
Some people also find it helpful to see a health provider trained in functional medicine, as they take a more comprehensive approach and they are sometimes able to figure out chronic pain/weakness conditions that have regular doctors stumped. Good luck!
Roxanna Johnston says
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.
Leslie Kernisan, MD MPH says
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!
Victoria Baker says
MY Mom was getting UTI’S ALL THE TIME. DRS WERE PUTTING HER OFF AS WELL. THAN 1 DAY SHE GOT JAUNDICE. DR FOUND A STONE IN HER LIVER. SPECIALIST HAD TO POKE IT OUT OF LIVER AN ERCT HAD TO GO IN AN PULL STONE OUT THRU MOUTH. NOW NO MORE UTI’S NO MORE DISTENDED STOMACH AN MA IS FINE.
Leslie Kernisan, MD MPH says
Hm. Well, it sounds like your mother had gallstones in her bile duct. This can cause belly pain, and can also cause jaundice if the bile duct is completely blocked. The treatment in this case is removal of the gallstone through an ERCP procedure (which is a type of endoscopy, so they put a tube down the mouth and into the stomach and beyond, which is where the bile duct drains out).
Gallstones would not cause UTI, and UTIs are not associated with distended stomachs. It’s possible that the belly pain related to gallstones was incorrectly attributed to a recurrent UTI. In any case, I’m glad she is better.
vanaly palmer says
WHY don’t you use a ‘hat’ to collect the urine and let her sit on a stool with arms???
Leslie Kernisan, MD MPH says
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.
Judith Williams says
Dr. Kernisan,
I have gotten many clean urine catches by having the person sit on a shower chair.
I hope that this will be helpful to someone.
Sincerely,
Judith
Nicole Didyk, MD says
Thanks for sharing your experience, Judith!
Em says
It sounds like you Mom should be sent to see a Uro-gynecologist. Roughly 50% of women who have had childbirth will develop pelvic organ prolapse (fallen bladder is part of this). This can create urinary retention and help grow UTI infections. If your Mom is not taking HRT, then genito-urinary atrophy can also be an issues contributing to vaginal/bladder pain and infections. Low Estrogen states mean the genito-urinary pH changes, allowing infection to grow. My Uro-gynecologist Rxs estrogen vaginal cream to women with these issues. HTH.
Sher says
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.
Leslie Kernisan, MD MPH says
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.
Sheila Oldring says
I have been suffering for years with what I thought was uti’s but now realise it most likely a asymptomatic bacteriuria. This has never been mentioned by the doctors. I have had antibiotics and two medical procedures which do not seemed to have helped. I had a scan Friday, my kidneys seem fine but I’m not able to completely empty my bladder. Whst can be done to improve this?
I shall be seeing my doctor in next few weeks, help!!
I am not in antibiotics at the moment but am taking D-Mannose. This does seem to help. Some mornings I have nitrites snd white blood cells are rife but then by the evening zero nitrates and white blood cells less in my itinerary stick test.
Whst shall I say to my doctor please?
Thank you
Sheila
Nicole Didyk, MD says
Hi Sheila and thanks for your comment!
It sounds like you’re checking your urine at home with a stick test and I’m not sure why you’ve been advised to do that. Asymptomatic bacteriuria doesn’t typically cause symptoms, hence the name. I’m also not sure what procedures you’ve had done. If you’re not emptying your bladder completely, that has me wondering about urinary retention, which can be related to medication side effects or a number of other things.
It’s always a good idea to ask about any medications that could be contributing to your symptoms, whether an opinion from a urologist would be helpful, and whether there are any exercises or lifestyle changes that you could make to help.
Good luck!
Em says
re: dangers of chronic antibiotic use. C.diff, damage by antibiotics (Cipro can cause leg tendon damage, making it hard to walk), Colitis, a type of IBD can be triggered by chronic antibiotic use, and also, it helps other infections to move in, when we wipe out the body’s microbiome.