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.
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!
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.
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
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.
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 February 2024. (The basics about asymptomatic bacteriuria and UTIs in aging adults don’t change much!)
Ellie says
I recently had a physical that included bloodwork and a urine test. The urine test came back with a 1+ for WBC Esterase and many bacteria although everything else was normal. I have not symptoms of a UTI. I do have a carunkle. I also did not use the vaginal wipe when collecting the urine. Should I be concerned that I do have a UTI or something else?
Nicole Didyk, MD says
This sounds like a case of asymptomatic bacteriuria, unless you are having urinary tract symptoms like pain or burning with urination, fever or a change in the smell of your urine.
A caruncle is a benign vascular growth in the urinary tract, more common after menopause. They can become inflamed but aren’t typically associated with infection.
Tali says
like many here my mom who is 92 suffered from securing UTI and after few antibiotic treatments and the UTI back after few weeks, urologist just said to stop the antibiotic and that some elderly people have bacteria in Urine.
My mom show signs of Delirium and as far as i know has no Dementia, the question is ,if a UTI can cause delirium and usually Urine should be sterile , how come experts don’t think that presence of bacteria in Urine can cause delirium( even without UTI symptoms), i mean bacteria in UTI can cause it so why not just the Presents of it?
Nicole Didyk, MD says
Your question really shows how tricky this issue can be!
Delirium has a specific set of symptoms including a sudden onset, serious changes in alertness or concentration, cognitive changes and fluctuations (symptoms come and go over a period of minutes or hours). Delirium can be due to a UTI and can be the only symptom of a UTI in a frail older adult. So if a person has persistent delirium symptoms after their UTI has been treated, that might be a reason to look for other causes.
The asymptomatic bacteriuria that Dr. K mentions is when the urine shows bacteria but there’s no delirium or other symptoms. That’s when antibiotics don’t help and may do harm.
Sandra Wilson says
I am 74 years old and am colonized or least the ure-gynocologist and infectious disease doctor. Although my cultures have bacteria below the infectious level, my colonization is not asymptomatic. I have frequent urination, an aching burning sensation, fatigue etc. The symptoms come and go but cause me a lot of discomfort. I am on Hiprex, estrogen, vitamin c, cranberry supplements, tropsium, and lots of fluid. What could be causing the symptomatic colonization? I am really miserable. Do you have any suggestions to improve my situation.
Nicole Didyk, MD says
I’m sorry to hear that you’re miserable, and it sounds like you’re seeing the right specialists.
Colonization doesn’t usually cause the symptoms you describe, in fact, it’s usually asymptomatic (that’s part of the definition of colonization) so that’s a bit puzzling. People with colonization can be more likely to have infections, though, so it’s possible that the symptoms are indicating an actual infection.
There are a few factors that can increase the risk of colonization, and some of them have to do with the type of bacteria that is doing the colonizing. Individuals may have certain features of their bladder microbiome that promotes colonization and asymptomatic bacteriuria as well. I couldn’t find any good scientific data about the use of probiotics for urinary tract infection.
Lyn says
Hi
I’m 36 and had this for about 2 years. I have frequent UTIs and no symptoms. I have in the past taken antibiotics but it always returns. I know it’s infected from the smell.
🙁 I don’t want to take more antibiotics, but I was worried it would lead to more trouble if I left it?
Nicole Didyk, MD says
That sounds frustrating. I usually look after older adults so I’m not sure what the best advice is for someone in your age group. I hope your primary care provider can give you some guidance and thanks for leaving a comment.
Bo says
HMO Drs have only minutes to offer each patient, and allready concerned with the next during the precious few minutes they can devote to each
As a result ime they are generally quite unwilling to go beyond the Typical Reasons For Most Complaints
Those of us who are younger have great difficulty being listened to when it come to matters such as this, where we fall outside the usual parameters. We are most often stuck between taking the automatically prescribed antibiotics with no real follow up, or going it on our own with folk/herbalist advice and hoping for the best
I realize that as a geriatric provider you have no realm of expertise with which to directly advise we youngers, but perhaps offering some resources to try for next steps would be more helpful to us than a simple, I’m Not Your Doctor So Sorry But Good Luck
Nicole Didyk, MD says
Thanks for the feedback. Here’s an article at the National Association for Continence website that might be of interest: https://www.nafc.org/bhealth-blog/recurrent-uti-what-it-is-and-what-to-do-about-it
It’s a very thorough review of the mechanism of UTI and what to think about if a person seems to be getting recurrent infections.
Lori says
Help. I have no infectious disease docs near me that have higher than a one star review. I have a uti with E. coli for years n years. I have symptoms that are minor , so I’m prob more asymptomatic than not. However , I worry that this will affect my kidneys as I get flank pain and pain in my kidney area as well. I need to find a doc – I need suggestions. Help please. Everyone in my family ( I was adopted and told this info ) died from kidney disease. I has a urologist for my kidney stones. The kidney docs won’t see me without a urologist and the urologists are horrible to 61 year old women. Does any large hospital have a place ( NYC ? , Maryland ?, Ohio ?) that can do it all for me under one roof. I don’t want to die from this. I had sepsis back in July from this as it got into my ear. Thank you.
Nicole Didyk, MD says
Hi Lori. I’m sorry to hear that you haven’t had a positive experience with your health care.
I’m not sure that online reviews are the best way to decide whether to see a doctor, although I know a lot of people read them. It also sounds like you have a lot of concerns that cover many body systems, so a specialist may not be the best provider to take a holisitic look at you, unless that person is a Geriatrician.
A good place to start is with your family doctor or other primary care provider. They will probably be able to determine which specialist is right for you, and should know about the resources in your area.
You may also want to look at the Mayo Clinic or Cleveland Clinic, which can do a comprehensive assessment, although this is usually quite costly and may involve travelling to that site.
Dian says
Very informative article and Q&A. I worked as a nurse for a urologist in the 1970’s to 80’s. He always stressed that there was a strong correlation between chronic constipation when bacteria was found in urinalysis. He prescribed taking fiber and drinking prune juice. Patients who complied had much less bacteria in follow-up UAs, fewer symptoms and felt better. Seems worth a try.
Nicole Didyk, MD says
There’s no doubt that keeping the bowels moving reduces urinary retention and incontinence, and subsequent urinary tract infection. Prunes and fiber are good , natural remedies for constipation, especially when combined with an adequate fluid intake. Your colleague was giving you sound advice!
JOANNE MOORE says
I’ve just gone through two courses of antibiotics for a UTI and my home test strip shows very positive for Leukocytes. (And the doctor’s test showed positive for a UTI.) I was going to take another prescribed course of Macrobid but decided to hold off because a skin biopsy became infected and I was put on doxycycline for ten days and didn’t want to take two different anti-biotics at the same time. I have no UTI symptoms. I’ll soon be 78 years old and have a couple of autoimmune illnesses. Could I just have a colony that won’t go away? I don’t have diabetes but I confess to being a sugar-aholic.
Nicole Didyk, MD says
You make a great point about not wanting to be on two antibiotics at the same time, and many people prefer to avoid them in general. In the medical community, we have concerns about too many courses of antibiotics because they can cause side effects, and can lead to bacteria that are resistant to common anti-bacterial drugs.
As Dr. Kernisan explains, we don’t want to treat asymptomatic bacteriuria with antibiotics. So, it really depends on your symptoms if treatment is needed. If recurrent antibiotic therapy doesn’t alleviate UTI-like symptoms, that is a good time to look at other issues that are affecting the bladder and the rest of the urinary tract. Some individuals do develop colonization of the bladder wall, which can cause symptoms and may require a different treatment approach. Best of luck.
Linda says
I was diagnosed with acute uti and had a negative culture but was given antibiotics. I continue to have discharge and it is now yellowish. My gyno doesn’t think it’s from my silicone permanent pessory and advised me to soak in bath with some epsom salt but nothing has changed. Should I worry? I can not remove the pessory myself and now with Coronavirus lock down I am not able to see my gyno. What should I do?
Nicole Didyk, MD says
Hi Linda. I’m not an expert in the use of pessaries, and I would defer to your gynecologist’s opinion on this one. Most physicians are still able to provide telephone advice, and many provinces (I see you are in Quebec) have a telehealth hotline where you can speak to a nurse. If you’re concerned, I would reach out to them. Good luck.
Lynn says
Thank you for your excellent article. I need some advice please. I am 61 and haven’t had a UTI in 40 years but developed one about 5 months ago. The symptoms were acute urinary urgency and leakage along with foul smelling urine. (Right before this, I noticed that my urine smelled heavily of ammonia. I thought that it could be dehydration due to Texas heat.) Anyway, 1st culture came back as positive Leukocytes. Was prescribed Cefuroxime 250 mg for 10 days. A month ago, same symptoms, same prescription. Both times, the incontinence got better but never completely went away. Today, I did a home strip which shows positive for Leukocytes. Upon reading your article, I wonder if I really had a UTI and maybe my hormones are the culprit or I have colonization. Maybe I just need to do pelvic strengthening exercises at this point. I’m at a loss. What do you suggest? My insurance won’t cover a specialist and I only have coverage for one more PCP visit this year so I need my treatment to be as effective as possible. I appreciate your help! Thanks again.
Nicole Didyk, MD says
Hi Lynn. White blood cells (or leukocytes) in the urine is usually not considered a definitive sign of an infection, so I would give a similar answer to the one here.
Incontinence can be a sign of a UTI, but can also be related to numerous other factors, and in fact is often related to more than one thing (what we in Geriatrics refer to as being “multifactorial” or having many causes). Dr. K and I have been discussing the idea of collaborating on an article about urinary incontinence, so keep watching the site for that!
Kennedy says
Very interesting article. My mother (85 y/o) experiences frequent UTIs and I buy here Cystex maintenance tablets which have cranberry and D-mannose. Although it seems to have helped her have fewer occurrences of urinary problems, now I wonder if she has urine bacteria rather than a UTI.
Nicole Didyk, MD says
Hi Kennedy. We’ve covered cranberries before in these comments, and my take is that they are not very effective at UTI prevention. That’s a good point about asymptomatic bacteriuria versus an actual UTI. Making this distinction can help avoid unnecessary courses of antibiotic treatment as Dr. K points out. Thanks for reading!