Background
Urinary tract infection (UTI) accounts for 1–3% of primary care consultations and 13.7% of community antibiotic prescriptions in the UK; worldwide, UTI affects around 92 million people annually.[1] The incidence of UTI increases with age and it is the most commonly diagnosed infection in long-term care facilities,[2,3] where 1-year recurrence rates are as high as 50%.[4] Although updated NICE guidance is timely,[5] they do not seem to have fully taken account of older people for whom UTI is a common presentation.
Ruling UTI in or out can be especially difficult in older people who often present with 'atypical' or non-specific presentations. Non-specific presentations include immobility, confusion, falls, incontinence (the 'geriatric giants')[6] and reduced functional abilities.[7–13] It can be difficult to assess lower urinary tract symptoms (LUTS) in older patients due to cognitive impairment and the high prevalence of chronic LUTS that are seen in conditions such as overactive bladder and genitourinary syndrome of menopause.[14]
A specific consideration in the context of older people is the frequency of asymptomatic bacteriuria (ASB), which should not be treated,[15–18] but may be misinterpreted as the cause of the presentation.[19] As many as 25–50% of older women and 15–40% of older men in long-term care facilities are bacteriuric.[20] Assessment can be further confounded if there is a urinary catheter in situ (due to less reliable symptoms or signs) and with bacterial colonisation of catheters being the norm.[21,22]
On the other hand under-diagnosis is also an important risk, as typical clinical markers for infection may not be helpful. For example, fever is neither sensitive nor specific for infection.[23] The pressure on clinicians to treat possible sepsis is significant, with national policies in place driving early and rapid treatment decisions.[24] So while avoiding over-treatment is important, it needs to be balanced against the risk of under-diagnosis and the development of sepsis.[25]
Existing guidelines[17,26,27] vary in their recommendations, often highlighting the difficulties in older people in whom tests are poorly validated[28] and ASB is common. The complexity surrounding the diagnosis of infection in older people can lead to uncertainty about treatment.[29] Over-treatment incurs the risks of unnecessary exposure to antibiotics and the associated side-effects (e.g. Clostridioides difficile infection), as well as of antimicrobial resistance, which means that the true explanation for the patient's presentation might be missed.
Age Ageing. 2023;52(3):afad013 © 2023 Oxford University Press
Copyright 2007 British Geriatrics Society. Published by Oxford University Press. All rights reserved.
