Urinary Tract Infection

Refers to acute infection of the bladder (cystitis) or kidney (pyelonephritis) and applies to patients presenting with no, mild or severe urological symptoms across various health care settings

Special Clinical Circumstances

The 2019 IDSA guidelines removed delirium as a reason to call bacteriuria "symptomatic"

Watchful waiting and investigating other causes is now a strong recommendation for delirious elderly with bacteriuria without urinary symptoms such as frequency, urgency, burning or supra-pubic discomfort

Watchful waiting is also recommended in elderly patients who experience a fall, regardless of mental status change

Delirium in the elderly should be worked up for:

  • dehydration

  • new medication side-effects or interactions

  • trauma

  • hypoxia

  • hypoglycemia

  • other infections

Antibiotic therapy in such cases has no benefit and is associated with harm such as antibiotic resistance and C. difficile infection

Sending urine for urinalysis and culture in otherwise asymptomatic individuals who are functionally impaired or residing in long-term care is no longer recommended

Many elderly with delirium have bacteriuria or pyuria. Urine should not be sent for urinalysis or cultures due to a cloudy appearance or foul smell.

Diagnosis of UTI requires a combination of reliable clinical signs and symptoms and a positive urine culture for bacteria and white cells

Do not send urine for culture or perform urine dipstick testing in patients who are asymptomatic (except pregnant patients or those undergoing urological procedures), including those with catheters

Cloudy or foul-smelling urine is NOT an indication for urinalysis or urine culture

Pyuria in an asymptomatic patient is not an indication for treatment

No magnitude of pyuria or bacteria warrants treatment without symptoms

There is no evidence that antibiotic therapy is beneficial in asymptomatic patients except in pregnancy or prior to genitourinary procedures in which mucosal trauma is expected

Empiric Therapy and Treatment Pearls

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