Asymptomatic bacteriuria in long-term care is more common than actual Urinary Tract Infections. About 35 to 40% of men and about 50% of women in long-term care have it –that’s even higher for women with urinary incontinence.
– Jamie Smith, MSN, FNP

When someone is aged and frail, the risk of a bladder infection is higher, raising the chances of delirium, hospital admission, or even death.

In this episode of This Is Getting Old: Moving Towards An Age-Friendly World,  Jamie Smith, a Family Nurse Practitioner in geriatrics and nursing home home care, describes bladder infections and things you and healthcare professionals should know about helping the older adults decide whether or not to treat with antibiotics.

Part One of ‘Bladder Infections:
To Treat or Not to Treat in Older Adults?’

What Is A Bladder Infection? 

A Urinary Tract Infection(UTI) a bacterial infection within the bladder. It’s an acute illness that affects the genitourinary system and is commonly known as a “bladder infection” – and means you you have an infection of your genitourinary system, so your bladder, kidneys, ureters or urethra with a “positive urine” with a urine sample.

The typical symptoms include: burning sensation with urination, abnormal urgency and frequency in urination. In addition, you may have severe pubic pain or “gross hematuria” (where your pee turns different colors like pinkish or reddish).

Asymptomatic Bacteriuria (ASB), also known as a colonized state.  ASB is where you have a positive urine sample, but lack the typical genitourinary symptoms that go along with a UTI. The presence of bacteria in ASB is in quantitative counts of ≥ 100,000 colony-forming units/milliliter (CFU/mL) or ≥ 100 CFU/mL in a catheterized specimen. Thus, in the absence of urinary tract symptoms, asymptomatic bacteriuria is determined by white blood cells in the urine.

It’s critical  to differentiate between UTI and colonized state because when you give antibiotics to older adults, that increases their risk of antibiotic resistance, drug to drug interaction, and increased health care cost.
– Jamie Smith, MSN, FNP.

To Treat or Not To Treat?

Telling the difference between a UTI and ASB is tricky in older adults, especially those in long-term care facilities because localized genitourinary symptoms are far less pervasive in them. Consequently, there have been differences in treatment protocols from place to place regarding a bladder infection.

  • Differences in Protocols For Treatment at ER/Hospital vs Long-term Care settings

Whenever a family member requests a patient to go out because they’re confused about whether it’s a UTI or ASB, one of the first things the ER does is check a Complete Blood Count (CBC) and a Basic Metabolic Panel (BMP). Even if the urine has trace amounts of bacteria, let’s say the patient is confused that they can’t tell if there are any genitourinary symptoms, the ER will typically go ahead and prescribe an antibiotic.

  • Protocols for Treatment at Skilled Nursing Facilities or at Home

Bladder infection treatments are different in long term care facilities or at home because the staff or family members can tell if the older adult is having symptoms.  If the older adult is not having any symptoms associated with the urinary tract, that’s classified as colonized. We don’t treat colonized states because we look at Loeb’s or McGreer’s Criteria, and if they don’t qualify, we don’t treat them because of the risk of harm by giving them an antibiotic.

Risks of Harm in Older Adults 

It’s imperative to differentiate between UTI and ASB (colonized state). Because when you give antibiotics to older adults, that increases their risk of Clostridium difficile (C. diff),  antibiotic resistance, a drug to drug interaction, and increased health care cost.


Part Two of ‘Bladder Infections:
To Treat or Not to Treat in Older Adults?’

Role of Cognition in Treating Asymptomatic Bacteriuria 

Remember that treating ASB is not always straightforward. Long term care patients sometimes will have a cognitive impairment, and they can’t always tell you if the symptoms are there.

There are several tools that you can use. The AMDA Watchlist, for instance, is a urinary tract infection flip manual. This one-pager watchlist can be used by staff or family members, and it helps care providers figure out if it’s a UTI or colonized state.

When you see a positive urine culture, don’t automatically assume it’s a UTI. You’ve got to make sure you look at your patient, look at the symptoms they’re having before you give them an antibiotic. Always keep in mind that the antibiotic can increase the risk of harm.
– Jamie Smith, MSN, FNP

What to look for in the AMDA Watchlist includes:

  • If the older adult is urinating more than usual.
  • If there’s anything abnormal going on.
  • Monitoring the vital signs.
  • Records of elevated heart rate and temperature,
  • Is there grimacing when the older adult urinates?
  • Do you notice discolored urine?
  • Is the burning urination new, or they’ve had it for a while?

However, a lot of times, older adults won’t have your typical textbook symptoms of a UTI. Thus, care providers often have to get a white blood cell count to help guide medical decision making. Other times they’ll get Procalcitonin lab to let them know if it’s an acute active bacterial infection right there.

Using these tools is crucial because even if you don’t notice the burning urination, the other two differential diagnoses you have to think about is vaginitis and interstitial cystitis, also known as painful bladder syndrome.

About Jamie Smith MSN, FNP 

Jamie Smith MSN, FNP is the author of Geriatric Notes. This pocket guide has been recommended and/or adopted into several nursing programs across the US and won the 3rd place award with the American Journal of Nursing in 2019 (under the category of Gerontologic Nursing). She is a full-time practicing NP in long-term care, trains new clinicians, precepts NP students, and is the Director of Education at Premier Geriatric Solutions.

Jamie’s book is available here:
**Use the  Code: GERIATRIC to save 20% plus free shipping.



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