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!)
Maria says
My spouse was septic in August 2016 due to blood contamination from feces bacteria while being cared for at a nursing home. He has had many real UTIs there which were treated with antibiotics, (Septra).
Tests show my spouse currently has two kinds of bacteria in his bladder. Also he has an indwelling catheter. In case it might be relevant, he also has an enlarged prostate.
I spend many hours per day with my spouse at the nursing home and know that he currently has symptoms namely, burning penis and urgency to urinate. I have reported these symptoms to the doctor. However the doctor will not accept my reports because he says he has to see them for himself or hear about them from my spouse. (The doctor is not respecting my Power of Attorney). But my spouse has dementia and can’t remember anything for more than a few minutes; the doctor doesn’t spend more than a few minutes per week with my spouse.
Question 1: Is there a way to tell if the symptoms are caused by the bladder bacteria or by some problem with the catheter?
My spouse (who is 90) was seen recently by a urologist. The urologist has recommended 7 days of Septra DS 2 times daily and 1 Septra DS lifelong. But the doctor refuses to take the advice of the urologist and my spouse is not being treated. The doctor also refuses to authorize changing the catheter ahead of schedule to see if that would make the symptoms go away.
Question 2: Does a doctor assigned to my spouse by the nursing home have the authority to override the recommendation of a specialist?
Question 3: Can the doctor just ignore my PoA? Is he putting the nursing home in any sort of legal jeopardy by doing so?
Question 4: My spouse has just been diagnosed with bacterial pneumonia. Could this have been caused by (or just made more likely because) the bladder bacteria were not treated?
I know this is a complicated situation, but can you provide any insight based on your experience?
Thank you.
Leslie Kernisan, MD MPH says
Yes, sounds like a complicated situation indeed.
You don’t say how long your spouse has had the indwelling catheter. Do they expect it to remain permanently, or is it supposed to be temporary?
Indwelling catheters do commonly cause chronic bacteriuria (once they are in for over a week or so), and I believe it’s not uncommon for them to cause irritation of the penis as well. This means it will probably be hard to tell if your husband’s symptoms are due to a true UTI or not, unless he also develops symptoms such as fever or lower abdominal pain.
I’m not aware of any research finding that you can reduce infections or improve outcomes by giving chronic antibiotics to someone with an indwelling urinary catheter. Bacterial resistance to Septra is quite common.
So I think the nursing home doctor’s reluctance to start chronic antibiotics sounds reasonable medically. But his job is not just to make a medically reasonable choice, it’s also to partner with you as your husband’s health proxy, and in this, it sounds like he’s not doing a good job at all.
In terms of your specific questions:
– #1: see above. Basically sounds hard to tell what is causing your husband’s symptoms.
– #2: As far as I know, a doctor is generally not required to implement the recommendations of a specialist or anyone else. Usually, it’s the PCP who refers to a specialist, but sometimes patients go see specialists on their own. Specialists do often prescribe directly to patients, but this gets trickier when a patient resides in a nursing home or facility. If a primary doctor and specialist are disagreeing about how to manage a particular problem, it is best for them to talk to each other and resolve the disagreement, or for the patient to stop seeing one of the clinicians. Again, this is harder to do when someone is in a nursing home and has limited options for a primary care provider.
– #3: Patients have rights in relation to their doctors, especially regarding access to their own medical information and privacy. You can learn more about many of those rights on the government’s HIPAA website, see here. Patients also have rights based on state law. As your husband’s proxy, you usually would enjoy similar rights. Honestly, I’m not sure what your options are if the doctor “won’t listen” to you. I doubt that you can truly compel a doctor to provide any specific evaluation or management. Generally, I recommend that people be polite but persistent in requesting more communication with their clinicians, and put things in writing as well. Reference any available rules or standards to bolster your case. You can also raise the possibility of legal action and malpractice, especially if what the doctor is doing is very dangerous or obviously not in line with the standard of care and best available evidence. However, that tends to make the relationship more negative, which is not great for patients and families.
Another option you could explore would be to talk to the nursing home about your concerns and also look into the long-term care ombudsman for your location. Your local Area Agency on Aging might also have ideas as to who can provide more information regarding your legal rights. Last but not least, there are probably elderlaw attorneys with nursing home experience in your area, but this would be a more costly approach.
#4: As far as I know, bacterial pneumonia would not be expected to result from urine bacteria (unless the person first developed full-blown sepsis in the bloodstream). My guess is that the pneumonia is the result of your husband being older, frail, and at generally high risk for infection and illness.
Unfortunately, your husband is likely at somewhat high risk for infection no matter what his doctors prescribe or don’t prescribe. If he has an enlarged prostate and won’t be able to urinate on his own, you could try to find out whether something other than an indwelling catheter is an option, such as intermittent catherization (we used this in the VA nursing home where I once worked).
I do think it’s important to have a decent working relationship with whichever doctors can prescribe medications and provide care in the nursing home. This might take some time and persistence for you to work out. If you can’t work it out with the current doctor, you will have to see if it’s possible to switch to another doctor, or perhaps even another facility.
I’m sorry you are in such a pickle. Do try to step back a bit to see the forest for the trees. I can’t tell from here whether these urine antibiotics are really worth you fighting for or not. I do think it’s a bigger problem that the communication with the doctor sounds difficult. Good luck working that out, and don’t forget to take care of yourself and get some support from other caregivers if you can (many have been in similar situations…)
Steve M. says
Dr. Kernisan,
Thank you so much for taking the time to write and post this article for us and more importantly taking the time to answer the questions that your readers have posted.
I have but one question for you however, is there ever a point in which the medical community “should” error on the side of prevention rather then taking the wait and see approach?
About 12 years ago my father had prostate cancer and elected to have the seeding procedure done with a very short round of radiation to follow. The cancer thankfully was knocked out and he has been cancer free since that time. One of the side effects from the seeding process was scar tissue in the urethra which has caused many problems over the years. One of which being many UTI’s and at times complete blockages which require surgery to open back up.
He has also had ESRD for the last 8 years and as of April of this year was placed on dialysis. His UTI’s have continued but this last time (about two months ago) he had no symptoms at all until he was on the dialysis machine one night and began shaking really bad. They explained to me that this is signs of sever infection. I immediately took him to the ER and they found that he was in septic shock caused but a UTI that showed no symptoms prior to the Septic Shock.
He spent almost 3 weeks in the hospital/ICU and they did not think he had a very good chance of pulling through because of his other medical conditions and his age (77) but he did. During his stay they did a couple of tests on his heart and he wound up having a double bypass & aortic valve replacement and a pacemaker put in which extended his stay a couple more weeks followed by two weeks of PT/OT.
They just did a urine culture on him a couple of days ago and again he has no symptoms of UTI right now but it came back with “Many Bacteria” Negative Occult Blood, WBC 20, Leukocyte Esterase 1+ and RBC 0-2.
I have read quite a few articles on sepsis – returning sepsis – ESRD & dialysis patients and I know that they are much more prone to a lot of medical issues especially infections and when you include the scar tissue it raises his chances of UTI greatly.
I realize there have been no studies to specifically cover my dad’s case but looking at all of the factors especially the high probability of sepsis returning at his age and ESRD/Dialysis wouldn’t it be prudent to error on the side of caution at some point rather then waiting for the sepsis to return and get him on antibiotics now?
My greatest fear is that it will return again with no signs/symptoms and it will be too late.
Best Regards,
Steve M.
Leslie Kernisan, MD MPH says
Yes, under certain circumstances, it’s reasonable to treat bacteria in the urine with antibiotics. Whether you will actually be preventing sepsis or progression to a clinically significant UTI is hard to say, but it’s a reasonable approach in someone like your father, who is at higher risk than most for developing a serious infection. Just bear in mind that by treating early, you are probably increasing the risk of infection with resistant bacteria down the line.
But for someone like your father, all the options involve some risks and there is no way to guarantee safety or a perfect outcome. Good luck!
Marilyn says
I’m a 74 year old female with a history of recurrent UTI from e coli. In 2014, I ended up in the hospital with severe kidney infection and dehydration. I’ve been thoroughly checked out by a urologist who found nothing wrong. I follow the guidelines for preventing infections. My doctor always does a culture before prescribing antibiotics. She is concerned about antibiotic resistance. The last time I had an infection (Aug. 4, 2017) my primary symptom, discomfort at the urethra, did not improve with the antibiotic. The doctor agreed to see if the symptom improved on its own. The discomfort comes and goes but is mostly present. Today I did an AZO Urinary Tract Infection Test at home. The leukocytes test was positive at the 500+++ point. The nitrite test was negative. Because of my past near tragic experience (kidney failure stage 3 was the hospital diagnosis), I don’t know if I can let this go. Since there’s no nitrate I think I don’t need an an antibotic. What might cause the leukocytes? Can I just wait until I have some other symptoms?
Leslie Kernisan, MD MPH says
Nitrites in the urine are generally caused by “gram-negative” bacteria. (Gram-negative versus gram-positive is a common way to classify bacteria.) Many bacteria which cause commonly cause UTIs are gram-negative (including E. coli) but there are also gram-positive bacteria that can cause UTIs.
So, a lack of nitrites does not mean you can assume you have no significant amounts of bacteria in the urine.
Leukocytes are white blood cells, and their presence in the urine is called “pyuria.” UTI is a cause of pyuria however it’s not uncommon for older women to have pyuria in absence of a UTI or bacterial colonization of the bladder. Possible causes include:
– contamination of the urine sample with vaginal secretions
– non-infectious inflammation of the bladder (e.g. interstitial cystitis) or kidney
– inflammation elsewhere in the abdomen (which can trigger white blood cells in the bladder)
I would recommend asking your doctor to advise you regarding your recent home testing findings. If you aren’t sure you are having symptoms, one reasonable approach might be to repeat the urine test in 3-7 days. However, your doctor will be best positioned to interpret these finding in light of your personal medical history, and your urological evaluation so far. Good luck!
B B Nayak says
I find this article very useful. I was searching for atypical UTI and UTI without fever and did not reach this site. I feel info given here presents my father’s case. My father is reaching 89 and was partly paralysed with stroke. Last month he had low fever (around 99 degree Fahrenheit) that subsided with paracetamol. Once he was out of fever, we noticed clouded dark yellow urine. He was treated initially with Ceftriaxone (I/V) and then maintained with nitrofurans and trimethoprim. After he was back from hospital, the clouded urine was back. Now it is three weeks since he is without fever or pain. He appears OK . Though nitrofurans and trimethoprim are still continuing, there is no change in clouded urine condition. He has serious issues with oral antibiotics but we have been pushing them with physicians advice. This article has bettered my understanding of the situation.
Leslie Kernisan, MD MPH says
Glad you found this helpful and hope your father feels better soon.
Jeannie says
My Mom is 87; she has had several so called UTI over the last 8 months with no signs of UTI. The Dr always has her take antibiotic! Over the last month she has been bleeding with clots from her Urethra – he scoped her and said her bladder lining has sores in it from previous UTI – he did not scrape it to test cells. He sent her Urine in for testing no sign of UTI – thou he still wants her to take Sulfa Antiobio! When asked again about sores in bladder he says oh not sure. Very Concerned. These antibio make my Mom very sick
Leslie Kernisan, MD MPH says
Hm, this does sound concerning. You might want to ask the doctor to explain why he is recommending antibiotics if there is no sign of UTI, and how does he know this is not asymptomatic bacteriuria.
It may also be worthwhile to get a second opinion from a urologist regarding her bladder lesions, and to ask whether cells should be tested (or a biopsy done). Good luck!
vanaly palmer says
i am 80, my husband 85… he seems to have that untreatable bacteria… i have clear urine, but sometimes it smells awful.. showering helps for a few hours… if it continues it will limit my small social activities… Church and Bible study… we are both doing well ‘for our age’ we are told…. can you tell me something i can do to get rid of the rotten smell/?? i had a hysterectomy and rectum repair in ’06…. i do have diverticulitis occasionally…we take vit. C, D, and B12 and flaxseed oil pills along with BP meds and sml dose hydrochlorot….
Leslie Kernisan, MD MPH says
Hm, hard to say what might be causing the smell in your urine. It can be caused by certain foods and medications. I also wonder if perhaps the smell isn’t related to something else going on in your pelvic area, given your history of past surgeries in this area. I would recommend talking to your doctor about what might be the cause. Also if you are experiencing any continence issues that are impacting your social activities, be sure to bring that up to the doctor as well.
If your PCP isn’t helpful, consider a consultation with a gynecologist specialized in urinary issues for older women. Such doctors do the most thorough pelvic exams, and have lots of experience helping older women manage continence and urinary issues. Good luck!
Kate says
Hi, appreciate your article. I am concerned about my otherwise healthy 90-year-old mom who frequently has positive cultures. Problem is, she had completely asymptomatic infection so we did not treat, and soon she almost died of sepsis—all with no symptoms. Even the sepsis had few symptoms until she was quite far along with it. Would you please explain how, in elderly who feel few or no symptoms, one can safely not treat —when there is always a possibility of progression to bacteremia and sepsis?
Leslie Kernisan, MD MPH says
Sorry to hear of your mother’s sepsis, that must have been scary for her and for your family.
To answer your question: I don’t know that there’s an entirely safe way to not treat her asymptomatic bacteriuria. Older adults of your mother’s age are at higher risk of infection overall, because their bodies and immune systems are weaker. And having asymptomatic bacteriuria is associated with a higher risk; on one hand, it’s often related to a less vigorous immune system, and on the other hand, it may in of itself facilitate sepsis.
So the issue isn’t really “is safe to not treat?” The issue is, which approach is more likely to do more good than harm: to treat her repeatedly, or to go with watchful waiting?
People who are treated repeatedly for their positive urine cultures can also develop sepsis. Once an older adult has developed chronic bacteriuria, it tends to persist for a while no matter what you do. Continuous antibiotics for UTI prophylaxis has been tried in younger adults, but as far as I know, has not been studied in people like your mom, so whether it actually is likely to improve outcomes is unknown.
The truth is that when it comes to older adults, all the options come with risks and uncertainties. I think there’s something to be said for a “less is more” approach, it does seem to benefit many of our patients in geriatrics. And it might be better for nurturing the overall health of one’s body and immune system. But sure, there is risk. Some people feel more comfortable doing more, especially if they’ve had an experience like sepsis.
What is most important is that they be informed of the uncertainty as to whether they’ll benefit, before proceeding with repeated antibiotics for positive urine cultures.
Antibiotics aside, you may want to look into factors affecting your mother’s overall physical wellbeing, like nutrition, exercise, social activity, and all the other non-medical things that we know promote better function of the body.
Hope this helps, good luck!
Lee Williams says
Hi Dr Kernisan,
Thank you so much for your very informative article on asymtomatic bacteriuria vs. UTI. My mum has this condition (asymptomatic bacteriuria). After several rounds of antibiotics this summer for what they were calling a UTI, we were sent to urology. They explained everything as you have, and placed Mum on Hiprex 500mg, and Vitamin C 500mg per day. The vitamin C is used to create an acidic bladder, and the Hiprex, as it enters this acidic environment, converts to formeldahyde which suppresses bacterial growth. Learning about this action this gives me cause for concern, since my association with formaldehyde (I’m a nurse) is thinking it should not be in the human body at all! Our pharmacist said as long as a doctor is monitoring my mum it should be ok. I would love to hear your thoughts on this medication. Mum is 90 years old.
Leslie Kernisan, MD MPH says
I recently looked up the research on these medications for one of my own consultation patients (also aged 90s), who was put on them by urology.
There has been interest in methenamine (Hiprex), but the main problem, from my perspective, is that it’s an unproven treatment, when it comes to women in their 80s and 90s. In 2012, a Cochrane review on methenamine for “preventing UTIs” found that it might be effective in some groups of people, but the vast majority of participants in the studies were younger.
On the flip side, methenamine seems to be well-tolerated, as best we can tell, and I’m not aware of any connection to worrisome side-effects or new health problems.
If your mother doesn’t mind taking these medications, one option would be to try it for a few months and see if things seem to be better.
For my own patient, she really hated taking the pills and wanted to be on fewer medications. In this case, a small chance of benefit didn’t seem worth the definite burden of taking the pills every day. So we discontinued them, and she seems to be doing the same as before.
I think that many doctors feel a bit compelled to offer their patients something for the urinary concerns. But as best I can tell, there is not yet good scientific evidence that this is likely to help women like your mom. Hope this helps!
Lee Williams says
Hi Dr K!
I had asked a question a while ago re: asymptomatic bacteriuria and the use of Hiprex and Vitamin C for treatment. I did get your answer, but hadn’t responded to you! Anyway, my Mum went to the urologist for a 3 month check up, and Dr. N was pleased with her progress. They apparently do not repeat a culture, because it’s a colonized situation. They just ask if she’s having symptoms; fever, burning, frequency. I told him I had a concern about her being on Hiprex long term, and he said it was actually safer than using antibiotics. I think he was surprised I had looked up the action, and agreed it does sound scary, so he doesn’t usually disclose the action to his patients (I disagree with this-everyone should be informed of what they’re taking). Me being a nurse of course I had to look it up! Mum seems to be tolerating it well, but the odor of the urine hasn’t changed, and since I’m sensitive to odors, cleaning her commode isn’t pleasant, but it’s short-lived! Thanks again for your input!
Leslie Kernisan, MD MPH says
Thanks for sharing this update. I’m glad your mom is doing ok.
Marilyn Shinkonis says
Is there a greater risk for people to develop bladder cancer when they have a history of colonized bacteria in the urinary tract?
Leslie Kernisan, MD MPH says
I am not aware of any data suggesting that asymptomatic bacteriuria is a risk factor for bladder cancer.
Karen says
How should a uti in an 87 year old woman that shows citrobacter fruendii complex be treated?
What happens if it is left untreated?
Leslie Kernisan, MD MPH says
If it’s a true clinically significant urinary tract infection (meaning, the person is having UTI symptoms as described in the article, versus having a positive urine culture but no clear signs of symptomatic infection), then usually the treatment is a course of antibiotics. Which antibiotic depends on many things, including the result of antibiotic resistance testing, whether it looks like the UTI is spreading beyond the bladder, the person’s past medical history, and the goals of care.
Because many urine bacteria are resistant to commonly used antibiotics, it’s common for laboratories to test urine bacteria for their susceptibility to antibiotics. Sometimes the person will have been started on an antibiotic at the time they are seen for symptoms, but the urine culture results and the antibiotic susceptibility results usually take an additional 1-2 days to come in. So doctors and families should follow-up on those results, to be sure they use an antibiotic that will work against the bacteria.
If a UTI is left untreated, it may eventually resolve on its own. The symptoms might go away given some time, as the body manages to fight the infection. Especially in someone who is 87, the bacteria will probably persist in the bladder for a while, but this is colonization, not an active infection.
It’s also possible for a UTI to worsen and for the infection to spread to the kidney or bloodstream. In this case, the person’s symptoms will get worse, or they will show signs of systemic infection. These might include signs such as fever, elevated heart rate, lower blood pressure, or weakness.
A study found that in women with UTI symptoms (they were mainly in their late 30s and 40s), a certain number of them get better without antibiotics: Women with symptoms of uncomplicated urinary tract infection are often willing to delay antibiotic treatment: a prospective cohort study.
MARY HILL says
When you have asymptomatic bacteruiria in urine test right after antibiotic treatment 14 days for a previous kblesia pneumatia bacteria (another with no symptoms at all) , if bacteria colonizes in bladder can it spread to kidneys or cause sepsis. I now have citrobacter freundii and prescribed nitrofurantoin antibiotics but have not taken yet. Waiting to see if I have any symptoms. Just concerned about the colonizing. Culture has not come back yet. Most all antibiotics really hard for me to take. I am so glad I found your site, so interesting. Wish I could get these post in print to review without searching on computer. Thanks so much for what you are doing for older adults.
Mary Hill October 16, 2017
Leslie Kernisan, MD MPH says
Yes, if the bladder is colonized with bacteria, then this is associated with a slightly higher chance of developing sepsis or a clinically important infection in the kidneys. The thing is, antibiotic treatment of asymptomatic bacteriuria has NOT been shown to reduce one’s chances of developing sepsis.
So if you have asymptomatic bacteriuria — and it sounds like you might, since your urine cultures remain positive despite antibiotic treatment — I would say it’s important to take some deep breaths and try to not worry too much about the colonization. It’s there, you can’t get rid of it with antibiotics.
Probably a better approach is to get lots of rest and try to take a holistic approach to health that can cultivate a stronger immune system. In truth, we don’t really know exactly how people can do this, but we do know that stress and sleep deprivation weaken the immune system. Probably adequate rest, social support, exercise, good nutrition, and other basics of good health can support the body and make it a little less likely that a person develops sepsis.
Antibiotics do affect the body’s “good bacteria” in the gut, and those play a role in regulating the immune system. It’s possible that by stopping antibiotics for a while, you’ll allow your body’s usual bacteria to recover and help protect you.
When to use antibiotics? You will have to discuss with your doctor to find what’s right for you, but in general, older adults with colonized bladders are most likely to benefit from antibiotics when they have a very clear, significant infection that is causing pain or seems to be spreading in the body.
Otherwise, I’m glad you’re finding the articles helpful. FYI, you should be able to see a small printer icon at the end of each article. If you click this, you should be able to easily print a copy of the article.
Good luck!
MARY HILL says
Thank you so much for our your answer. I have not heard from the culture and still do not have any symptoms. I feel fine today, just getting over the 14 days of other antibiotics I took. No symptoms then either. I am going to stop worrying over this and get on with my life. Again I appreciate your answer. God bless. Mary Hill