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  • The following flowchart has been designed to help nursing and care staff and prescribers manage patients/residents with urinary tract infection. Dipstick testing should not be used to diagnose UTI in patients over 65 years
  • If a patient/resident has a fever (defined as temperature >37.9°C or 1.5°C increase above baseline occurring on at least two occasions in last 12 hours) this suggests they have an infection
  • Hypothermia (low temperature of <36°C) may also indicate infection, especially in those with co-morbidities (heart or lung disease, diabetes)
  • Some patients/residents may also have non-specific symptoms of infection such as abdominal pain, alteration of behaviour, delirium (confusion) or loss of diabetes control. The information below provides good practice points and evidence sources for prescribers

Algorithm 1: Decision aid flowchart for the diagnosis and management of suspected urinary tract infection (UTI) in older people

SAPG—Decision aid for diagnosis and management of suspected urinary tract infection (UTI) in older people

SAPG—Decision aid for diagnosis and management of suspected urinary tract infection (UTI) in older people

Good practice points

Urine culture

  • Older people often have asymptomatic bacteriuria (no symptoms but bacteria in urine) which does not indicate infection 
  • Dark or foul smelling urine alone does not mean infection, and may be a sign of dehydration 
  • Do not perform urine dipsticks as they become more unreliable with increasing age over 65 years
  • Do not send catheter specimens of urine (CSU) unless patient has signs and symptoms of infection as CSU samples will almost always have bacteriuria (bacteria in urine)
  • Review urine culture results to check organism is sensitive to antibiotic prescribed and change to an alternative antibiotic if necessary
  • Interpretation of the urine culture results—high epithelial cell count or heavy mixed growth may indicate contamination. Ensure correct sampling process is followed and take repeat urine sample if clinically indicated
  • Be alert to UTI due to resistant organisms such as Extended Spectrum Beta-Lactamase E. coli. Microbiology will provide advice on treatment options. In patients with a previous ESBL UTI discuss with Microbiology the potential treatment options should the patient become symptomatic again
  • Do not send urine samples for post-antibiotic checks or clearance of infection.

Antibiotic therapy

  • Older people are vulnerable to infection, particularly Clostridium difficile infection, therefore use of broad spectrum antibiotics such as ciprofloxacin, co-amoxiclav, and cephalosporins should be avoided if possible
  • First choice antibiotics for uncomplicated lower UTI in non-catheterised patients are trimethoprim 200 mg twice daily or nitrofurantoin 50 mg four times daily (or nitrofurantoin MR 100 mg twice daily). Recommended course duration is three days for women and seven days for men
  • BNF suggests avoid nitrofurantoin if eGFR <45 ml/min/1.73m3 but can be used with caution if GFR 30–44 ml/min/1.73m3 as a short course only (3–7 days). Nitrofurantoin should be used with caution in patients with interstitial lung disease due to the increased risk of adverse effects
  • In men, if there is clinical suspicion of acute prostatitis (suggested by fever and pain at the base of the penis, around the anus, just above the pubic bone and/or in the lower back), a 28-day course of ciprofloxacin or ofloxacin is recommended. Trimethoprim may be used if the organism is sensitive
  • In catheterised patients with symptoms of UTI, a seven-day course of antibiotics, following local antibiotic guidelines is recommended in both men and women. The catheter should be removed then replaced if necessary
  • The national catheter passport should be used to support good practice
  • Second-choice antibiotics should always be guided by urine culture and history of antibiotic use.

Prophylaxis of urinary tract infection

  • The evidence base supporting antibiotic use for prophylaxis of UTI is not strong; all studies were conducted pre-2000 and none evaluated patients beyond one year
  • Female patients who do not have a catheter and have more than three UTIs within a 12 month period may be considered for a trial of nightly antibiotic prophylaxis with trimethoprim or nitrofurantoin. The risk of adverse effects versus the potential benefit needs to be considered carefully
  • Long-term antibiotics prescribed for UTI prophylaxis do promote resistance and there is no evidence to support their use beyond three to six months. Therefore ongoing clinical need should be reviewed after six months
  • Cranberry products may be considered as an alternative but evidence of their efficacy is lacking
  • In post-menopausal women consider the possibility of recurrent symptoms being associated with vaginal atrophy

For guidance for care home staff, refer to the full guideline.

Full guideline:

Scottish Antimicrobial Prescribing Group. Decision aid for diagnosis and management of suspected urinary tract infection (UTI) in older people. Available at: www.sapg.scot/quality-improvement/primary-care/urinary-tract-infections

Published date: March 2015.

Last updated: December 2018.