Decision aid for diagnosis and management of

suspected urinary tract infection (UTI) in older people

This 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 2 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
overleaf provides good practice points and evidence sources for prescribers.

Are there any symptoms suggestive of non-urinary infection?

Contact medical/clinical staff to request
review of patient/resident Respiratory – shortness of breath, cough or sputum (phlegm) production, new pleuritic chest
pain (sharp pain across ribs)
YES

Take appropriate specimens and manage Gastrointestinal – nausea/ vomiting, new abdominal pain, new onset diarrhoea
following local antibiotic policy
Skin/soft tissue – new redness, warmth, swelling, purulent drainage (pus)

Yellow action boxes provide advice for nursing and care staff. NO

Red action boxes provide advice for nursing staff and

prescribers (medical and non-medical). Does the patient/ resident have a urinary catheter?
YES NO

Does patient/resident have one or more of following signs or Does patient/resident have two or more of following signs or
symptoms? symptoms?
• shaking chills (rigors) • dysuria (pain on urination)
• new costovertebral (central low back)tenderness • urgent need to urinate
• new onset or worsening of pre-existing delirium (confusion) or • frequent need to urinate
agitation • new or worsening urinary incontinence
• shaking chills (rigors)
• pain in flank (side of body) or suprapubic (above pubic bone)
• frank haematuria (visible blood in urine)
• new onset or worsening of pre-existing delirium (confusion) or
agitation
NO YES YES NO

UTI unlikely but continue to monitor UTI unlikely but continue to monitor
symptoms for 72 hours and ensure symptoms for 72 hours and ensure
adequate hydration adequate hydration
UTI likely
Ongoing fever and development of Ongoing fever and development of
YES

YES

one or more of above symptoms? two or more of above symptoms?

Contact medical/clinical staff to request review of patient/resident

• Assess if retention or sub-acute retention of urine is likely – blocked catheter or distended bladder
• DO NOT use dipstick test in diagnosis of UTI in older people
• Obtain a sample for urine culture and send to Microbiology
• Catheter samples should be taken from the sample port
• Start antibiotic therapy following local policy or as advised by Microbiology
• If patient has a urinary catheter, remove and replace it. Do not allow catheter removal or change to delay antibiotic treatment. Consider the
ongoing need for a long-term catheter in consultation with specialists.
• Consider use of analgesia (paracetamol or ibuprofen) to relieve pain
• Consider admission to hospital if patient has fever with chills or new onset hypotension (low blood pressure)
• Review response to treatment daily and if no improvement of symptoms or deterioration, consider admission to hospital or an increased level of care
• Ensure urine culture results are reviewed when available in order to streamline antibiotic therapy

December 2018 Review date: December 2021

Good practice points
Urine culture Antibiotic therapy

• Older people often have asymptomatic bacteriuria • Older people are vulnerable to infection, particularly
(no symptoms but bacteria in urine) which does not Clostridium difficile infection, therefore use of broad
indicate infection. spectrum antibiotics such as ciprofloxacin, co-
• Dark or foul smelling urine alone does not mean amoxiclav and cephalosporins should be avoided if
infection, and may be a sign of dehydration. possible.

• Do not perform urine dipsticks as they become more • First choice antibiotics for uncomplicated lower UTI
unreliable with increasing age over 65 years. in non-catheterised patients are trimethoprim 200mg
twice daily or nitrofurantoin 50mg four times daily (or
• Do not send catheter specimens of urine (CSU) unless nitrofurantoin MR 100mg twice daily). Recommended
patient has signs and symptoms of infection as CSU course duration is three days for women and seven
samples will almost always have bacteriuria (bacteria in days for men.
urine).
• BNF suggests avoid nitrofurantoin if eGFR < 45ml/
• Review urine culture results to check organism is min/1.73m3 but can be used with caution if GFR 30-
sensitive to antibiotic prescribed and change to an 44ml/min/1.73m3 as a short course only (3-7 days).
alternative antibiotic if necessary. Nitrofurantoin should be used with caution in patients
• Interpretation of the urine culture results – high with interstitial lung disease due to the increased risk of
epithelial cell count or heavy mixed growth may adverse effects.
indicate contamination. Ensure correct sampling • In men, if there is clinical suspicion of acute prostatitis
process is followed and take repeat urine sample if (suggested by fever and pain at the base of the penis,
clinically indicated. around the anus, just above the pubic bone and/or
• Be alert to UTI due to resistant organisms such in the lower back), a 28 day course of ciprofloxacin or
as Extended Spectrum Beta-Lactamase E. coli. ofloxacin is recommended. Trimethoprim may be used
Microbiology will provide advice on treatment options. if the organism is sensitive.
In patients with a previous ESBL UTI discuss with • In catheterised patients with symptoms of UTI, a seven
Microbiology the potential treatment options should day course of antibiotics, following local antibiotic
the patient become symptomatic again. guidelines is recommended in both men and women.
• Do not send urine samples for post-antibiotic checks or The catheter should be removed then replaced if
clearance of infection. 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 UTI

• 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 3-6 months. Therefore ongoing clinical need should be reviewed after 6 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.

References
1. Lohfeld L, Loeb M, Brazil K, Evidence-based clinical pathways to manage urinary tract infections in long-term care facilities: a qualitative case study describing
administrator and nursing staff views. J Am Med Dir Assoc 2007; 8: 477–484
2. Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected
urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ 2005;331(7518):669.
3. Scottish Intercollegiate Guideline Network, Guideline 88 Management of Bacterial Urinary Tract Infection https://www.sign.ac.uk/sign-88-management-of-
suspected-bacterial-urinary-tract-infection-in-adults.html
4. Health Protection Agency, Diagnosis of UTI – Quick Reference Guide for Primary Care http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947404720
5. Public Health England, Flowchart for men and women over 65 years with suspected UTI https://assets.publishing.service.gov.uk/government/uploads/
system/uploads/attachment_data/file/755889/PHE_UTI_flowchart_-_over_65.pdf
 Older People >65 years with Suspected Urine Infection (UTI) - Guidance for Care Home staff
Complete resident’s details, flow chart and actions (file in resident’s notes after). DO NOT PERFORM URINE DIPSTICK – No longer recommended in >65yrs.
Any symptoms suggesting alternative diagnosis? Tick if present
Resident:……………………………………………… DOB:………………………. UTI unlikely
Increased breathlessness or new cough Any
Seek guidance
Carer:……………….……………………………. Date:……………………………. Diarrhoea and vomiting ticks
A new red warm area of skin as appropriate
Care Home:………………………………………….………………………………….
No
ticks
YES Does the person have a catheter? NO

New Problem Tick if 1 or more ticks 2 or more ticks New Problem

Tick if
present present

Inappropriate shivering/chills Pain on passing urine

or High or low temperature UTI possible – Actions needed Tick when Need to pass urine urgently or
>38°C or <36°C if measured done new or worse incontinence
document Phone and fax form to GP Practice. Need to pass urine much more often than usual
...............°C
Pain between belly button and pubic hair
New lower back pain Obtain urine sample and arrange
Blood in urine
catheter change if catheterised: see
New or worsening reverse of form. Inappropriate shivering/chills or
confusion or agitation High or low temperature >38°C or <36°C if measured
Outside Mon-Fri normal working hours,
phone 111 as normal document …………°C
New lower back pain
New or worsening confusion or agitation
UTI unlikely

No ticks If concerned about resident, please seek

guidance from GP or Care Home Liaison Nurse
Less than 2 ticks
 Residents with Urinary Catheters: Residents without a Urinary
Sampling & Changing Catheter: Obtaining a Urine Sample

For Nursing Residents: For Residential Residents: Urine cultures are very important in the elderly
to guide antibiotic choice.
• Registered Nurse only to take • Contact District Nursing Team to
catheter urine sample using arrange for a sample to be • Try to obtain a urine sample when the
aseptic non-touch technique. taken. resident is in the middle of passing urine
• If antibiotics are commenced • If antibiotics are commenced for (rather than at the start).
for UTI, catheter change should UTI, catheter change should be • Put the urine in a Red Top urine bottle, filling
be performed by Registered arranged with District Nurses to the 20ml line.
Nurse as soon as possible. as soon as possible. • Fill in the resident’s details and type of
sample carefully to help the lab to process
the sample.
• Samples should be taken to the GP practice
Fill red top urine as soon as possible. If there is a delay, they
*If there is not enough bottle to 20ml line can be refrigerated until taken to the GP
urine to fill to 20ml line, practice at the next possible opportunity.
then use a white top
specimen bottle instead
Fill in resident • Ensure the GP practice know what to write
details carefully on the request card (the information from
the assessment tool).