Urinary infections in the elderly: symptomatic or asymptomatic?

Asymptomatic bacteriuria is common in the elderly, occurring in as many as 25-50% of elderly nursing home residents. Asymptomatic bacteriuria itself s hould not be treated with antimicrobial therapy. Difficulties in communicat ion, chronic genitourinary symptoms, and the high frequency of positive uri ne cultures, make ascertainment of symptomatic infection problematic for th e functionally impaired elderly. Chronic genitourinary symptoms are not a m anifestation of acute urinary infection, although acute deterioration in sy mptoms may be consistent with infection. Fever in an institutionalized elde rly subject with a positive urine culture and without an indwelling cathete r is due to urinary infection in less than 10% of episodes. However, there are no criteria to differentiate urinary infection from other sites in this clinical scenario. Thus, neither urine culture nor clinical presentation a llows a diagnosis of symptomatic urinary infection to be made with a high l evel of certainty. Decisions with respect to antimicrobial therapy must be made on an individual basis and with an understanding of these diagnostic l imitations. It is not realistic to expect to optimize antimicrobial usage i n this population until issues of diagnostic uncertainty are addressed. (C) 1999 Elsevier Science B.V. All rights reserved.