How to manage UTIs in older adults in the community

Urology specialist nurse, Helen Lake, discusses the challenges of managing UTIs in older adults in the community, and offers some practical steps for pharmacists to follow.

Improving recognition, prevention and antimicrobial stewardship

Urinary tract infection (UTI) is the most common infection seen in primary care in people over the age of 65 and is associated with significant morbidity. What’s more, the diagnosis of UTI in this group of patients presents challenges due to the often atypical presentation of symptoms.¹

Studies have found that care homes residents are more likely to experience UTIs caused by antibiotic-resistant bacteria than those living in their own homes, with some suggesting the risk may be more than four times higher.² Nevertheless, antibiotic-resistant UTIs are increasingly seen in community settings and should be considered where there is treatment failure, resurgent symptoms and/or recurrent infection.

While prompt antibiotic treatment of UTIs may reduce the risk of bloodstream infection and mortality in older adults, clinicians must balance this against the risk of over treating non-specific symptoms where true infection is uncertain.³

Improving how UTIs are recognised and managed in older adults is essential for both patient safety and reducing pressure on urgent and secondary care services.

Why can diagnosing UTIs in older adults be difficult?

Changes in bladder function, asymptomatic bacteriuria, and testing

Older adults commonly experience changes in bladder function including incomplete bladder emptying, pelvic floor prolapse, constipation and increased catheter use. The prevalence of asymptomatic bacteriuria – the presence of significant bacteria in the urine – also increases with age, complicating the interpretation of UTI testing.⁴

Diagnosis of UTIs should be symptom-based and culture confirmed as urine dipsticks have been found to be unreliable in adults aged older than 65 years due to asymptomatic bacteriuria and pyuria – presence of elevated white blood cells in the urine – being common.⁵

Studies have shown that treating asymptomatic bacteriuria provides no clinical benefit and contributes to antimicrobial resistance.⁶

Recognising symptoms

Symptoms more suggestive of lower UTI include dysuria, new urinary urgency, incontinence, frequency, suprapubic pain and visible haematuria.

Post-menopausal women may also present differently from younger women with cystitis, sometimes reporting pelvic pressure, nocturia, urgency or worsening urinary leakage rather than classic dysuria.⁷

Urine sampling and culture

When infection is suspected, obtaining a good quality urine sample is essential. Because contamination is common, patients should be advised to provide a clean catch midstream specimen using a sterile container.⁶ Assistance should be provided when necessary.

Bladder emptying and residual urine

Incomplete bladder emptying is a significant contributor to recurrent UTIs and may occur with obstruction, prolapse, neurological disease or medication effects. Raised post-void residual volumes are associated with increased infection risk. When available, bladder scanning can help identify residual urine.

Catheter-associated risk

Indwelling urinary catheters are also a major risk factor for infection. Regular review of catheter necessity, good catheter care and maintaining a closed drainage system are essential for reducing UTI risk.¹⁰

Delirium

A common diagnostic pitfall is assuming that confusion or delirium in older adults is caused by a UTI without other supporting symptoms.¹

Delirium has many potential causes including dehydration, constipation, medication effects and metabolic disturbance. While infection can contribute to delirium, assuming confusion automatically represents a UTI may lead to unnecessary antibiotic prescribing and delay in diagnosis.

Where systemic features such as fever, tachycardia, hypotension or acute deterioration are present, patients should be assessed urgently for possible sepsis.⁹

What does current guidance say about antibiotic treatment?

National antimicrobial prescribing guidance recommends using the shortest effective course of antibiotics.⁶

While a three-day course is recommended for uncomplicated infections in women, some patients may not experience full symptom resolution and will require a longer course of treatment.⁶

For catheter-associated UTIs, oral antibiotics should be used where clinically appropriate. If an indwelling catheter has been in place for more than seven days it should be replaced once antibiotic treatment has started.¹⁰

Do preventive antibiotics increase antimicrobial resistance?

Preventive low-dose antibiotics are often used for people experiencing recurrent UTIs. While effective, infections often return after discontinuation. Emerging evidence highlights potential risks, including increasing antimicrobial resistance.^11,12

A target trial emulation by Sanyalou et al (2026) found that patients receiving long-term antibiotic prophylaxis were more likely to develop infections caused by antibiotic-resistant organisms.¹¹

The AnTIC trial (2018) found reduced symptomatic UTIs in adults performing intermittent self-catheterisation, but antimicrobial resistance was significantly more common.¹²

These findings highlight the balance between symptom control and antimicrobial resistance. Current guidance recommends considering non-antibiotic approaches before long-term prophylaxis.¹³

What non-antibiotic strategies may help prevent UTIs?

Prevention and alternatives to antibiotics are receiving increasing attention, particularly in the context of antimicrobial resistance. For example:

Hydration and bowel health

Mild dehydration is common in older adults as thirst declines and kidneys become less efficient at concentrating urine. Encouraging adequate fluid intake may support bladder health by promoting regular emptying. Constipation can also impair bladder emptying and contribute to recurrent UTIs.

Methenamine hippurate

Methenamine hippurate is increasingly being used as a non-antibiotic alternative to antibiotic prophylaxis. It produces a bactericidal effect in acidic urine. The ALTAR trial found methenamine to be non-inferior to antibiotics in preventing recurrent UTIs in women.¹⁴

Vaginal oestrogen and the vaginal microbiome

Vaginal oestrogen plays an important role in preventing recurrent UTIs in post-menopausal women. Oestrogen deficiency alters the vaginal microbiome, reducing protective lactobacillus species which increases susceptibility to infection.¹⁵

Probiotics

Research has explored the use of lactobacillus probiotics to help restore the vaginal microbiome. While results are showing promise there is currently a lack of agreement on optimal strains, dosage or routes of administration.¹⁶

Cranberry products

A Cochrane review (2023) found cranberry products can reduce symptomatic UTIs in some groups, although in older adults remains limited.¹⁷

When recommending cranberry products clinicians should also be aware of potential interactions such as cranberry with warfarin.¹⁸

D-mannose

A 2024 randomised trial found D Mannose did not significantly reduce recurrent UTIs despite earlier promising research.¹⁹ The study was limited to younger women, however, and some patients report benefits in practice, particularly with infections caused by E coli.

Over-the-counter preparations.

Many preventive approaches involve supplements which can be expensive. Clinicians should help patients weigh potential benefits against the strength of the evidence.

When should patients be referred?

Most uncomplicated lower UTIs can be managed in primary care. However, clinicians should be alert to features requiring urgent assessment or referral.

These include systemic symptoms suggesting sepsis, visible haematuria requiring urgent investigation, persistent or unexplained urinary symptoms in patients aged 60 and over, and infections that do not respond to treatment. Repeated antibiotics without symptom resolution should prompt further investigation.

Visible haematuria should never be attributed to infection alone without appropriate follow-up, and further assessment should be arranged in line with national referral guidance.²⁰

The role of community pharmacists

Community healthcare providers play an important role in managing UTIs in older adults. Assessment should include consideration of possible underlying contributors such as incomplete bladder emptying, pelvic organ prolapse, constipation, catheter use and hydration status.

Practical steps include:

• Avoiding routine dipstick testing in adults aged over 65
• Not treating asymptomatic bacteriuria
• Encouraging adequate fluid intake
• Supporting bowel and bladder management
• Considering post-menopausal changes, including reduced oestrogen, as a contributing factor to urinary symptoms and recurrent UTIs
• Reviewing catheter care
• Ensuring appropriate antibiotic duration

Pharmacists are also well placed to support with early advice. Although Pharmacy First pathways for uncomplicated UTIs are limited to women aged between 17 and 65 years, pharmacists can still play an important role for those outside their remit by providing information and signposting them to the appropriate resources.

Improving recognition and prevention of UTIs in the community can reduce antimicrobial resistance, prevent avoidable hospital admissions and help older adults remain well at home.

Helen Lake is a Urology Specialist Nurse and UTI Information Nurse at The Urology Foundation.

A version of this article was first published on our sister title, Nursing in Practice.