Management

Good practice point
Exercise caution in women who are on fluid restriction for medical reasons (for example, those with chronic heart failure or on renal dialysis).

Good practice point
The Care Inspectorate document Eating and Drinking Well in Care provides best practice guidance on older people's dietary needs and related food and fluid requirements.

Discuss steps women can take to reduce the chances of having further UTIs, including:

• drinking plenty of fluid.
• avoidance of spermicide containing contraceptives.
• personal hygiene.
• voiding behaviours.  

Evidence – See section 4.2.1 in full guideline.

• In women over 65 antimicrobials remain an effective way to achieve clinical cure of LUTI.
• No evidence was identified that describes specifically the risks inherent to antimicrobial treatment of acute UTI in women aged over 65 years, but the risks described for women aged under 65 are likely to be similar.
• Older people are more likely to be affected by multimorbidity and be subject to polypharmacy and the resulting higher risk of drug interactions which can be associated with preventable harm.^{93, 94}
• Due to the difficulties in diagnosing UTI in older women, particularly frail elderly women in long-term care facilities, decisions on how to manage symptoms should be made on an individual patient basis taking account of the risks and benefits of various treatment options.

Choice of agent

Recommendation
Consider use of a narrow-spectrum antimicrobial with activity against common uropathogens for treatment of LUTI in women aged 65 years and over. Consider individual patient factors such as impaired renal function, polypharmacy and adverse effects, such as CDI and antimicrobial resistance.

See Table 4: Comparison of selected antimicrobial agents for treatment of lower urinary tract infection.

No studies were identified which examined choice of antimicrobial agents for treatment of LUTI in this age group. The recommendation is extrapolated from evidence in women aged under 65 years. 

Evidence – See section 3.2.4.1 in full guideline.

Duration of treatment

One RCT was identified which provides data on the effectiveness of different durations of treatment for LUTI in older women, suggesting that 3-day courses are as effective as 7-day courses in controlling most symptoms of LUTI, apart from urgency, and are less likely to cause side effects. ⁹⁵

Adverse events

Trimethoprim was significantly associated with hyperkalaemia within 14 days of antibiotic initiation.  Adverse events caused by prophylactic antimicrobials for prevention of recurrent UTI are common.

Evidence – See section 4.2.2.3 in full guideline.

Treatment of asymptomatic bacteriuria

Recommendation
Do not treat asymptomatic bacteriuria in non-pregnant women of any age.

A Cochrane review comparing treatment of asymptomatic bacteriuria in men and non pregnant women with antimicrobials or placebo reported an increased risk of adverse events associated with antimicrobial treatment (RR 3.77, 95% CI 1.4 to 10.15).⁷⁶   Six of the nine studies included in this review recruited patients over the age of 65 years.

No evidence was identified on the use of NSAIDs specifically in women aged 65 years and over.

No evidence was identified on the use of non-pharmacological treatment for UTI specifically in women aged 65 years and over.

Go to this section of the app for information on non-pharmacological treatment in women with recurrent UTI, including those aged 65 years and over.

Follow link to 'Provision of Information' section to view checklist.