What is a Bladder Infection?

 In my world, the big question is “What is important about a bladder infection for the older individual, and particularly a person with dementia”.  I often hear that the urine is “smelly” or “darker” and that a “urine culture” should be checked to see if there are bacteria. This is not necessarily true.

First, what are the symptoms?

Is there a fever, urinary burning, frequent urination, poor appetite, lethargy? Those are the specific symptoms.  Those symptoms indicate the need to be treated.  With my elders with dementia, it is often not so straightforward.  Sometimes the symptom is that the person more is more agitated, aggressive or more lethargic.

The person with dementia may not feel well, but not be able to communicate their symptoms.  This is serious.

Studies show an elder with fairly advanced dementia has a 25% chance of dying from pneumonia, even when treated with antibiotics.  This is related to the fact that they are not aware that something bad is happening to their body and don't communicate that need for evaluation.

A urine test should be done, but just finding some bacteria or some white blood cells in the urine, or a “Positive” urine culture, does not mean that there is a bladder infection that needs to be treated.

It is very important to order a urinalysis with microscopy and Urine culture if needed.  Nothing less is sufficient in my practice.

It is often hard to get a good sample for a test.  The elder may be incontinent or very private and not allow anyone near them in the bathroom.  So a “hat” for collection in the toilet is a good start.  I would say there needs to be a discussion about goals of care before we forcibly stick a catheter into the bladder of anyone, let alone someone who does not understand what is being done, and may think they are being violated (that is another discussion).  (How to use a hat)


So if we get the urine, just seeing white cells or bacteria is not an accurate diagnosis.

I have seen patients in the ER diagnosed with urosepsis presenting with a fever of 102 and urine with 5-10 white blood cells (WBCs).  More likely would be urine with more than 20 wbcs or 100, if it was really the infection of the bladder making this person sick. 

Remember, an elder may have 100 WBC in the urine, but without symptoms. The new geriatric guidelines advise not to treat.  But be aware and watch.

Also, it is important to look at how many epithelial cells are found.  If there are more than a few, the specimen is likely not a “clean catch” and there is likely contamination.  Redo the test with more care to cleaning the perineal area.

The culture alone does not tell who has an infection.  It may be positive from contamination, and the urine would not show more than a few WBCs.  That would not be an infection (unless the person has an immune problem, which is not common).

Those are the first steps needed before treating any bladder infection.  Using antibiotics is not benign.  I have seen three frail people die from the Clostridia Dificille infection, or antibiotic associated colitis; often found in hospitals. It is also more likely for antibiotic use to cause c diff diarrhea.

Please share any questions you have related to bladder infections at our community chat.

Elizabeth Landsverk, MD