The call you have had before
«She seemed a bit off, so we sent a urine sample, and she has another UTI. We have started her on antibiotics.» You heard it in February, in May, and now again. Nobody sounds worried. It sounds like good care — something was noticed, something was tested, something was treated.
It may be exactly that. But there is a very common way this goes wrong, and it is worth understanding before the next call, because the fix is not more vigilance. It is a better question.
The fact that changes how you hear that sentence
In older people — particularly older women, and particularly in residential aged care — bacteria in the urine with no symptoms are extremely common. It has a name, asymptomatic bacteriuria, and in this population it sits closer to normal than to abnormal. It is not an infection. Treating it does not make people better, does not prevent later infections, and causes real harm.
So a urine culture that grows something is not, on its own, a diagnosis. If a sample goes off every time a resident seems «off», something will eventually grow — and antibiotics will follow. That is not detection. That is the test manufacturing the diagnosis.
Two more things that are not evidence of infection but get treated as if they were: cloudy urine and strong-smelling urine. Both are usually about concentration — that is, about how little she has had to drink.
What would actually justify antibiotics
Before treating a suspected urinary infection there should be new urinary symptoms or systemic signs: fever, new burning or pain passing urine, new loin or lower abdominal pain or tenderness, new visible blood, rigors. A change in behaviour on its own is not one of them.
Which brings us to the sentence at the centre of this article, and you can ask it on the phone:
«Apart from the confusion, what symptoms did she have that met the criteria for starting antibiotics?»
A fair, factual question — not an accusation, and any clinician will recognise it as routine. If there is fever and pain passing urine, you have your answer and the treatment is right. If the answer is «she just wasn't herself», you are very likely looking at a different problem dressed up as a urinary one.
«Not herself» has a long list of causes
- Dehydration — the most common and the most fixable, and the very thing that makes urine cloudy and strong-smelling.
- Pain she cannot report: arthritis, a bad tooth, a pressure injury, an ingrown toenail.
- Constipation or urinary retention, both genuinely distressing and easy to check.
- A new medicine or a dose change in the last fortnight.
- A chest infection, which in older people often arrives without a cough.
- Poor sleep, a room change, a new neighbour, a missing hearing aid.
If the urine sample was the only thing checked, the search stopped at the first door.
Why the extra course is not «just in case»
- C. difficile — antibiotics disturb the gut and can trigger severe, sometimes dangerous diarrhoea that spreads within a home.
- Resistance — every course selects for the organisms that survive it. The bill arrives later, on the day she has a real infection and the usual medicine no longer works.
- Side effects and interactions — falls, nausea, thrush, kidney effects, and interactions with anticoagulants that matter a great deal at this age.
The Australian lever: prescribing here is measurable
This is the part most families do not know. Antimicrobial stewardship is part of what providers are expected to do under the Aged Care Quality Standards on clinical care and infection prevention — it is not optional good practice.
And there is something more concrete still: Australian aged care homes can take part in the Aged Care National Antimicrobial Prescribing Survey, a national audit in which a home reviews its own antibiotic prescribing — how much, for what, and how much of it had no documented indication or no signs or symptoms recorded. Homes that participate get their own numbers back and can compare them nationally.
So the second question lands differently from a complaint:
«Does the home take part in the aged care antimicrobial prescribing survey — and what does your stewardship approach say about a positive urine culture in a resident with no urinary symptoms?»
A home that works at this answers comfortably. A home that has the policy and not the practice answers differently, and you will hear it.
You can also ask for a medication review by a pharmacist, which the resident's GP can arrange, and which is exactly the setting for «why is she on her fourth course this year?»
The catheter question
If she has an indwelling catheter, the whole conversation changes shape. A catheter left in guarantees bacteria in the urine — that is not a complication, it is what happens. It then produces repeated «positive» samples and repeated antibiotics, and each course raises the risk of a genuinely dangerous infection.
Ask two things: why is the catheter there, and what is the plan to remove it? Catheters are sometimes inserted for a sound reason and then never revisited, because nobody owns the decision. «It is easier for staff» is not a clinical indication — and if that is the honest answer, the honest next step is a removal plan.
What to ask for, concretely
- That a sample be sent before antibiotics start, where treatment is indicated, so it can be narrowed once the result is back.
- A review at 48 to 72 hours: is she better, does the result support continuing, can it be narrowed or stopped? Ask for that review to go into the care plan with a date.
- A hydration plan in the care and services plan, with a named person and a frequency.
- If courses keep recurring, a conversation with the GP about whether repeated treatment is helping her at all.
What you can do yourself, for free
Count. On your next visit, watch how much she actually drinks while you are there, whether the glass is within reach, and whether anyone refills it. Look at her lips and mouth. Dehydration in a home is rarely anyone's decision — it is what happens when nobody is counting, and it sits underneath «she seemed a bit off» more often than anything else.
Keep the tone in mind. You are not arguing that she should be denied treatment. You are asking that the treatment aim at what is actually wrong. Most GPs and nurses want exactly that; the pressure to «just treat it» often comes from wanting to reassure the family. Being the family that asks the better question removes that pressure.
When the home is the wrong home
Sometimes the answer is not «ask again» but «different home». A home with real stewardship and someone counting fluids is a different product from one that sends a sample every time and starts a course.
That is where Curalune helps. We look at your situation, tell you which homes near you are realistic, and what to ask each one — including how they handle antibiotics and hydration. The case review costs A$109 and takes a few minutes to start. If you don't receive at least 3 homes matching the area and criteria you gave us, we refund you in full. Start your request here
The short version
- Bacteria in the urine without symptoms are common in older people and are not an infection. Cloudy or smelly urine is usually about hydration.
- Ask: «apart from the confusion, what symptoms met the criteria for starting?»
- «Not herself» has a long list of causes — dehydration, pain, constipation, a new medicine, a chest infection.
- Over-treatment causes real harm: C. difficile, resistance, interactions.
- Stewardship sits inside the Quality Standards, and homes can measure their own prescribing through the national aged care survey. Ask whether they take part.
- If there is a catheter, ask why and when it comes out. Ask for a 48–72 hour review, and count what she drinks.
This article is general information and does not replace medical advice or an individual clinical assessment. Decisions about testing and treatment rest with the treating clinician. Curalune does not allocate beds and does not guarantee availability.