The diagnosis of urinary tract infections (UTI) in institutionalized elderly patients is complex, due to vague symptomatology. Moreover, the high prevalence of asymptomatic bacteriuria (ABU) is often ignored in clinical decision making, leading to a vast overprescription of antibiotics. Pragmatic clinical guidelines have been published to reduce the ordering of urinary cultures and prescription of antibiotics. Nitrite and leukocyte esterase dipstick tests have a high negative predictive value. Urinary cultures should only be ordered to guide antibiotic therapy after said decision has been taken based on clinical grounds. Apart from these pragmatic recommendations, current research is focussing on pathogen as well as host-derived factors. A smart combination of virulence factors and detection of immunological biomarkers could help clinicians to decide whether antibiotics should be initiated or not.