Suspected UTI in Nursing Home Patients: When to Test

Q: Is it appropriate to routinely order urinalysis for patients in a nursing home (both with and without dementia) when they exhibit behavioral changes but show no signs or symptoms of urinary tract infection (UTI)?

A: Practitioners who work in nursing homes frequently face this dilemma. Currently, 2 sets of diagnostic, treatment, and surveillance criteria for UTIs in nursing home residents are available to provide guidance with such decisions.

McGeer criteria. Published in 1991, these criteria were developed by infectious disease experts for purposes of surveillance and outcome assessment in nursing homes.¹ According to these criteria, to make an empiric diagnosis of UTI in a nursing home resident who does not have an indwelling catheter, 3 of the following symptoms must be present:

• Fever (temperature of at least 38°C [100.4°F]).
• New or increased frequency, urgency, or burning on urination.
• New flank or suprapubic pain or tenderness.
• Change in character of urine.
• Worsening of mental or functional status.¹

Urine culture results are not included in these criteria because of the high prevalence of asymptomatic bacteriuria in elderly nursing home residents. When an appropriately collected specimen is sent for analysis and bacteria are detected, the result must be reported as either positive or contaminated.¹

The McGeer criteria have been accepted as a standard for nursing homes by 2 national infection control organizations (the Association for Professionals in Infection Control and the Society for Healthcare Epidemiology of America).² In addition, the Department of Health and Human Services and the Centers for Medicare and Medicaid Services issue yearly guidelines for nursing homes stating that only residents who meet the McGeer criteria should be treated for UTI.³

Loeb criteria. In 2001, another consensus group recommended a set of clinical criteria for the initiation of antibiotic therapy for UTI in nursing home residents. Referred to as the Loeb criteria, they specify that empirically initiated antibiotic therapy in a resident who does not have an indwelling catheter is appropriate only when he or she has acute dysuria or fever (temperature higher than 37.9°C [100°F] or more than 1.5°C [2.4°F] higher than baseline), accompanied by the new or worsening presence of at least one of the following:

• Urgency.
• Frequency.
• Suprapubic pain.
• Gross hematuria.
• Costovertebral angle tenderness.
• Urinary incontinence.⁴

Criteria-based answer. Thus, based on both the Loeb and McGeer criteria, UTI should not be diagnosed in either a demented or cognitively intact resident on the basis of behavioral changes alone--even in the presence of bacteriuria and pyuria. It is true that both sets of currently available criteria have been derived by consensus and are not evidence-based. Nevertheless, my clinical experience supports the view that behavioral changes alone should not prompt evaluation for UTI.

Ongoing study. Our group at the Yale School of Medicine is conducting a prospective cohort study among nursing home residents with suspected UTI to determine which combinations of clinical features (eg, behavioral changes, mental status changes, functional status changes, change in voiding pattern, fever) are associated with laboratory evidence of UTI (bacteriuria [more than 100,000 colony-forming units on urine culture] plus pyuria [more than 10 white blood cells per high-power field on urinalysis]). We hope that the results of this study will identify the clinical features that should prompt testing for UTI in these patients.

References:

REFERENCES:
1. McGeer A, Campbell B, Emori TG, et al. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control. 1991;19:1-7.
2. Smith PW, Rusnak PG. Infection prevention and control in the long-term-care facility. SHEA Long-Term-Care Committee and APIC Guidelines Committee. Infect Control Hosp Epidemiol. 1997;18:831-849.
3. Centers for Medicare & Medicaid Services. State Operations Manual. Appendix PP, Section 483.25(d); 2005. Publication #100-07. Available at: http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed August 23, 2006.
4. Loeb M, Bentley DW, Bradley S, et al. Development of minimum criteria for the initiation of antibiotics in residents of long-term care facilities: results of a consensus conference. Infect Control Hosp Epidemiol. 2001;22:120-124.