Practice Rational testing

Investigation of suspected urinary tract infection in older people

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4070 (Published 03 July 2014) Cite this as: BMJ 2014;349:g4070
  1. Sean Ninan, specialist registrar, geriatric medicine1,
  2. Carly Walton, VTS trainee2,
  3. Gavin Barlow, consultant physician/honorary senior clinical lecturer3
  1. 1Calderdale Royal Hospital, Salterhebble, Halifax HX3 0PW, UK
  2. 2Pinderfields General Hospital, Wakefield WF4 1DG, UK
  3. 3Department of Infection and Tropical Medicine, Castle Hill Hospital, Cottingham, Hull HU16 5JQ, UK
  1. Correspondence to: S Ninan sean.ninan{at}nhs.net
  • Accepted 8 May 2014

Learning points

  • Do not use urine dipstick tests to diagnose urinary tract infection in older people; if they are performed at all, only a negative result should be considered useful in excluding a urinary tract infection

  • In patients who are able to provide a history, urinary tract infection should be diagnosed only in the presence of a combination of at least three acute urinary symptoms or signs, such as dysuria, urgency, frequency, or suprapubic tenderness

  • In patients who are unable to provide a history, urinary tract infection should be diagnosed only when evidence exists of acute inflammation (for example, fever/hypothermia or raised white cell count or C reactive protein) associated with bacteriuria on urine culture and no other more likely cause of their acute illness exists

  • Asymptomatic bacteriuria is common in older people; avoid treating bacteriuria in patients with non-specific symptoms that cannot be attributed to urinary tract infection, as this confers no benefit and may cause harm

An 84 year old woman, who lived in a residential home, was referred to the acute medical assessment unit with a two day history of increasing confusion of unclear cause. She was unable to provide a clear history, but her daughter mentioned that she was not usually confused. On examination, her temperature was 36.8°C, her heart rate was 67 beats per minute, and her blood pressure was 135/70 mm Hg. She looked dehydrated and was noted to be incontinent of dark, offensive smelling urine. Urinary tract infection was suspected.

What is the next investigation?

Suspected urinary tract infection is a common scenario when evaluating ill older adults. The diagnosis may be challenging, as patients are often unable to provide a history of acute urinary symptoms (for example, owing to delirium or dementia), and asymptomatic bacteriuria (see table 1 for definitions) is common in older people. The prevalence of …

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