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
- Sean Ninan, specialist registrar, geriatric medicine1,
- Carly Walton, VTS trainee2,
- Gavin Barlow, consultant physician/honorary senior clinical lecturer3
- 1Calderdale Royal Hospital, Salterhebble, Halifax HX3 0PW, UK
- 2Pinderfields General Hospital, Wakefield WF4 1DG, UK
- 3Department of Infection and Tropical Medicine, Castle Hill Hospital, Cottingham, Hull HU16 5JQ, UK
- 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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