Clinical uncertainties in the approach to long term care residents with possible urinary tract infection

Urinary tract infection (UTI) is arguably the most common infection in the long term care (LTC) setting. Making the diagnosis of UTI and deciding when to initiate treatment with antimicrobial therapy is a challenge to all LTC providers. Widespread prevalence of asymptomatic bacteriuria, lack of an accepted clinical or laboratory gold standard to start antibiotics for UTI, and a high prevalence of cognitive impairment in the LTC population all contribute to this challenge. Several consensus based criteria for diagnosing UTI have been published, though these vary from each other owing to different intended purposes. The McGeer and updated Stone criteria are intended for surveillance and benchmarking purposes. The 2005 Loeb criteria represent minimal criteria for the initiation of antimicrobial therapy. Our review focuses on residents without a urinary catheter. The Loeb criteria should be updated, by inclusion of isolated fever in those with profound cognitive impairment as well as scrotal or prostate swelling tenderness to be consistent with the updated McGeer criteria by Stone et al. Urine testing and antimicrobial therapy should not be ordered in those with isolated nonspecific signs or noninfectious symptoms such as fatigue or delirium. Both cavalier urine testing and unnecessary antimicrobial therapy contribute to direct patient harm as well as the rapidly escalating threat of antimicrobial resistance. Observation and monitoring of residents in whom the diagnosis of UTI is unclear is a best practice that should be implemented. Facilities should consider addressing UTI management as part of their quality assurance and performance improvement process.