Community management of possible Urinary Tract Infection in the confused elderly

Scope

  • This guideline covers the community management of possible UTI in a confused elderly patient.
  • Many cases of delirium are previously unrecognised dementia, or expected disease progression.
  • Delirium may present with non -specific symptoms and fever may be absent.

Out of scope

Assessment

History and Examination

  • Obtain a collateral history if possible, or previous AMT results
    • Consider non-infective causes of delirium.
    • Isolated rises in inflammatory markers cannot be used to distinguish infective causes.
    • Many elderly patients have unexplained high CRP values.

Red Flags

Management

If infection remains in the differential

Obvious localising signs - treat as per appropriate infection management guideline

  • Localising signs maybe misleading in the elderly.
  • In particular chest signs are a common presenting feature of UTI in this group.
  • Urine dipstick probably has reasonable sensitivity but specificity is poor.
  • Do not confidently diagnose UTI purely on the basis of a dipstick result.

No localising signs / vague non-specific symptoms

  • Perform urine dipstick
    • If negative for nitrate and leucocyte esterase – UTI unlikely
    • If positive for nitrate or leucocyte
  • Send MSU
    • Form must include clinical details, including confusion with positive urinalysis
    • Mixed culture results may inform management.
    • Urines received without clinical details will not be processed.
  • Review previous culture results
  • Severe delirium with no other cause for acute confusion
  • Mild delirium (AMT greater than 7)
    • Either watch and wait or
    • Treat as cystitis
  • If patient not improved after 24 hours review culture results if available
    • Consider discussion with microbiology
  • Final review of diagnosis
    • Use:
      • Collateral history
      • UTI is unlikely in the absence of positive urine cultures
      • Clinical Progress
    • UTI unlikely
        • negative urine cultures
        • amend clinical notes
    • UTI possible
      • positive urine culture with no other explanation for symptoms
      • positive urine culture has a low specificity in this age group.

Joint formulary – Chapter 5 - Infections

Joint formulary – Chapter 7 – Urinary Tract Disorders

Supporting Information

This pathway was signed off by the NEW Devon CCG Northern Locality Clinical Pathway Group.

Publication date: May 2017

 

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