Abstract
BackgroundNon-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI despite many other potential causes. This leads to significant overdiagnosis of UTI, inappropriate antibiotic use and potential harmful outcomes. This problem is particularly prevalent in nursing home settings.MethodsA systematic review of the literature was conducted assessing the association between confusion and UTI in the elderly. PubMed, Scopus and PsychInfo were searched with the following terms: confusion, delirium, altered mental status, acute confusional state, urinary tract infection, urine infection, urinary infection and bacteriuria. Inclusion criteria and methods were specified in advance and documented in the protocol, which was published with PROSPERO (registration ID: CRD42015025804). Quality assessment was conducted independently by two authors. Data were extracted using a standardised extraction tool and a qualitative synthesis of evidence was made.ResultsOne thousand seven hunderd two original records were identified, of which 22 were included in the final analysis. The quality of these included studies varied, with frequent poor case definitions for UTI or confusion contributing to large variation in results and limiting their validity. Eight studies defined confusion using valid criteria; however, no studies defined UTI in accordance with established criteria. As no study used an acceptable definition of confusion and UTI, an association could not be reliably established. Only one study had acceptable definitions of confusion and bacteriuria, reporting an association with the relative risk being 1.4 (95% CI 1.0–1.7, p = 0.034).ConclusionsCurrent evidence appears insufficient to accurately determine if UTI and confusion are associated, with estimates varying widely. This was often attributable to poor case definitions for UTI or confusion, or inadequate control of confounding factors. Future well-designed studies, using validated criteria for UTI and confusion are required to examine the relationship between UTI and acute confusion in the elderly. The optimal solution to clarify this clinical issue would be a randomized controlled trial comparing the effect of antibiotics versus placebo in patients with new onset or worsening confusion and presence of bacteriuria while lacking specific urinary tract symptoms.
Highlights
Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI despite many other potential causes
Thirty-five articles were excluded at this stage, with the most common reason being the study reported confusion and UTI/bacteriuria in their population, but not in relation to each other [20,21,22,23,24,25,26,27,28,29,30,31,32,33,34]
Other common reasons included: the study did not report confusion [35,36,37,38,39], the study did not report UTI/ bacteriuria [2, 40,41,42,43], the study only reported the association in a specific subpopulation [44,45,46], or the study combined their measurement of confusion with other parameters [7, 47,48,49,50]
Summary
Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI despite many other potential causes. This leads to significant overdiagnosis of UTI, inappropriate antibiotic use and potential harmful outcomes. Despite new onset or worsening of confusion being a non-specific symptom, it continues to be the most common reason for suspecting a lower UTI in elderly patients, often leading to antibiotic treatment [2,3,4]. Due to all of these confounding factors, new onset or worsening of non-specific symptoms in residents is one of the major diagnostic challenges in caring for the elderly
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have