Abstract
BackgroundDiagnosing urinary tract infections (UTI) in nursing home residents is complex, due to frequent non-specific symptomatology and asymptomatic bacteriuria. The objective of this study was to explore health care professionals’ perceptions of the proposed use of inflammatory marker Point-Of-Care Testing (POCT) in this respect.MethodsWe conducted a qualitative inquiry (2018–2019) alongside the multicenter PROGRESS study (NL6293), which assessed the sensitivity of C-reactive protein and procalcitonin POCT in UTI. We used semi-structured face-to-face interviews. The participants were physicians (n = 12) and nurses (n = 6) from 13 nursing homes in the Netherlands. Most respondents were not familiar with inflammatory marker POCT, while some used POCT for respiratory tract infections. Both the interview guide and the analysis of the interview transcripts were based on the Consolidated Framework for Implementation Research.ResultsAll respondents acknowledged that sufficiently sensitive POCT could decrease diagnostic uncertainty to some extent in residents presenting with non-specific symptoms. They primarily thought that negative test results would rule out UTI and justify withholding antibiotic treatment. Secondly, they described how positive test results could rule in UTI and justify antimicrobial treatment. However, most respondents also expected new diagnostic uncertainties to arise. Firstly, in case of negative test results, they were not sure how to deal with residents’ persisting non-specific symptoms. Secondly, in case of positive test results, they feared overlooking infections other than UTI. These new uncertainties could lead to inappropriate antibiotics use. Therefore, POCT was thought to create a false sense of confidence.ConclusionsOur study suggests that inflammatory marker POCT will only improve UTI management in nursing homes to some extent. To realize the expected added value, any implementation of POCT requires thorough guidance to ensure appropriate use. Developing UTI markers with high negative and positive predictive values may offer greater potential to improve UTI management in nursing homes.
Highlights
Diagnosing urinary tract infections (UTI) in nursing home residents is complex, due to frequent nonspecific symptomatology and asymptomatic bacteriuria
Our current research focuses on the sensitivity of two blood inflammatory markers (C-reactive protein [CRP] and procalcitonin [PCT]), measured in point-of-care testing (POCT) to support diagnosing UTI [17]
Role of Point-Of-Care Testing (POCT) in urinary tract infections Only added value in case of non-specific symptoms About half of the respondents explicitly stated that, in nursing home residents presenting with specific urinary symptoms, inflammatory marker POCT has no added value as there is no diagnostic uncertainty, but that attaining such diagnostic certainty was only possible in a small minority of nursing home residents able to adequately express complaints
Summary
Diagnosing urinary tract infections (UTI) in nursing home residents is complex, due to frequent nonspecific symptomatology and asymptomatic bacteriuria. The only presenting feature of UTI may be non-specific symptoms [8] Such symptoms are frequently reported in nursing home residents, but could be attributed to many causes, including deterioration of underlying cognitive impairments [9]. Urine tests to detect bacteria, such as dipstick analysis and bacterial culture, lack specificity in diagnosing UTI For this reason, most guidelines on UTI in nursing home residents do not recommend the use of dipstick urinalysis, or only recommend it to ‘rule out’ UTI [13, 14]. Most guidelines on UTI in nursing home residents do not recommend the use of dipstick urinalysis, or only recommend it to ‘rule out’ UTI [13, 14] Due to these difficulties in recognizing and diagnosing UTI, inappropriate antibiotic use is common, which increases the risk of antimicrobial resistance development [15, 16]
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