Infectious Diseases

Urinary Tract Infection (UTI) in the Nursing Home Patient

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OVERVIEW: What every practitioner needs to know

Are you sure your nursing home patient has urinary tract infection? What should you expect to find?

  • Urinary tract infection (UTI) is one of the most common diagnoses in nursing home residents.

  • There is substantial uncertainty in the diagnosis of symptomatic urinary infection in this population. Diagnostic accuracy is compromised by limitations in communication and in clinical assessment of signs and symptoms in elderly residents with functional and mental impairment.

  • The prevalence of asymptomatic bacteriuria in long-term care facility residents is 35-50%.

    • Screening for or treatment of asymptomatic bacteriuria is not beneficial and is not recommended.

    • Treatment of asymptomatic bacteriuria is a major contributor to inappropriate antimicrobial use in this setting.

  • Infection may present as cystitis (bladder infection) or pyelonephritis (renal infection).

  • Localizing genitourinary symptoms should be present.

    • Key symptoms include new or increased dysuria, frequency, incontinence, urgency, and costovertebral or suprapubic pain.

    • Key signs include costovertebral or suprapubic tenderness and hematuria.

  • If acute localizing genitourinary signs or symptoms are not present, symptomatic urinary tract infection is unlikely in the non-catheterized resident.

    • Non-specific and non-localizing signs and symptoms, such as increased falls, confusion, or decreased oral intake, should not be attributed to UTI, even when the urine culture is positive.

    • Cloudy and foul smelling urine are not considered symptoms or signs of symptomatic UTI in this population.

    • Chronic genitourinary symptoms, such as incontinence, frequency, or nocturia, are consistent with symptomatic urinary infection only when there is acute deterioration.

  • Residents with a clinical presentation of severe sepsis (i.e., hemodynamic instability, acute onset of confusion) without localizing genitourinary signs or symptoms are unlikely to have a urinary source, unless underlying urologic abnormalities are present. However, if no other site for infection is apparent, management should include antimicrobial coverage for urosepsis pending results of cultures and other investigations.

How did this nursing home patient develop urinary tract infection? What was the primary source from which the infection spread?

  • Organisms are usually acquired from colonizing flora of the gut and periurethral area.

  • Asymptomatic bacteriuria in residents of long-term care facilities is associated with chronic comorbidities accompanied by impaired voiding (e.g., chronic neurologic diseases) and urologic abnormalities (e.g., prostate hypertrophy in men and cystoceles in women).

  • Men using condom catheters have heavy periurethral colonization, often with multiple Gram-negative organisms; kinking or obstruction of the condom or tubing increases the likelihood that bacteriuria will develop.

Which individuals are at greater risk of developing a urinary tract infection in a nursing home?

  • Determinants of symptomatic infection are not well described. Residents with urologic abnormalities accompanied by obstruction or hematuria are at increased risk of infection, but these precipitating events occur in only a small proportion of symptomatic episodes.

  • The presence of asymptomatic bacteriuria correlates with increased functional disability, dementia, urinary and fecal incontinence, and, in men, prostate disease.

  • Although loss of the estrogen effect on the genitourinary mucosa has been suggested to contribute to urinary infection in post-menopausal women, evidence to date does not support estrogen deficiency as an important factor contributing to bacteriuria or symptomatic urinary infection for female residents of nursing homes.

  • Prostate hypertrophy in men results in urinary retention and turbulent urethral urine flow, facilitating urinary infection. Chronic bacterial prostatitis often presents as recurrent symptomatic lower tract infection when bacteria in the prostate are repeatedly reintroduced into the bladder. Prostate infection may be impossible to cure because of limited diffusion of antimicrobials into the prostate.

  • Men using an external (condom) catheter for urine drainage experience an increased prevalence of bacteriuria and incidence of symptomatic infection compared with incontinent men without a condom catheter.

  • The post-void residual urine volume does not predict development of asymptomatic or symptomatic infection in residents of long-term care facilities.

Beware: there are other diseases that can mimic urinary tract infection in a nursing home:

  • The high prevalence (25-50%) of asymptomatic bacteriuria in nursing home residents leads to substantial over-diagnosis of UTI when residents with bacteriuria develop non-specific changes in clinical status without localizing genitourinary signs or symptoms.

  • Fever in a resident with bacteriuria but without localizing genitourinary signs or symptoms will have a urinary source in less than 10% of episodes. The only resident variable associated with a urinary source is a prior history of symptomatic urinary infection.

  • Gross hematuria is rarely attributable to acute urinary infection (i.e., hemorrhagic cystitis). Bacteriuric residents with fever and hematuria usually have bacterial invasion following mucosal injury from a urologic abnormality. When gross hematuria occurs, a urologic abnormality, such as stones, ulcers, malignancy, or diverticulae, should be considered.

  • Localizing genitourinary signs and symptoms may be caused by other genitourinary diseases, such as vulvovaginal candidiasis, periurethral abscesses, ulcerations, tumors, strictures, or stones. New or increased incontinence may result from many causes, including medication (e.g., diuretics), comorbidities, such as congestive heart failure, or impaired mobility.

  • Other intra-abdominal or retroperitoneal illness may present with suprapubic or costovertebral angle pain or tenderness.

What laboratory studies should you order and what should you expect to find?

Results consistent with the diagnosis

  • A positive urine culture is necessary for a diagnosis of urinary infection. However, without accompanying acute genitourinary signs or symptoms, a positive culture has a low positive predictive value for symptomatic infection.

    • Urine specimens must be collected in a manner that minimizes contamination from periurethral or vaginal bacteria. If a clean catch-voided urine specimen cannot be obtained, a specimen should be collected by in and out catheterization. For men, a urine specimen may also be collected using a clean, freshly applied condom catheter and leg bag.

    • Microbiologic diagnosis requires a urine culture with greater than 105 CFU/mL, usually of a single organism. From 10 to 25% of residents may have two or more organisms grown at greater than 105 CFU/mL. Men with voiding managed by external condom catheters are more likely to have multiple organisms isolated.

    • Lower quantitative counts (less than 105 CFU/mL) are occasionally isolated from residents with symptomatic urinary infection. If there is isolation of a single Gram-negative organism in lower quantitative counts from a voided urine, contamination is possible and the diagnosis of UTI should be reconsidered. A voided urine specimen with more than one organism isolated with quantitative counts less than 105 CFU/mL should be interpreted as contaminated and a repeat specimen obtained by in and out catheter, if required.

    • Any quantitative count greater than 102 CFU/mL is considered infection when a specimen is collected by in and out catheter.

  • Pyuria identified by leukocyte esterase dipstick or urinalysis is a non-specific finding and not reliable for either diagnosis of bacteriuria or differentiating asymptomatic from symptomatic infection. However, a negative test for pyuria effectively excludes UTI.

  • Residents with more severe clinical presentations usually have an elevated peripheral leukocyte count or left shift (greater than >6% bands or absolute band count greater than 1500) in peripheral leukocytes.

Results that confirm the diagnosis

  • The only diagnostic test that confirms symptomatic UTI is a positive blood culture with the same isolate grown from blood and urine.

  • A negative urine culture obtained prior to institution of antimicrobial therapy excludes a diagnosis of UTI.

What imaging studies will be helpful in making or excluding the diagnosis of urinary tract infection in nursing home residents?

  • Imaging studies are not usually indicated.

  • Imaging to exclude obstruction, renal or perinephric abscesses, or other complications that require intervention should be considered when:

    • the clinical presentation is consistent with severe sepsis/septic shock

    • there is no clinical response by 48-72 hours after instituting effective antimicrobial therapy

    • there is rapid (less than 1 month) symptomatic recurrence following a course of effective therapy

  • Imaging studies are also indicated to identify alternate diagnoses, such as cholecystitis, diverticulitis, or other intra-abdominal or retroperitoneal illness when there is diagnostic uncertainty.

  • Residents with persistent or recurrent gross hematuria should have appropriate imaging and urologic investigations to identify underlying causes for the hematuria.

  • The optimal imaging study is a contrast-enhanced computed tomography (CT) scan. When contrast media is contraindicated (diabetes, renal failure) a non-contrast enhanced CT scan is recommended. If a CT scan is not readily available, ultrasound examination may identify major abnormalities, such as obstruction or abscesses, which may require intervention.

What consult service or services would be helpful for making the diagnosis and assisting with treatment?

  • For most episodes, no consultation is necessary.

  • When there is diagnostic uncertainty, a severe clinical presentation (i.e., severe sepsis or septic shock) or frequent recurrent symptomatic episodes, consultation may be considered with urology, infectious diseases, or geriatric medicine.

If you decide the patient has urinary tract infection, what therapies should you initiate immediately?

1. Anti-infective agents

If I am not sure what pathogen is causing the infection, what anti-infective should I order?

  • Key principles of therapy:

    • Do not treat asymptomatic bacteriuria.

    • Optimize resident quality of life; consider advance directives before initiating therapy.

    • Limit antimicrobial adverse effects and costs.

    • Limit emergence of resistant organisms.

  • Empiric antimicrobial therapy is selected considering:

    • known or suspected susceptibilities of infecting pathogens

    • patient tolerance, including renal function

    • need for parenteral or oral therapy (based on presentation, oral tolerance, potential antimicrobial susceptibilities)

    • renal excretion of the antimicrobial and anticipated renal and urine antimicrobial levels

  • If residents present with questionable or mild symptoms, it is preferable to monitor the patient while the urine culture is pending, rather than initiating empiric antimicrobial therapy.

  • For cystitis, nitrofurantoin or trimethoprim/sulfamethoxazole (TMP/SMX) is preferred. TMP/SMX for empiric use, however, is often limited by antimicrobial resistance. Fluoroquinolones should not be used for first-line treatment of cystitis, to limit antimicrobial pressure promoting emergence of fluoroquinolone resistant organisms.

Table I, Table II, Table III, and Table IV summarize treatment options.

Table I.

Preferred regimens of anti-infective agents for oral empiric antimicrobial therapy

Table II.

Alternative regimens of anti-infective agents for oral empiric antimicrobial therapy

Table III.

Preferred regimens for anti-infective agents for parenteral empiric antimicrobial therapy

Table IV.

Alternative regimens for anti-infective agents for parenteral empiric antimicrobial therapy

2. Other key therapeutic modalities

  • Patients with severe presentations, including hemodynamic instability, high fever, vomiting, or acute onset of confusion, require supportive therapy, including rehydration, antiemetics, pain control, and management of comorbidities. Considering advance directives and available institutional resources, some severely ill residents may require transfer to an acute care hospital for additional care.

  • The clinical response to empiric antimicrobial therapy should be reviewed at 48-72 hours, when urine culture results are usually available.

    • Consider modifying to more specific antimicrobial therapy once culture results are available.

    • For patients receiving parenteral therapy, step down to oral therapy if there has been a satisfactory clinical response.

  • When the infecting organism isolated is not susceptible to the initial empiric regimen, antimicrobial therapy should be modified to an effective agent, even if there has been a satisfactory clinical response.

What complications could arise as a consequence of urinary tract infection in the nursing home patient?

  • Diabetic patients are at increased risk of complications, such as perinephric or renal abscesses, emphysematous pyelonephritis or cystitis, or papillary necrosis.

  • Residents with infection with some urease producing organisms (i.e., Proteus mirabilis, Providencia stuartii) may develop renal or bladder stones.

  • Metastatic infection at distant sites may be a complication of bacteremia. The skeletal system is most frequently involved, with the vertebral column the single most frequent site. Endocarditis may also occur.

  • Infection does not progress to renal failure in the absence of complicating factors, such as obstruction or renal stones.

What should you tell the family about the patient’s prognosis?

  • The prognosis is excellent when effective treatment is initiated promptly.

  • Patients with severe presentations, including septic shock, have a mortality of 10-20%.

  • Patients who experience an initial symptomatic UTI are at increased risk for subsequent infections.

What-if scenarios:

  • If there is not a clear clinical response by 48-72 hours following initiation of antimicrobial therapy, reassess the patient considering:

    • resistant organism—repeat urine culture

    • alternate diagnoses

    • possibility of underlying urologic abnormalities, such as obstruction or abscesses, which require intervention

  • If the patient responds clinically to antimicrobial therapy but symptomatic infection recurs within 1 month of discontinuation of the antimicrobial, reassess susceptibility of the infecting organism. If the organism is susceptible, consider investigations to determine whether there is an underlying urologic abnormality that may require intervention.

  • For the rare patient who experiences frequent symptomatic episodes and has a persistent underlying abnormality that cannot be corrected, such as a persistent infected stone, infected non-functioning kidney or, for men, chronic bacterial prostatitis, long-term suppressive therapy may be considered for control of symptoms.

How do you contract urinary tract infection in the nursing home and how frequent is this disease?

Detailed epidemiology

  • Symptomatic urinary infection is one of the most common infections diagnosed in nursing home residents.

    • The reported incidence ranges from 1 to 2.4 per 1,000 resident days or from 0.11 to 0.15 per 1,000 days when restrictive definitions requiring localizing signs or symptoms are applied.

    • The incidence of urinary infection presenting with fever is 0.49-1.04 per 10,000 resident days.

  • The prevalence of asymptomatic bacteria in nursing home residents is 30-50% for women and 15-40% for men.

    • The prevalence of bacteriuria increases with increasing functional disability and correlates with mental impairment and incontinence of bladder and bowel.

    • Bacteriuria in nursing home residents is dynamic. From 10 to 20% of initially non-bacteriuric institutionalized men or women will acquire bacteriuria by 6 or 12 months follow-up, and 25-30% of initially bacteriuric residents will become non-bacteriuric during this time. Some residents, however, will have persistent bacteriuria with the same organism for years.

Mode of spread

  • Residents develop infection by the ascending route following periurethral and, for women, vaginal colonization by endogenous flora from the gut.

  • Colonizing organisms may also occasionally be transmitted between patients by environmental exposures or on the hands of residents or health care workers.

What pathogens are responsible for this disease?

  • The single most common organism is Escherichia coli. In some reports, P. mirabilis is more frequent in men.

  • A wide variety of other organisms may be isolated. These include Klebsiella species, Enterobacter species, Citrobacter freundii, Serratia species, Pseudomonas aeruginosa, Acinetobacter species, Enterococcus species, Streptococcal species, coagulase-negative staphylococci, and Candida species.

  • Resistant organisms, including vancomycin-resistant enterococci and extended spectrum β-lactamase or carbapenemase producing E. coli and K. pneumoniae, may occur. Staphylococcus aureus, including methicillin-resistant S. aureus, are occasionally isolated but are relatively uncommon.

How do these pathogens cause urinary tract infection?

  • Nursing home residents have "complicated UTI"; host factors rather than organism virulence is the important determinant of infection.

    • E. coli isolated from symptomatic or asymptomatic infection in nursing home residents have a low frequency of virulence factors compared with strains isolated from women with acute, uncomplicated cystitis or pyelonephritis.

  • Urease producing organisms, particularly Proteus mirabilis and Providencia stuartii, are associated with crystalline biofilm formation that may cause bladder or renal infection stones.

  • There is a robust host response to infection, both local (i.e., pyuria, cytokines, antibodies) and, for more severe cases, systemic (i.e., leukocytosis, elevated inflammatory markers and acute phase response, systemic antibody response). This host response may facilitate resolution of acute infection but does not prevent subsequent recurrence.

What other clinical manifestations may help me to diagnose and manage urinary tract infection in nursing home patients?

When taking the patient’s history, include prior UTI and recent urologic interventions. During the physical exam, look for purulent discharge from the urethra and, in men, swollen or tender prostate or epididymis.

How can urinary tract infection in nursing home residents be prevented?

  • Identification and correction of urologic abnormalities that contribute to infection may prevent subsequent episodes.

  • Prophylactic antibiotics are not recommended. In the context of complicated urinary infection, resistant organisms emerge rapidly.

  • Topical vaginal estrogen has not yet been shown to decrease recurrent bacteriuria or symptomatic infection in female nursing home residents.

  • Cranberry products or probiotics have not been shown to be beneficial for preventing bacteriuria or symptomatic infection for nursing home residents.

WHAT’S THE EVIDENCE for specific management and treatment recommendations?

Barabas, G, Mölstad, S. "No association between elevated post-void residual volume and bacteriuria in residents of nursing homes". Scand J Prim Health Care. vol. 23. 2005. pp. 52-6.

(In 147 elderly residents, prevalence of post-void residual [PVR] volume was 51% [greater than 30mL], 39% [greater than 50mL], 20% [greater than 100mL], and 7% [greater than 150mL]. Bacteriuria was identified in 46% of women and 28% of men, and did not correlate with PVR volume.)

Boscia, JA, Kobasa, WD, Abrutyn, E, Levison, ME, Kaplan, AM, Kaye, D. "Lack of association between bacteriuria and symptoms in the elderly". Am J Med. vol. 257. 1986. pp. 1067-71.

(There were no differences in the presence or severity of chronic genitourinary or non-specific symptoms in women in an assisted living facility when they were bacteriuric or not bacteriuric.)

D’Agata, E, Loeb, MB, Mitchell, SL. "Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections". J Am Geriatr Soc. vol. 61. 2013. pp. 62-66.

(Only 16% of episodes diagnosed as urinary tract infection met criteria for initiation of antimicrobials. Only 11.4% met clinical and laboratory criteria.)

Gomolin, IH, Siami, PF, Reuning-Scherer, J, Haverstock, DC, Heyd, A. "Efficacy and safety of oral ciprofloxacin suspension versus trimethoprim-sulfamethoxazole oral suspension for treatment of older women with acute urinary tract infection". J Am Geriatr Soc. vol. 49. 2001. pp. 1603-13.

(In a randomized open trial, 10 days ciprofloxacin therapy cured 94% and TMP/SMX 83% of nursing home residents. More than 10% of pre-therapy isolates were TMP/SMX resistant.)

High, KP, Bradley, SF, Gravenstein, S. "Clinical practice guidelines for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America". Clin Infect Dis. vol. 48. 2009. pp. 149-71.

(These practice guidelines recommend that, when a diagnosis of urinary tract infection is considered [acute onset of genitourinary symptoms or signs, source of fever, or other clinical deterioration] a urine culture should be obtained to confirm infection only if the urine specimen shows pyuria.)

Juthani-Mehta, M, Quagliarello, V, Perrelli, E, et, al. "Clinical features to identify urinary tract infection in nursing home residents: a cohort study". J Am Geriatr Soc. vol. 57. 2009. pp. 963-70.

(Only 43% of patients thought to potentially have urinary tract infection by relatives or nursing home staff had a positive urine culture with pyuria. There was no control group, and the overall prevalence of bacteriuria of 43% is similar to that reported for asymptomatic nursing home populations. Only dysuria, increased mental confusion, or change in character of the urine were independent predictors of a positive urine culture with pyuria. The observed associations with mental status and changes in character of the urine, however, are subject to confounding, as residents with these characteristics are more likely to be bacteriuric at any time.)

Juthani-Mehta, M, Tinetti, M, Perrelli, E, Towle, V, Quagliarello, V. "Role of dipstick testing in the evaluation of urinary tract infection in nursing home residents". Infect Control Hosp Epidemiol. vol. 28. 2007. pp. 889-91.

(The negative predictive value of dipstick leukocyte esterase and nitrite was 100% [95% confidence interval, 74-100%) for bacteriuria [greater than 105 CFU/mL] with pyuria [10 WBC/mm3 on urinalysis.)

Loeb, M, Bentley, DW, Bradley, S. "Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference". Infect Control Hosp Epidemiol. vol. 22. 2001. pp. 120-4.

(These consensus guidelines recommend clinical criteria for initiating antimicrobial therapy for residents of long-term care facilities. Empiric antimicrobial therapy for presumed urinary tract infection should be considered for residents without an indwelling catheter only when there is either acute dysuria or one or more of temperature greater than 37.9°C, acute confusion, or rigors with at least one of new or worsening urgency, frequency, supra-pubic pain, gross hematuria, costovertebral angle tenderness, and urinary incontinence.)

Loeb, M, Brazil, K, Lohfeld, L. "Effect of a multifaceted intervention on number of antimicrobial prescriptions of suspected urinary tract infections in residents of nursing homes: cluster randomized controlled trial". BMJ. vol. 331. 2005. pp. 669.

(This prospective randomized cluster controlled trial evaluated the consensus guidelines for institution of antimicrobial therapy. The application of the consensus guidelines for respiratory or urinary tract infection had similar outcomes to "standard therapy" for efficacy and safety and, overall, lower antimicrobial use.)

McMurdo, ME, Argo, I, Phillips, G, Daly, F, Davey, P. "Cranberry or trimethoprim for the prevention of recurrent urinary tract infections? A randomized controlled trial in older women". J Antimicrob Chemother. vol. 63. 2009. pp. 389-95.

(This prospective randomized double blind trial reported that 300mL cranberry juice daily versus placebo was not effective for prevention of urinary tract infection in the hospitalized elderly. Symptomatic urinary infection occurred in 7.4% [14/189] of placebo patients and 3.7% [7/187] cranberry [risk ratio 0.51; 95% confidence interval 0.21-1.22]; only 8 [4.2%] placebo and 6 [3.2%] cranberry subjects required treatment with antibiotics.)

Mylotte, JM. "Nursing home-acquired bloodstream infection". Infect Control Hosp Epidemiol. vol. 26. 2005. pp. 833-7.

(The urinary tract is the source of 45-56% of episodes of bacteremia in nursing homes. However, 21-93% of residents with bacteremic urinary infection have a chronic indwelling catheter; bacteremia from urinary infection is uncommon in residents without catheters.)

Nicolle, LE. "Urinary tract infections in the elderly". Clin Geriatr Med. vol. 25. 2009. pp. 423-36.

(A detailed review of asymptomatic and symptomatic urinary infections in elderly populations, including nursing home residents.)

Nicolle, LE, Bradley, S, Colgan, R. "Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults". Clin Infect Dis. vol. 40. 2005. pp. 643-54.

(These evidence-based guidelines recommend not screening for or treatment of asymptomatic bacteriuria in nursing home residents with grade 1A evidence.)

Nicolle, LE, Orr, P, Duckworth, H. "Gross hematuria in residents of long-term-care facilities". Amer J Med. vol. 94. 1993. pp. 611-8.

(In a prospective 2-year study in two nursing homes, 87 episodes of gross hematuria were identified in 49 residents [3.1 per 10,000 resident days]. Fever accompanied 29% of episodes; bacteriuria was present in 74%. Only 1 of these episodes was considered hematuria directly caused by infection [i.e., hemorrhagic cystitis].)

Nicolle, LE. "Antimicrobial stewardship in long-term care facilities. What is effective?". Antimicrob Res Infect Control. vol. 3. 2014. pp. 6.

(Antimicrobial stewardship programs for long-term care facilities should include components which limit prophylaxis for urinary tract infection or treatment of asymptomatic bacteruria.)

Omli, R, Skotnes, LH, Mykletun, A, Bakke, AM, Kuhry, E. "Residual urine as a risk factor for lower urinary tract infections: a 1-year follow-up study in nursing homes". J Am Geriatr Soc. vol. 56. 2008. pp. 871-4.

(For 98 residents, 34.7% had a PVR greater than 100mL. During 1-year follow-up, PVR greater than 100 mL was not associated with symptomatic infection, 31% of residents with greater than 100mL PVR and 36% with less than 100mL PVR.)

Orr, PH, Nicolle, LE, Duckworth, H. "Febrile urinary infection in the institutionalized elderly". Am J Med. vol. 100. 1996. pp. 71-7.

(This prospective cohort study measured antibody response to uropathogens to identify urinary infection as a source of fever in institutionalized individuals. For bacteriuric subjects without an indwelling catheter and no localizing genitourinary signs, only 10% of episodes of fever were attributed to urinary tract infection.)

Ouslander, JG, Greengold, B, Chen, S. "External catheter use and urinary tract infection among incontinent male nursing home patients". J Am Geriatr Soc. vol. 35. 1987. pp. 1063-70.

(Higher rates of bacteriuria [87 versus 46%] and symptomatic urinary infection [40 versus 8%; 0.08 versus 0.05 per patient month] were observed in men using condom catheters for voiding management compared with incontinent men without condom catheters.)

Ouslander, JG, Schapira, M, Schnelle, JF. "Does eradicating bacteriuria affect the severity of chronic urinary incontinence in nursing home residents?". Ann Intern Med. vol. 122. 1995. pp. 749-54.

(Antimicrobial treatment of bacteriuria did not decrease the frequency or volume of incontinence in women with chronic incontinence.)

Rowe, T, Towle, V, Van Ness, PH, jethani-Mehta, M. "Lack of positive association between falls and bacteriuria plus pyuria in older nursing home residents". J Am Geriatr Soc. vol. 61. 2013. pp. 653-654.

(The occurrence of falls did not correlate with the presence of bacteriuria and pyuria in women residents in nursing homes. Falls were not a symptom of urinary tract infection.)

Stevenson, KB, Moore, J, Colwell, H, Sleeper, B. "Standardized infection surveillance in long-term care: interfacility comparisons from a regional cohort of facilities". Infect Control Hosp Epidemiol. vol. 26. 2005. pp. 231-8.

(A state-wide surveillance program for infections in long-term care facilities used standardized surveillance definitions for symptomatic infection and uniform training of individuals performing surveillance. The incidence of symptomatic urinary tract infection was 0.6 per 1,000 resident days, and these were 16% of all infections. The rate was 0.57 per 10,000 resident days for all episodes of urinary infection and 3.2 per 10,000 resident days for residents with indwelling catheters.)

Stone, NP, Ashraf, MS, Calder, J. "Surveillance definitions of infections in long-term-care facilities, revisiting the McGeer criteria". Infect Control Hosp Epidemiol. vol. 33. 2012. pp. 965-977.

(Evidence based criteria developed for surveillance of urinary infection in long term care facilities. Definitions differ for residents with or without a chronic indwelling catheter.)
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