The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing - a systematic literature review

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.

Development of a Tailored, Complex Intervention for Clinical Reflection and Communication about Suspected Urinary Tract Infections in Nursing Home Residents

“…The literature identifies two sources of antibiotic overtreatment of UTIs in nursing homes: treatment of nonspecific symptoms and asymptomatic bacteriuria [ 7 ]. Health professionals often consider nonspecific behavioural symptoms as an indication of UTIs in the elderly, but guidelines recommend that these symptoms should not be treated with antibiotics [ 8 , 9 , 10 , 11 ]. Asymptomatic bacteriuria is the presence of bacteria in a urine sample from a patient that shows no signs or symptoms originating from the urinary tract [ 12 ].…”

Defeito Cognitivo e COVID-19

“…O surgimento de alterações agudas do estado cognitivo (prostração, confusão e delirium) mais provavelmente refletirá encefalopatia metabólica secundária, sobretudo em doentes idosos e com compromisso cognitivo de base. 12,13 A demência como comorbilidade…”

Diagnosis of urinary tract infection in older persons in the emergency department: To pee or not to pee, that is the question

“…Studies of the diagnosis of UTI are associated with significant risk of misclassification bias due to their lack of use of established definitions of UTI …”