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Table 2 Data extracted from the articles contributing to updating of the algorithm

From: Developing evidence-based guidance for assessment of suspected infections in care home residents

Author & Year

Setting

Design

Population & Condition

Objective

Relevant information for updating/refining algorithm

Group agreement for updating algorithm

Falcone et al. [14]

Community and hospital (includes care home setting)

Narrative review

Older people, Pneumonia [Community Acquired Pneumonia (CAP), Healthcare Associated Pneumonia (HCAP) and Hospital Acquired Pneumonia (HAP)]

This review sought to produce a summary of therapeutic recommendations on the basis of the most up to date clinical and pharmacological data.

Signs and symptoms most commonly associated with pneumonia: cough, fever, chills, pleuritic chest pain. Extra-pulmonary symptoms such as nausea, vomiting, alternation to sensory stimuli or diarrhoea may also be present. It is important to remember that pneumonia in older patients tends to occur more often with extra-pulmonary manifestations. For example, the appearance of a delirium or acute confusion is found in approximately 45% of elderly patients with pneumonia.

Agreed to add in extra-pulmonary symptoms.

Juthani-Mehta et al. [15]

Nursing home

Prospective observational cohort study

Older people, UTI

To identify, among non-catheterised nursing home residents with clinically suspected

UTI, clinical features associated with bacteriuria plus pyuria.

The most commonly reported clinical features for suspected UTI in this cohort were change in mental status (39%), change in behaviour (19%), change in character of the urine (i.e., gross haematuria and change in the colour or odour of urine; 15.5%), fever or chills (12.8%) and change in gait or a fall (8.8%). Dysuria, change in character of urine, and change in mental status were significantly associated with the combined outcome of bacteriuria plus pyuria. Absence of these clinical features identified residents at low risk of having bacteriuria plus pyuria (25%), while presence of dysuria plus one or both of the other clinical features identified residents at high risk of having bacteriuria plus pyuria (63%).

Change in character of urine (i.e., gross haematuria and change in the colour or odour of urine) was considered but not supported by more recent guidelines.

Scottish Inter-collegiate Guidelines Network (SIGN) 88, [16]

All settings

Clinical Practice Guideline

Older people, UTI

To provide guidance in the diagnosis and management of suspected UTI in older people

Algorithm to be used in people/residents with fever defined as temperature > 37.9 °C or 1.5 °C above baseline.

First stage of algorithm used to differentiate between UTI, RTI, SSTI and gastro-intestinal infection.

Advises against using dipstick test in diagnosis of infection. Provides supportive care advice.

Agreed to add supportive care advice to algorithm.

Stone et al.– updated McGeer [17]

Long-term care

Position paper

Older people, infection (general)

To update the 1991 McGeer criteria (Infection surveillance definitions for long-term care facilities) using an evidence-based structured

review of the literature in addition to consensus opinions

from industry leaders including infectious diseases physicians

and epidemiologists, infection control specialists, geriatricians,

and public health officials.

Acute swelling of the testes, epididymis and prostate should be included in surveillance definitions for UTIs as these symptoms are a common complication of UTI in both catheterised and non-catheterised males

Agreed to add acute swelling of testes, epididymis and prostate.

D’Agata et al. [18]

Nursing home

Prospective study

Older people, UTI

To describe the presentation of suspected UTI in nursing home residents with advanced dementia and how they align with minimum criteria to justify antimicrobial treatment.

In long-term care residents with dementia, the most common reason for suspected UTI was a change in mental status (44.3%).

Agreed to sub-divide the UTI element of the algorithm into two sections to account for two populations within care homes - those with and without dementia; changed in later iterations

Rowe et al. [19]

Nursing home

Review

Older people, UTI

This review sought to provide an overview of the prevalence, diagnosis and diagnostic challenges, management, and prevention of UTI and asymptomatic bacteriuria in older adults.

The most commonly reported clinical features for suspected UTI in this cohort were change in mental status (39%), change in behaviour (19%), change in character of the urine (i.e., gross haematuria and change in the colour or odour of urine; 15.5%), fever or chills (12.8%) and change in gait or a fall (8.8%) [Juthani-Mehta et al., 2009 – see above].

Change in character of urine (i.e., gross haematuria and change in the colour or odour of urine) was considered but not supported by UK SIGN guidelines.