Diagnostic value of symptoms and signs for identifying urinary tract infection in older adult outpatients: Systematic review and meta-analysis

Abstract

Objectives: To critically appraise and evaluate the diagnostic value of symptoms and signs in identifying UTI in older adult outpatients, using evidence from observational studies.

Methods: We searched Medline and Medline in process, Embase and Web of Science, from inception up to September 2017. We included studies assessing the diagnostic accuracy of symptoms and/or signs in predicting UTI in outpatients aged 65 years and above. Study quality was assessed using the QUADAS-2 tool.

Results: We identified 15 eligible studies of variable quality, with a total of 12,039 participants (range 65-4259), and assessed the diagnostic accuracy of 66 different symptoms and signs in predicting UTI. A number of symptoms and signs typically associated with UTI, such as nocturia, urgency and abnormal vital signs, were of limited use in older adult outpatients. Inability to perform a number of acts of daily living were predictors of UTI: For example, disability in feeding oneself, + ve LR: 11.8 (95% CI 5.51-25.2) and disability in washing one's hands and face, + ve LR: 6.84 (95% CI 4.08-11.5).

Conclusions: The limited evidence of varying quality shows that a number of symptoms and signs traditionally associated with UTI may have limited diagnostic value in older adult outpatients.

Keywords: Diagnosis; Older adults; Symptoms and signs; Urinary tract infection.

Fig. 1

Flow chart showing the process for identification of studies eligible for inclusion.

Fig. 2

(a) Risk of bias graph. (b) Risk of bias summary.

Fig. 3

Likelihood ratios and pre- and post-test probabilities for urinary symptoms in predicting UTI). When possible, gender specific estimates have been presented; the dumbbell plots have been separated according to sex [Male and female combined (‘All’); women; and men]. Within each plot, symptoms have been divided into categories. Positive and negative likelihood ratios with 95% confidence intervals are presented for each symptom. The black dot within the dumbbell plot represents the pre-test probability of UTI (i.e. prevalence). The red dot represents the probability of UTI after a positive test (i.e. given that the symptom is present), and the green dot represents the probability of UTI after a negative test (i.e. given that the symptom is absent).

Fig. 4

Likelihood ratios and probability plot for non-urinary tract symptoms and signs in predicting UTI. Plots have been separated according to symptom/sign category, and then ordered according to gender within each category. Likelihood ratios with 95% confidence intervals, and pre- and post-test probability of UTI given presence or absence of a symptom/sign, are presented. † Non-specific symptoms include: fatigue, restlessness, confusion, aggressiveness, loss of appetite, frequent falls, not being herself/himself HR: heart rate; SBP: systolic blood pressure.

Fig. 5

Likelihood ratios and probability plot for markers of functional and cognitive status in predicting UTI. Plots have been separated according to symptom/sign category, and then ordered according to gender within each category. Likelihood ratios with 95% confidence intervals, and pre- and post-test probability of UTI given presence or absence of a symptom/sign, are presented. BMI: body mass index; GDS-15: geriatric depression scale; MMSE: mini mental state examination.

Fig. 6

Summary receiver operating characteristic (ROC) curves for urinary incontinence and dysuria. ROC curves and summary statistics with 95% confidence intervals for urinary incontinence and dysuria in relation to UTI. Individual study estimates for both symptoms are represented by hollow circles. The summary point is represented by a red square. Summary statistics are presented within the boxes adjacent to the graphs DOR: diagnostic odds ratio; +’ve LR: positive likelihood ration; −’ve LR: negative likelihood ratio.