Beyond the dipstick: why we need better UTI diagnosis in care homes

Urinary tract infections (UTI) are among the most common bacterial infections seen by GPs. You may have experienced one yourself or know someone who has. You may also be aware of the usual symptoms – like pain passing urine or passing urine more frequently.

However, it isn’t always straightforward for GPs to know whether someone has a UTI and whether they would benefit from antibiotic treatment. You may not be aware that the most common rapid test for UTI used in the NHS – the urine dipstick – has been around for over 50 years and is not 100% accurate.

It is important to know whether someone really has a UTI. If you don’t treat an infection there can be serious consequences, like sepsis. However, giving antibiotic treatment when there isn’t an infection can cause antibiotic resistance and side effects.

The challenge in care homes

I am a care home GP and for me, it can be particularly challenging to diagnose UTI. There are several reasons for this in the older care home population:

• Vague symptoms: UTIs don’t always cause the common symptoms. Instead, they can cause vague symptoms like confusion, which can be precipitated by conditions other than UTI.
• Communication barriers: It may be hard for people living with dementia to say how they are feeling.
• Practical difficulties: It may be difficult for some to easily provide a urine sample to be tested.
• Asymptomatic bacteria: Many people who live in care homes have bacteria present in their urine even when they are well; this is not harmful and does not need treatment.

Crucially, the urine dipstick mentioned above is not recommended to be used at all in this population in UK guidelines. This is because it can’t tell the difference between bacteria in the urine causing infection (needing treatment), and bacteria in the urine not causing infection.

Researching new solutions

All of this means that, at present, I just use my clinical judgement if I need to decide quickly whether someone has a UTI needing treatment. Risks of hospital admission and sepsis are higher in older people. As you can imagine, older people in care homes may therefore be more likely to get antibiotics when they don’t actually need them.

We desperately need new and more accurate methods to diagnose UTI in care home residents. As part of my DPhil, I have been trying to generate early evidence to show that we can study UTIs in care homes in England and to explore new ways of diagnosing UTI.

In my observational cohort study, DISCO UTI, I followed 81 care home residents for up to 12 months and collected urine samples when they experienced possible UTI. I was also able to try out innovative rapid tests for UTI that have been developed but had never previously been used in this setting.

Taking the message to Parliament

This week I had the opportunity to attend the All-Party Parliamentary Group (APPG) on Antimicrobial Resistance (AMR) with the British Society for Antimicrobial Chemotherapy (BSAC) and Antimicrobial Action UK (AMR Action).

We highlighted to the government that there are new diagnostic tests available and in development, and that these could be the key to better targeting antibiotic treatment for UTI and reducing the impact of AMR.

However, there are significant regulatory hurdles to get new technology into routine NHS use, and we need to generate real-world evidence to show that these tests work. I was pleased to be able to share my clinical and research insights with MPs and to speak about the particular challenges associated with care home UTI.

Find out more

If you want to read more about the work our group is doing on UTI, please visit:

• TOUCAN platform for UTI diagnostic evaluation
• Duration UTI Trial