Prevalence, management, and outcomes of urinary tract infection in older adults in versus outside of care homes in the UK: a propensity-score-matched case-control analysis
File(s)
Accepted version
Author(s)
Zhu, Nina
Type
Journal Article
Abstract
Background: Rising drug-resistant urinary tract infection (UTI) affect older populations disproportionally, worldwide. We aimed to assess the incidence and management of UTI in English care homes.
Methods: Using linked primary, secondary, social care, and pathology data for a 2·5 million population in London between 2018 and 2023, we matched older adults with UTI in and outside care homes using propensity scores. We performed a time-series analysis of incidence, and compared urine culture turnaround time and results (including AMR). We assessed UTI-related outcomes, including death, complication, recurrent infection, and antibiotic re-prescription within 60 days using generalised estimating equations (GEE), adjusted for demographic and other risk factors.
Findings: We identified 91,501 UTI cases, including 6,648 (7·3%) in care homes. The incidence rate was 1909.4 per 100,000 person-months in care homes (increasing by 3.7 [95% CI 0·8 – 6·6] per month), compared with 543.5 outside (decreasing by 1.3 [-1·8 – -0·7] per month). Urine cultures were less used in care homes (20·6% [19·6% – 21·5%] vs 29.1% [28·8% – 29·4%]), were polymicrobial (suggesting contamination) (30·5% [28·1% – 32·9%] vs 17·5% [17·0% – 18·0%]), and the turnaround time was longer (52·9% turnaround in one day [50·3% – 55·6%] vs 66·2% [65·6% – 66·8%]). Escherichia coli UTI in care homes had higher resistance to trimethoprim (46·4% [41·0% – 51·9%] vs 32·0% [30·9% – 33·1%]) and nitrofurantoin (7·5% [4·9% – 10·8%] vs 2·4% [2·0% – 2·8%]). Care home cases had significantly worse 60-day outcomes, measured by the adjusted odds ratio (aOR) of death (1·99 [95% CI 1·67 – 2·36]), presenting with complications to GPs (1·38 [1·01 – 1·89]) and to hospitals (1·15 [1·01 – 1·32]), recurrent infection (1·22 [1·08 – 1·36]), and antibiotic re-prescription (1·11 [1·01 – 1·21]).
Interpretation: Older adults residing in care homes experienced higher burden and worse clinical outcomes than matched community-dwelling older adults. Possible explanatory factors include inadequate care, discordant prescribing decisions, and disconnect with diagnostic capabilities, in addition to the exacerbations due to COVID-19. These findings highlighted the need for improvement in infection management in this setting.
Funding: National Institute for Health and Care Research (NIHR), Wellcome Trust, Fleming Initiative
Methods: Using linked primary, secondary, social care, and pathology data for a 2·5 million population in London between 2018 and 2023, we matched older adults with UTI in and outside care homes using propensity scores. We performed a time-series analysis of incidence, and compared urine culture turnaround time and results (including AMR). We assessed UTI-related outcomes, including death, complication, recurrent infection, and antibiotic re-prescription within 60 days using generalised estimating equations (GEE), adjusted for demographic and other risk factors.
Findings: We identified 91,501 UTI cases, including 6,648 (7·3%) in care homes. The incidence rate was 1909.4 per 100,000 person-months in care homes (increasing by 3.7 [95% CI 0·8 – 6·6] per month), compared with 543.5 outside (decreasing by 1.3 [-1·8 – -0·7] per month). Urine cultures were less used in care homes (20·6% [19·6% – 21·5%] vs 29.1% [28·8% – 29·4%]), were polymicrobial (suggesting contamination) (30·5% [28·1% – 32·9%] vs 17·5% [17·0% – 18·0%]), and the turnaround time was longer (52·9% turnaround in one day [50·3% – 55·6%] vs 66·2% [65·6% – 66·8%]). Escherichia coli UTI in care homes had higher resistance to trimethoprim (46·4% [41·0% – 51·9%] vs 32·0% [30·9% – 33·1%]) and nitrofurantoin (7·5% [4·9% – 10·8%] vs 2·4% [2·0% – 2·8%]). Care home cases had significantly worse 60-day outcomes, measured by the adjusted odds ratio (aOR) of death (1·99 [95% CI 1·67 – 2·36]), presenting with complications to GPs (1·38 [1·01 – 1·89]) and to hospitals (1·15 [1·01 – 1·32]), recurrent infection (1·22 [1·08 – 1·36]), and antibiotic re-prescription (1·11 [1·01 – 1·21]).
Interpretation: Older adults residing in care homes experienced higher burden and worse clinical outcomes than matched community-dwelling older adults. Possible explanatory factors include inadequate care, discordant prescribing decisions, and disconnect with diagnostic capabilities, in addition to the exacerbations due to COVID-19. These findings highlighted the need for improvement in infection management in this setting.
Funding: National Institute for Health and Care Research (NIHR), Wellcome Trust, Fleming Initiative
Date Acceptance
2026-08-28
Citation
The Lancet. Healthy Longevity
ISSN
2666-7568
Publisher
Elsevier
Journal / Book Title
The Lancet. Healthy Longevity
Copyright Statement
Copyright This paper is embargoed until publication. Once published the Version of Record (VoR) will be available on immediate open access.
License URL
Publication Status
Accepted