Prevalence, management, and outcomes of urinary tract infections in older adults living in care homes versus older adults living outside care homes in the UK: a propensity score-matched case-control analysis.

BACKGROUND

Globally, rising drug-resistant urinary tract infections (UTIs) affect older populations disproportionally. We aimed to assess the incidence, management, and patient outcomes of UTIs in English care homes.

METHODS

Using linked primary, secondary, social care, and pathology data covering 2·5 million patients in London between 2018 and 2023, we matched older adults with UTIs living in care homes with older adults living outside care homes using propensity scores. We performed a time-series analysis of incidence and compared urine culture turnaround time and results (including antimicrobial resistance). We assessed UTI-related patient outcomes, including death, complications, recurrent infection, and antibiotic re-prescription within 60 days, using generalised estimating equations, adjusted for demographic and other risk factors.

FINDINGS: We identified 91 501 UTI cases, including 6648 (7·3%) in care homes. In care homes, 4678 (70·4%) of the 6448 UTIs occurred in women and 3779 (56·8%) involved individuals aged 85 years or older. The older adults living in care homes were older (median age: 86 years [IQR 80-91] vs 76 years [71-83]) and more frequently White (70·3% vs 56·7%) than older adults living outside care homes. The incidence rate of community-acquired UTIs was 1909·4 per 100 000 person-months in care homes (increasing by 3·7 [95% CI 0·8-6·6] per month), as compared with 543·5 outside care homes (decreasing by 1·3 [-1·8 to -0·7] per month). Urine cultures were used less (1366 [20·5%] of 6648 [95% CI 19·6-21·5] vs 24 699 [29·1%] of 84 853 [28·8-29·4]), were more likely to be polymicrobial (suggesting contamination; 416 [30·4%] of 1366 [28·1-32·9] vs 4325 [17·5%] of 24 699 [17·0-18·0]), and had a longer turnaround time (52·9% turnaround in 1 day [50·3-55·6] vs 66·2% [65·6-66·8]) in care homes than outside care homes. Escherichia coli UTIs had higher resistance to trimethoprim (46·4% [95% CI 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]) in care homes than outside care homes. Care home cases had significantly worse 60-day outcomes, with higher risk of death (1·99 [95% CI 1·67-2·36]; p<0·001), presenting to general practitioners (1·38 [1·01-1·89]; p=0·042) and to hospitals (1·15 [1·01-1·32]; p=0·041) with complications, recurrent infections (1·22 [1·08-1·36]; p=0·001), and antibiotic re-prescription (1·11 [1·01-1·21]; p=0·024).

INTERPRETATION: Older adults residing in care homes had higher UTI infection burden and worse clinical outcomes than matched older adults residing outside care homes. Possible explanatory factors include inadequate care, discordant prescribing decisions, and disconnect with diagnostic capabilities, in addition to the exacerbating effects on infection management during the COVID-19 pandemic. These findings highlight the need for improvement in infection management in care home settings.

FUNDING: National Institute for Health and Care Research; Wellcome Trust; Fleming Initiative.