The clinical usefulness of guideline-based strategies with and without the role of nonspecific symptoms to predict urinary tract infections in nursing homes: a decision curve analysis.

OBJECTIVE

The aim of this study was to assess the clinical value of urinary tract infections (UTIs) guideline algorithms and the role of nonspecific symptoms to support clinical decision-making in nursing home residents.

DESIGN

In a preplanned secondary analysis of a cross-sectional study including nursing home residents with a presumed UTI, 2 prediction models were used in a decision curve analysis (DCA): (1) guideline-based and (2) extended: nonspecific symptom(s) added to the guideline model. The stringent outcome definition for "true UTIs" included symptom improvement during adequate antimicrobial therapy, based on susceptibility test results. The outcome of a DCA is the Net Benefit to quantify the performance of the prediction models, visualized in a decision curve.

SETTING

Dutch nursing homes (n = 13).

PATIENTS

Nursing home residents with a presumed UTI.

RESULTS

Of the 180 residents with a presumed UTI, 43 fulfilled the definition of "true UTI" (23.9%). The Net Benefit of the guideline-based model was low and the corresponding threshold range was small (21%-28%). The extended model improved the prediction of UTIs. However, the clinical usefulness of the extended model was still limited to a small threshold range (10%-28%).

CONCLUSIONS

The clinical usefulness of the current guideline-based algorithm to diagnose UTI in nursing home residents seems limited, and adding nonspecific symptoms does not further improve decision-making due to the small threshold probability. Given the poor performance of the guideline-based model, refinement of the guidelines may be required.

TRIAL REGISTRY

Dutch trial registry: NTR6467; date of first registration, 25/05/2017.