Guidelines for Urinalysis in Skilled Nursing Facilities to Rule Out UTI
Do not perform urinalysis or urine culture on asymptomatic SNF residents—testing should only be done when specific UTI symptoms are present, not for nonspecific changes like confusion alone. 1
When to Suspect UTI and Order Urinalysis
For Non-Catheterized Residents
Reserve urinalysis for residents with acute onset of specific UTI symptoms: 1
- Acute dysuria (most predictive symptom) 2
- Acute suprapubic pain 2
- Fever (single oral temp ≥100°F/37.8°C OR repeated temps ≥99°F/37.2°C OR increase ≥2°F/1.1°C over baseline) 1
- Gross hematuria 1
- New or worsening urinary incontinence 1
- Suspected bacteremia/sepsis 1
For Catheterized Residents
Only evaluate if suspected urosepsis is present: 1
- Fever with shaking chills 1
- Hypotension 1
- Delirium 1
- Especially in context of recent catheter obstruction or change 1
Critical Pitfall: Nonspecific Symptoms Alone Do NOT Justify Testing
Do not order urinalysis based solely on: 1, 3
- Change in mental status/confusion alone 3
- New or worsening incontinence alone 3
- Falls 1
- Reduced food intake 1
- Functional decline 1
These nonspecific symptoms are common in SNF residents and are frequently not associated with true UTI. 1, 3 Research shows that 74.5% of suspected UTI episodes lacking minimum criteria still receive unnecessary antibiotics. 3
Stepwise Diagnostic Approach
Step 1: Initial Urinalysis (Screening Test)
Perform dipstick urinalysis for leukocyte esterase and nitrite PLUS microscopic examination for WBCs: 1, 4
- If NEGATIVE for pyuria (no leukocyte esterase, no nitrite, <10 WBCs/hpf): STOP—do not order urine culture 1, 5
- The negative predictive value is 96%, effectively ruling out UTI 2
Step 2: Urine Culture (Only If Step 1 Positive)
Order urine culture with antimicrobial susceptibility testing ONLY if: 1, 4
- Pyuria present (≥10 WBCs/high-power field) OR 1
- Positive leukocyte esterase OR 1
- Positive nitrite test 1
Step 3: If Urosepsis Suspected
Obtain both urine and paired blood cultures for culture/susceptibility testing, plus Gram stain of uncentrifuged urine: 1, 4
Proper Specimen Collection Technique
Non-Catheterized Men
- Midstream clean-catch if cooperative and functionally capable 1
- Freshly applied clean condom catheter with frequent bag monitoring if unable to cooperate 1
Non-Catheterized Women
- In-and-out catheterization often required for reliable specimen 1
Catheterized Residents with Suspected Urosepsis
- Change the catheter BEFORE specimen collection and antibiotic initiation 1, 4
- Obtain specimen from new catheter, not drainage bag 1
Additional Laboratory Testing
Complete Blood Count
Obtain CBC with differential within 12-24 hours of symptom onset for all residents with suspected infection: 1, 4
- Elevated WBC ≥14,000 cells/mm³ warrants careful bacterial infection assessment 1, 4
- Left shift (band neutrophils ≥16% or total bands ≥1,500 cells/mm³) indicates likely bacterial infection even without fever 1, 4
Key Evidence Limitations
The diagnostic accuracy of all consensus-based UTI criteria in SNF residents is poor, with sensitivities of only 19-30% and specificities of 79-89%. 6 Research confirms that 79% of suspected UTI episodes have positive urinalysis and culture regardless of whether minimum clinical criteria are met. 3 This underscores why asymptomatic bacteriuria (present in 10-50% of SNF residents) must not be treated. 1
The bottom line: Strict adherence to symptom-based testing criteria prevents massive antibiotic overuse in this vulnerable population. 2, 3