What are the McGeer criteria for diagnosing urinary tract infection and respiratory tract infection in long‑term‑care residents, and how should they guide antibiotic prescribing?

McGeer Criteria for Long-Term Care Facility Infections

What Are the McGeer Criteria?

The McGeer criteria are standardized surveillance definitions developed specifically for identifying infections in long-term care facility (LTCF) residents, but they were NOT designed to guide antibiotic prescribing decisions—the Loeb criteria serve that purpose. 1, 2, 3

The McGeer criteria are intended for infection surveillance and benchmarking purposes across facilities, not for determining when to start antibiotics. 2, 3 Understanding this distinction is critical to avoid inappropriate antibiotic use.

McGeer Criteria for Urinary Tract Infection (Without Catheter)

For residents without indwelling catheters, UTI diagnosis requires the presence of at least THREE of the following criteria: 4, 5

• Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate
• Fever (≥37.9°C or 100.2°F) or leukocytosis AND at least ONE of:
  • Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate
  • Acute frequency
  • Acute urgency
  • Acute suprapubic pain
  • Gross hematuria
  • Acute costovertebral angle pain or tenderness
  • Urinary incontinence (new or worsening)

Critical pitfall: The McGeer criteria have poor diagnostic accuracy—only 30% sensitivity and 57% positive predictive value when compared to laboratory evidence of UTI (bacteriuria plus pyuria). 5 This means 70% of true UTIs will be missed, and nearly half of residents meeting McGeer criteria don't actually have laboratory-confirmed infection.

McGeer Criteria for Respiratory Tract Infection

For lower respiratory tract infection (pneumonia), residents must have chest radiograph evidence of new infiltrate PLUS at least ONE of the following: 4

• New or increased cough
• New or increased sputum production
• Oxygen saturation <94% on room air or reduction ≥3% from baseline
• New or changed lung examination findings
• Pleuritic chest pain
• Respiratory rate ≥25 breaths/minute

For upper respiratory tract infection, residents must have at least TWO of the following with no other recognized cause: 4

• Rhinorrhea or nasal congestion
• Sore throat or hoarseness
• Dry cough
• Swollen or tender cervical lymph nodes

Why McGeer Criteria Should NOT Guide Antibiotic Prescribing

Use the Loeb criteria (2005) instead of McGeer criteria when deciding whether to initiate antibiotics. 2, 3 Here's why:

• Only 29% of antibiotic courses in nursing homes satisfy McGeer criteria, while 51% satisfy Loeb criteria, with only 23% satisfying both—demonstrating poor agreement (κ = 0.35). 3
• Agreement is particularly poor for respiratory infections (κ = 0.17) and only moderate for UTIs (κ = 0.45). 3
• In one study, 77% of UTI antibiotic prescriptions and 61% of RTI prescriptions were inappropriate when judged against McGeer criteria. 4

Loeb Criteria: The Appropriate Standard for Antibiotic Initiation

The Loeb criteria represent MINIMUM criteria for initiating antimicrobial therapy and should be the standard used in clinical practice. 2

For UTI (Loeb Criteria):

Antibiotics should be started when residents have:

• Acute dysuria alone, OR
• Fever (≥37.9°C or 100.2°F) or rigors with at least ONE of: new or worsening urgency, frequency, suprapubic pain, gross hematuria, costovertebral angle tenderness, or urinary incontinence 2

For RTI (Loeb Criteria):

The Loeb criteria for respiratory infections align closely with McGeer but emphasize clinical judgment over rigid surveillance definitions. 2

Common Pitfalls and How to Avoid Them

Do NOT order urine testing or antibiotics for isolated nonspecific symptoms like fatigue, delirium, or functional decline alone. 2 These contribute to overdiagnosis—46% of presumed UTIs in one study were actually asymptomatic bacteriuria. 6

Do NOT treat asymptomatic bacteriuria. 7, 2 Widespread prevalence of asymptomatic bacteriuria in LTCFs (present in up to 50% of residents) makes urine cultures without clinical symptoms meaningless and drives inappropriate antibiotic use.

Recognize that fever definitions differ in LTCFs: A single oral temperature ≥37.8°C (100°F), repeated temperatures ≥37.2°C (99°F), or temperature increase ≥1.1°C (2°F) over baseline all indicate possible infection. 1, 8 Fever may be absent in 15% of serious infections in elderly residents. 8

Functional decline is present in 77% of LTCF infections and includes new confusion, falls, decreased mobility, incontinence, or decreased oral intake—these warrant evaluation but not automatic antibiotics. 8, 2

Practical Algorithm for Clinical Decision-Making

1. Assess for specific localizing symptoms (dysuria, cough with sputum, skin erythema) rather than nonspecific changes 2
2. Apply Loeb criteria to determine if minimum threshold for antibiotics is met 2, 3
3. Obtain appropriate cultures before starting antibiotics when Loeb criteria are satisfied 9
4. When diagnosis is unclear, observe and monitor rather than reflexively prescribing antibiotics 2
5. Document advance directives as these appropriately limit evaluation in comfort-care-only residents 1, 9

Only 21% of LTCF infections are "adequately" evaluated by acute-care standards, but these standards may not be appropriate for LTCF settings. 1, 9 The key is matching evaluation intensity to goals of care while avoiding both under-treatment of true infections and over-treatment of colonization.