Investigations at home should begin with a thorough history and physical examination. In homebound patients who may have cognitive impairment with or without urinary incontinence, this history may need to be obtained from the caregiver to reliably determine whether a patient is experiencing urinary frequency or dysuria. For functionally impaired patients, it may be challenging to ascertain whether a patient is experiencing urinary urgency. New or increased incontinence should prompt consideration of further work-up as a possible symptom of a UTI [4–6]. Caregivers and patients can be asked about foul-smelling urine, with the caution to clinicians in interpreting the significance of this sign: not all malodorous urine is due to a UTI, and not all UTIs produce foul-smelling urine. Malodorous urine may be associated with bacteriuria, caused by the polyamine production of the bacteria. However, malodorous urine does not help the clinician to understand if the patient is experiencing a UTI or ASB or simply volume depletion or dehydration [1, 5, 6]. Caregivers and patients should also be asked about gross hematuria, fever, and suprapubic and costovertebral pain.

When a UTI in a homebound elder is on the differential diagnosis, the clinician should pay close attention to certain aspects of the physical exam, including level of consciousness, vital signs, and suprapubic and costovertebral tenderness.

Urine dipstick testing for nitrite and leukocyte esterase (LE) can be done at home with results available within minutes. Nitrite is used as a surrogate for bacteriuria, but has a low sensitivity. Indeed when nitrite is positive, the test does not distinguish between asymptomatic and symptomatic bacteriuria [4]. Leukocyte esterase) is used as a surrogate for pyuria. Pyuria indicates an inflammatory process in the genitourinary tract, which can include, but is not limited to a UTI. While a result of positive LE is not conclusive in making the diagnosis of a UTI, a negative LE has high specificity for excluding a UTI [1].

Urine can also be collected in the home and be analyzed in a lab for more extensive microscopic testing, with results within hours. A urine culture can be collected in the home and sent to the laboratory with results available within days. Ideally, the urine sample collected for a urine culture should be a straight catheterization or clean catch sample to avoid contamination with perineal flora. Urine cultures should be obtained for all male patients with symptomatic UTIs and all women with presumed kidney involvement or underlying functional or anatomical GU abnormalities. Expert opinion and guidelines suggest that community-dwelling women with a history of recurrent uncomplicated cystitis who present with typical urinary symptoms can be treated empirically without a culture. However, if these patients present with atypical symptoms, have recently been on antibiotics, or have had a rapid recurrence of urinary symptoms following treatment for a presumed cystitis, a urine culture should be obtained to help guide diagnosis and appropriate therapy [4, 8].

It should be noted that most homebound elderly patients likely have some functional or structural impairment in their urinary tract system and thus most UTIs in the homebound elderly would be classified as having a complicated UTI. As such, it is rare for a female homebound patient to have both an uncomplicated UTI and typical symptoms. In the vast majority of homebound elderly patients with a suspected UTI, a urine culture should be obtained. Whether to treat the patient empirically while waiting for culture results or to wait for culture results and then choose an antimicrobial is discussed below [4, 8].

Significant bacteriuria is defined as greater than or equal to 10⁵ colony forming units (CFU)/mL for noncatheterized patients. A clean catch specimen can be challenging to obtain in homebound elderly patients because of the possible visual, cognitive, and dexterity impairment, as well as the possibility of incontinence, and in this situation, the gold standard is a sample collected by clean intermittent catheterization (CIC) [1]. Most home-based practices obtain a culture by this method when there is a high clinical suspicion of a UTI, when the culture results are likely to change management (i.e., a patient who has previously had an multidrug-resistant UTI) and after having evaluated the individual patient’s goals of care to weigh the risks and benefits of obtaining a urine sample by CIC. The procedure itself can lead to bacteriuria, cause some discomfort, and increase agitation in cognitively impaired patients [1, 6]. The urine sample being collected for culture should be sent to the laboratory as soon as possible to obtain accurate CFU counts.

For patients who have external (condom) urinary catheters at baseline, we institute the following procedure to decrease the risk of contamination with perineal flora. (1) Clean the glans. (2) Apply a new external catheter including a new collecting bag. (3) Collect the urine sample immediately after voiding [4, 6]. There is insufficient evidence as to what constitutes “significant” bacteriuria for patients with condom catheters.

For patients who have an indwelling urethral or suprapubic or intermittent catheterization, signs and symptoms compatible with a catheter-associated UTI include acute onset fever, rigors, delirium, malaise with no other identified cause, costovertebral pain, new onset of hematuria, and pelvic discomfort. Patients who have had their catheters removed may experience urinary urgency, frequency, or dysuria [6]. Spinal cord injury patients may experience increased muscle spasticity, autonomic dysfunction, or malaise [6]. Significant bacteriuria is defined as greater than or equal to 10³ colony-forming units (CFU)/mL for patients with chronic-indwelling urethral or suprapubic catheters. Further complicating the diagnosis of a UTI in patients with chronic-indwelling catheters are the high rates of ASB found in these patients: ASB was found in 100 % of patients with chronic-indwelling catheters in one study [5, 6]. In a chronically catheterized patient suspected of having a UTI, if the catheter has been in place for more than 2 weeks, the catheter should be replaced and the urine culture should be obtained from the newly placed catheter ideally prior to starting antibiotics [6].

A common and controversial situation in the homebound, functionally impaired, noncatheterized elderly occurs when a patient presents with a change in mental status. In an ideal situation, the clinician would be able to elicit urinary symptoms from the patient or caregiver and order further work-up, or conversely, obtain a negative urinary review of systems (ROS) and investigate other possible causes of delirium. What happens more frequently is that a family member or caregiver of a more severely cognitively impaired, noncatheterized patient notes increasing lethargy and it is impossible to obtain an accurate urinary ROS. The clinician obtains a urinalysis and finds significant bacteriuria. The clinician now has to decide whether the bacteriuria represents ASB or a UTI. While we caution healthcare providers in attributing delirium without urinary symptoms to a UTI, as ASB has a higher prevalence in the functionally impaired elderly, most practices that treat functionally impaired geriatric patients acknowledge the challenges of obtaining a history regarding urinary symptoms from a patient with advanced cognitive impairment or who has baseline chronic urinary symptoms [1, 5].

Repeatedly treating ASB with multiple courses of antibiotics leads to resistant UTIs and other infectious complications including Clostridium difficile. Other potential harms of antimicrobial treatment include acute kidney injury, noninfectious diarrhea, nausea, and cachexia [1, 5, 6].

When a patient is suspected of having a UTI, clinicians must decide whether to start antibiotics empirically or wait for urine culture results. We suggest that this decision should be based on a combination of factors including the severity of the patient’s clinical presentation, whether or not the patient has a chronic-indwelling catheter and the clinician’s index of suspicion for a UTI.

For all patients with moderate to severe symptoms (fever defined as >37.9 °C or 1.5 °C above baseline temperature, CVA tenderness, rigors, hypotension, tachycardia, suprapubic pain, or gross hematuria), empiric antibiotic therapy should be initiated while waiting for the results of the urine culture results [8]. For patients (regardless of catheter status) with milder symptoms and when the clinical suspicion of a UTI is lower, we suggest waiting for the culture results to return before starting antimicrobial therapy [8]

For noncatheterized patients, we generally favor empiric treatment with either nitrofurantoin monohydrate/macrocrystals (100 mg orally twice daily for 5 days) or trimethoprim–sulfamethoxazole (TMP–SMX) (160/800 mg orally twice daily for 3–7 days). For a patient with a sulfa allergy, TMP monotherapy can be used. Both nitrofurantoin and TMP–SMX are cost-effective. Nitrofurantoin should be avoided in patients with renal impairment or those suspected of having pyelonephritis.

There are increasing rates of TMP–SMX and fluoroquinolone resistance in the community, as well as multidrug-resistant vancomycin-resistant Enterococci and extended-spectrum beta-lactamase producing Escherichia coli and Klebsiella pneumoniae. The Infectious Diseases Society of America (IDSA) recommends using TMP–SMX as empiric treatment for a UTI only if local resistance patterns show a resistance rate of E. coli of less than 20 % and it has NOT been used for this patient to treat a UTI in the past 3 months [1, 4]. The use of fluoroquinolones as empiric treatment for UTIs is controversial. Some studies have shown fewer adverse effects with ciprofloxacin use, while other guidelines advise against empirically using fluoroquinolones because of the risk of increasing uropathogen resistance. Moxifloxacin should not be used to treat UTIs as it has poor urinary excretion. Levofloxacin can cause glucose abnormalities in diabetic patients. Amoxicillin can be effective as a targeted therapy for Gram-positive organisms, but it is NOT recommended as a first-line agent because of the high prevalence of Gram-negative bacteria resistance to this agent. Amoxicillin/clavulanic acid and cephalosporins can also be effective as targeted therapy, but are also NOT recommended as empiric therapy because of their broad-spectrum activity and expense [1, 4]. Given the decrease in glomerular filtration rate seen in older adults, the cautious clinician should be sure to renally dosed antibiotics (see Table 9.2). For patients on warfarin who require antibiotic therapy, we recommend one of the two strategies. The first option is to check an INR within 1 week of initiating antibiotic therapy, regardless of the class of antibiotics, and adjust the warfarin dose as needed. The second option is to preemptively decrease the dose of warfarin by 15–20 % when antibiotics are initiated. There is insufficient data for us to recommend one strategy over the other [9, 10].

There is some evidence that topical estrogen therapy (but NOT systemic estrogen therapy) can decrease the risk of recurrent UTIs in elderly women. Pain and fever can be treated with acetaminophen [1].

Oral hydration is recommended for UTIs, as well as for the isolated symptom of foul-smelling urine. Avoidance of unnecessary urinary catheterization, appropriate perineal hygiene, and incontinence care are recommended. The evidence for the use of cranberry products for the prevention of UTIs in the homebound elderly is inconclusive [1, 5, 6].

Pneumonia is one of the most common diseases diagnosed and treated in the United States. Pneumonia is defined as an acute infection of the pulmonary parenchyma and can be caused by various pathogens including bacteria, viruses, or fungi. Most homebound patients will acquire pneumonia in the community (community-acquired pneumonia, CAP), including aspiration pneumonia (pneumonia contracted through aspiration of bacteria from oral or pharyngeal contents). Hospital-acquired pneumonia (HAP) is pneumonia that develops while patients are in the hospital, and healthcare associated pneumonia (HCAP) develops while patients are in other facilities such as nursing homes or other chronic care facilities. For the purposes of this discussion, we will focus on CAP and aspiration, as most homebound patients will be diagnosed with these types of pneumonia.