Accuracy of leukocyte esterase and nitrite tests for diagnosing bacteriuria in older adults: A systematic review and meta-analysis

Background: Urine dipsticks are commonly used for the diagnosis of bacteriuria or urinary tract infections (UTIs). Objectives: To perform a systematic review and meta-analysis to evaluate the accuracy of positive leukocyte esterase or nitrite results from dipsticks (index test) for diagnosing bacteriuria in older individuals, using urine culture as the reference standard. Data sources: MEDLINE (PubMed), EMBASE, and Cochrane Database of Systematic Reviews from the inception date up to September 2025. We also searched the reference lists of all the studies identified. Study eligibility criteria: Both prospective observational cohort and case-control diagnostic studies were included. No language restriction was applied. Participants: Individuals aged ≥60 years with or without symptoms of UTI in the community, nursing homes or hospitalized. Assessment of risk of bias: We used the Quality Assessment tool for Diagnostic Accuracy Studies (QUADAS)-2 tool for assessing risk of bias. Methods of data synthesis: A random-effect meta-analysis was performed to determine the pooled sensitivity, specificity and predictive values of leukocyte esterase or nitrites for the detection of bacteriuria. International Prospective Register of Systematic Reviews (PROSPERO) identifier: CRD42024561882. Results: Of 1933 articles screened, 16 met inclusion criteria and had a moderate risk of bias. Ten studies were hospital-based; six were in nursing homes. Pooled urine dipstick sensitivity and specificity for bacteriuria were 90% (95% CI, 84%–94%) and 56% (43%–68%), respectively (diagnostic OR 11.4; 10.2–12.8). In symptomatic older adults, the sensitivity and specificity for predicting UTI were 92% (76%–97%) and 39% (19%–62%), respectively, with a diagnostic OR of 7.4 (3.9–10.9). Discussion: A positive dipstick result is inconclusive and does not confirm bacteriuria or UTI in symptomatic older adults. Because of high asymptomatic bacteriuria prevalence in older individuals, bacteriuria alone lacks diagnostic value. These findings support discontinuing dipstick testing for UTI diagnosis in this population.