Diagnosis and Management of Urinary Tract Infection in Hospitalized Older People

Prospective evaluation of the management of urinary tract infections in 134 French nursing homes

OBJECTIVE

Prospective assessment of the management of urinary tract infections (UTI) in the nursing homes of the Hauts-de-France region.

PATIENTS AND METHODS

A 50-question form had to be filled in for up to five consecutive residents treated for UTI in each nursing home. If necessary, diagnoses were reclassified according to the 2014 French Infectious Diseases Society guidelines. Analyses were presented per supposed (reported) and reclassified diagnoses.

RESULTS

Of 397 contacted facilities, 134 participated and informed 444 UTI episodes. Reported diagnostic criteria were burning urination (32%), malodorous urine (29%), confusion (28%), and turbid urine (19%). Twenty-one percent of diagnoses were based on erroneous criteria. Less than 50% of residents had a urine dipstick test performed and 94% a urine culture. The main pathogen was Escherichia coli. Reported indications were uncomplicated cystitis (32%), unspecified UTI (26%), complicated cystitis (9%), while no reason was given in 25% of cases. Only 10% of diagnoses were consistent with the guidelines: complicated cystitis (49%), asymptomatic bacteriuria (21%), acute pyelonephritis (21%), male UTI (9%). Almost 85% of prescriptions were active on the isolated bacteria. The empirical antibiotic therapy was consistent with the diagnosis in 16% of cases (30% for reclassified diagnoses). The two most prescribed antibiotic classes were fluoroquinolones (22.1%) and oral third-generation cephalosporins (19.1%). Only two of 157 possible de-escalations were performed. Duration of treatment was adequate for 19% of UTIs (9.6% of reclassified cases).

CONCLUSION

Our study revealed multiple deficiencies in diagnosis, antibiotic choice, treatment duration, and reevaluation.

Utility of initial procalcitonin values to predict urinary tract infection

BACKGROUND

Urinary tract infections (UTIs) are one of the most common reasons women seek treatment in the emergency department (ED). The biomarker procalcitonin (PCT) has gained popularity over the last decade to improve the diagnosis of bacterial infections and reduce unnecessary exposure to antibiotics. PCT has been extensively studied in patients with pneumonia and sepsis and may have additional role in UTI.

METHODS

A retrospective study of patients who presented to the ED in which a urinalysis test and a PCT level was obtained within the first 24h of presentation. Signs and symptoms of UTI and urine cultures were reviewed to determine a positive diagnosis of UTI. The area under the receiver operating curve was used to calculate the test characteristics of PCT. Different breakpoints were analyzed to determine which PCT level corresponded to the highest sensitivity and specificity.

RESULTS

293 patients were included in this single center, retrospective study. The AUC of PCT to predict UTI was 0.717; 95% CI: 0.643-0.791 (p<0.001). A PCT threshold of 0.25ng/ml corresponded to the best combination of sensitivity (67%) and specificity (63%), with a positive predictive value and negative predictive value of 26% and 91%, respectively.

CONCLUSIONS

A PCT threshold <0.25ng/ml was a strong predictor of the absence of UTI. The high negative predictive value of PCT may be useful as an adjunct to urinalysis results to rule out UTI and facilitate noninitiation or earlier discontinuation of empiric antibiotics.

Sensitivity of the dipstick in detecting bacteremic urinary tract infections in elderly hospitalized patients

BACKGROUND

The sensitivity of the dipstick in elderly patients with a suspected urinary tract infection (UTI) is unclear because of the inclusion of patients with urine contamination or asymptomatic bacteriuria in previous studies.

METHODS

We selected consecutive patients aged 65 years or older hospitalized in internal medicine departments with bacteremic UTI (same organism in blood and urine cultures) minimizing misclassifications. The false positive rate was determined in consecutive patients with negative culture results. A positive dipstick was a test result with a trace leukocyte esterase and/or nitrite positivity. Bacteriuria was the growth of at least 105 colony-forming units per milliliter of urine.

RESULTS

Of 20,555 consecutive patients, 228 had a bacteremic UTI, and 4069 a negative culture result. The sensitivity of the dipstick was 96.9% (95% CI-93.7-98.6) with a false positive rate of 42.4% (95% CI, 41.0-43.8) in those with a negative culture result.

CONCLUSIONS

In elderly hospitalized patients with a bacteremic UTI, the dipstick urinalysis is highly sensitive, much higher than reported previously in studies of UTIs in the elderly. It is unclear whether the observed high sensitivity of the dipstick was due to the exclusion of patients with asymptomatic bacteriuria or to spectrum bias. Studies of the clinical utility/disutility of using a negative dipstick to rule out a urinary tract infection are warranted.

Diaper-Embedded Urinary Tract Infection Monitoring Sensor Module Powered by Urine-Activated Batteries

Urinary tract infection (UTI) is one of the most common infections in humans. UTI is easily treatable using antibiotics if identified in early stage. However, without early identification and treatment, UTI can be a major source of serious complications in geriatric patients, in particular, those suffering from neurodegenerative diseases. Also, for infants who have difficulty in describing their symptoms, UTI may lead to serious development of the disease making early identification of UTI crucial. In this paper, we present a diaper-embedded, wireless, self-powered, and autonomous UTI monitoring sensor module that allows an early detection of UTI with minimal effort. The sensor module consists of a paper-based colorimetric nitrite sensor, urine-activated batteries, a boost dc-dc converter, a low-power sensor interface utilizing pulse width modulation, and a Bluetooth low energy module for wireless transmission. Experimental results show a better detection of nitrite, a surrogate of UTI, than that of conventional dipstick testing. The proposed sensor module achieves a sensitivity of 1.35 ms/(mg/L) and a detection limit of 4 mg/L for nitrite.

Antibiotic Resistance and Virulence Phenotypes of Recent Bacterial Strains Isolated from Urinary Tract Infections in Elderly Patients with Prostatic Disease

Acute bacterial prostatitis is one of the frequent complications of urinary tract infection (UTI). From the approximately 10% of men having prostatitis, 7% experience a bacterial prostatitis. The purpose of this study was to investigate the prevalence of uropathogens associated with UTIs in older patients with benign prostatic hyperplasia and to assess their susceptibility to commonly prescribed antibiotics as well as the relationships between microbial virulence and resistance features. Uropathogenic Escherichia coli was found to be the most frequent bacterial strain isolated from patients with benign prostatic hyperplasia, followed by Enterococcus spp., Enterobacter spp., Klebsiella spp., Proteus spp., Pseudomonas aeruginosa, and Serratia marcescens. Increased resistance rates to tetracyclines, quinolones, and sulfonamides were registered. Besides their resistance profiles, the uropathogenic isolates produced various virulence factors with possible implications in the pathogenesis process. The great majority of the uropathogenic isolates revealed a high capacity to adhere to HEp-2 cell monolayer in vitro, mostly exhibiting a localized adherence pattern. Differences in the repertoire of soluble virulence factors that can affect bacterial growth and persistence within the urinary tract were detected. The Gram-negative strains produced pore-forming toxins-such as hemolysins, lecithinases, and lipases-proteases, siderophore-like molecules resulted from the esculin hydrolysis and amylases, while Enterococcus sp. strains were positive only for caseinase and esculin hydrolase. Our study demonstrates that necessity of investigating the etiology and local resistance patterns of uropathogenic organisms, which is crucial for determining appropriate empirical antibiotic treatment in elderly patients with UTI, while establishing correlations between resistance and virulence profiles could provide valuable input about the clinical evolution and recurrence rates of UTI.

Treatment of asymptomatic UTI in older delirious medical in-patients: A prospective cohort study

BACKGROUND

Despite clinical practice guidelines, asymptomatic bacteriuria (ASB) in older people is frequently treated. A common reason for treating ASB is a change in mental status.

OBJECTIVE

To determine how often asymptomatic UTI is treated in older medically ill delirious individuals and its association with functional recovery.

METHODS

Consecutive older medical in-patients were screened for delirium, and followed in hospital. Treatment for asymptomatic UTI was defined as documented treatment for a possible urinary tract infection with antibiotics, without concurrent infectious or urinary symptoms. The primary outcome was functional recovery at discharge or 3 months post-discharge. Poor functional recovery was defined by any one of death, new permanent long-term institutionalization or decreased ability to perform activities of daily living.

RESULTS

The study sample comprised 343 delirious in-patients, of which 237 (69%) had poor functional recovery. Ninety two (27%) delirious in-patients were treated for asymptomatic UTI. Treatment for asymptomatic UTI was associated with poor functional recovery compared to other delirious in-patients (RR 1.30, 95% CI: 1.14-1.48 overall). Similar results were seen when the analysis was restricted to only bacteriuric delirious individuals. Seven (7.5%) individuals treated for asymptomatic UTI developed Clostridium difficile infection compared to eight (3.2%) in the remainder of the delirious cohort (OR 2.45, 95% CI: 0.86-6.96).

CONCLUSIONS

These results suggest that treatment of asymptomatic UTI in older medical in-patients with delirium is common, and of questionable benefit. Further research is needed to establish guidelines to minimize over-treatment of UTI in older delirious in-patients.

Long-term antibiotics for prevention of recurrent urinary tract infection in older adults: systematic review and meta-analysis of randomised trials

OBJECTIVE

To address clinical uncertainties about the effectiveness and safety of long-term antibiotic therapy for preventing recurrent urinary tract infections (UTIs) in older adults.

DESIGN

Systematic review andmeta-analysis of randomised trials.

METHOD

We searched Medline, Embase, The Cumulative Index to Nursing and Allied Health Literature(CINAHL), and the Cochrane Register of Controlled Trials from inception to August 2016. Eligible studies compared long-term antibiotic therapy with non-antibiotic therapy or placebo in men or women aged over 65, or in postmenopausal women, with recurrent UTIs.

RESULTS

We did not identify any studies that included older men. Three randomised controlled trials compared long-term antibiotics with vaginal oestrogens (n=150), oral lactobacilli (n=238) and D-mannose powder (n=94) in postmenopausal women. Long-term antibiotics reduced the risk of UTI recurrence by 24% (three trials, n=482; pooled risk ratio (RR) 0.76; 95% CI 0.61 to 0.95, number needed to treat=8.5). There was no statistically significant increase in risk of adverse events (mild adverse events: pooled RR 1.52; 95% CI 0.76 to 3.03; serious adverse events: pooled RR 0.90, 95% CI 0.31 to 2.66). One trial showed 90% of urinary and faecal Escherichia coli isolates were resistant to trimethoprim-sulfamethoxazole after 1 month of prophylaxis.

CONCLUSIONS

Findings from three small trials with relatively short follow-up periods suggest long-term antibiotic therapy reduces the risk of recurrence in postmenopausal women with recurrent UTI. We did not identify any evidence to inform several clinically important scenarios including, benefits and harms in older men or frail care home residents, optimal duration of prophylaxis, recurrence rates once prophylaxis stops and effects on urinary antibiotic resistance.

Risk factors for urinary tract infections in geriatric hospitals

BACKGROUND

Urinary tract infection (UTI) is the most frequent nosocomial infection in geriatric units. An understanding of risk factors for infection may help to identify prevention strategies.

AIM

Identification of the risk factors for UTI in elderly patients.

METHODS

Retrospective analysis of three prospective cohorts. All hospitalized patients present in, or admitted to, a geriatric unit from June 1st to June 28th, for the years 2009, 2012, and 2015 were included and followed until discharge or until June 30th of the year concerned. For each patient, type and dates of stay, type and dates of catheter, risk factors, and nosocomial UTI (NUTI) data were collected. Univariate and multivariate (Cox model) analyses were made using SPSS software.

FINDINGS

A total of 4669 patients were included and were followed for a total of 83,068 days. There were 189 NUTIs (4.0% patients). NUTIs were significantly more frequent among female patients, in rehabilitation units, in immunosuppressed patients, among those with acute retention, post-void residual, history of urinary tract infection in the previous six months, and in case of dependency. NUTIs were significantly more frequent among those who had a catheter (Z-test, P < 0.001). NUTIs were more frequent among patients with intermittent, indwelling, or suprapubic catheters. They were also more frequent in acute/subacute care or rehabilitation units, in women, in immunosuppressed patients, and in those with a history of previous UTI; they were less frequent in dementia patients.

CONCLUSION

The occurrence of NUTI is an important issue in both catheterized and non-catheterized patients; prevention programmes should be widened to include non-catheterized patients.

Accuracy of Current Diagnostic Criteria for Acute Bacterial Infection in Older Adults in the Emergency Department

OBJECTIVES

To compare the accuracy of the Loeb criteria, emergency department (ED) physicians' diagnoses, and Centers for Disease Control and Prevention (CDC) guidelines for acute bacterial infection in older adults with a criterion standard expert review.

DESIGN

Prospective, observational study.

SETTING

Urban, tertiary-care ED.

PARTICIPANTS

Individuals aged 65 and older in the ED, excluding those who were incarcerated, underwent a trauma, did not speak English, or were unable to consent.

MEASUREMENTS

Two physician experts identified bacterial infections using clinical judgement, participant surveys, and medical records; a third adjudicated in cases of disagreement. Agreement and test characteristics were measured for ED physician diagnosis, Loeb criteria, and CDC surveillance guidelines.

RESULTS

Criterion-standard review identified bacterial infection in 77 of 424 participants (18%) (18 (4.2%) lower respiratory, 19 (4.5%) urinary tract (UTI), 22 (5.2%) gastrointestinal, 15 (3.5%) skin and soft tissue). ED physicians diagnosed infection in 71 (17%), but there were 33 with under- and 27 with overdiagnosis. Physician agreement with the criterion standard was moderate for infection overall and each infection type (κ = 0.48-0.59), but sensitivity was low (<67%), and the negative likelihood ratio (LR(-)) was greater than 0.30 for all infections. The Loeb criteria had poor sensitivity, agreement, and LR(-) for lower respiratory (50%, κ = 0.55; 0.51) and urinary tract infection (26%, κ = 0.34; 0.74), but 87% sensitivity (κ = 0.78; LR(-) 0.14) for skin and soft tissue infections. CDC guidelines had moderate agreement but poor sensitivity and LR(-).

CONCLUSION

Emergency physicians often under- and overdiagnose infections in older adults. The Loeb criteria are useful only for diagnosing skin and soft tissue infections. CDC guidelines are inadequate in the ED. New criteria are needed to aid ED physicians in accurately diagnosing infection in older adults.

Source Identification and Source Control

Identifying sources of infection and establishing source control is an essential component of the workup and treatment of sepsis. Investigation with history, physical examination, laboratory tests, and imaging can in identifying sources of infection. All organ systems have the potential to develop sources of infection. However, there are inherent difficulties presented by some that require additional diligence, namely, urinalysis, chest radiographs, and intraabdominal infections. Interventions include administration of antibiotics and may require surgical or other specialist intervention. This is highlighted by the Surviving Sepsis Campaign with specific recommendations for time to antibiotics and expeditious time to surgical source control.

Impact of Antimicrobial Stewardship on Physician Practice in a Geriatric Facility

BACKGROUND

There is a paucity of literature describing the implementation of antimicrobial stewardship programs (ASPs) in long-term care (LTC) facilities. The current study evaluated the impact of an ASP that was implemented across a geriatric facility, which included an inpatient specialty hospital and an LTC facility. The program included prospective audits with feedback, multidisciplinary education, information technology interventions, and guideline development.

OBJECTIVE

To investigate the impact of the ASP on physicians' prescribing practices in this geriatric facility.

METHODS

Utilization data for antibiotics commonly used to treat urinary tract infections were retrieved for the period September 1, 2011, to August 31, 2013. The study examined whether there were significant changes in overall antibiotic use, ciprofloxacin use, and physician prescribing behaviour after program implementation in September 2012.

RESULTS

There was no significant change in the total number of antibiotic prescriptions for urinary tract infections in the hospital or the LTC facility after ASP implementation. Significant reductions were seen in the average days of therapy initially prescribed and the actual days of therapy after ASP implementation in the LTC facility but not the hospital. Across both facilities, significant reductions were seen in the number of ciprofloxacin prescriptions.

CONCLUSIONS

The current study showed that an ASP can affect physicians' antibiotic prescribing behaviour and antibiotic usage in an LTC environment.

Treatment of febrile geriatric patients with suspected urinary tract infections in a hospital with high rates of ESBL producing bacteria: a cohort study

PURPOSE

To determine the consequences of treating febrile geriatric patients with a suspected urinary tract infection (UTI) with antibiotics that have high resistance rates due primarily to extended-spectrum β-lactamase (ESBL) producing bacteria.

METHODS

In this cohort study, we selected 257 consecutive hospitalised patients aged ≥70 years with a chief symptom of fever, possibly due to a UTI and initially treated with antibiotics with rates in our hospital of urinary culture resistance >20%. Patients with severe sepsis were excluded. The main outcomes measures were in vitro bacterial resistance to initial antibiotic therapy (BRIAT), response to therapy, hospitalisation days and mortality.

RESULTS

Urine cultures were positive in 64.2% (165 of 257) of the patients and BRIAT occurred in 28.0% (72 of 257). Response rates were 100% (93 of 93) in those with bacteria sensitive to initial antibiotic therapy, 95.7% (88 of 92) in the culture negative patients, and 66.7% (48 of 72) in those with BRIAT (p<0.001). There were no deaths due to deterioration during the initial treatment period because of BRIAT. In the patients with BRIAT, the median length of hospitalisation was 3 days longer than that in the other patients (7 and 4 days, respectively, p<0.001).

CONCLUSIONS

We conclude that initial broad spectrum antibiotic treatment could potentially lower the median length of hospitalisation by 3 days in many hospitalised geriatric patients without an extra-urinary tract source for their fever. This benefit needs to be balanced against the risk to the individual patient and to the general public of increasing bacterial resistance rates to broader spectrum antibiotics often held in reserve.

Prevalence and prognostic influence of bacterial pyuria in elderly patients with pneumonia: A retrospective study

AIM

The number of elderly patients with pneumonia is significantly increasing as the populations in many countries age. Although elderly patients with pneumonia are at risk of developing urinary tract infections, no studies have examined the prevalence or the prognostic impact of this complication. The aim of the present study was to investigate the prevalence of comorbid bacterial pyuria and the impact on the prognosis of elderly patients with pneumonia.

METHODS

We retrospectively evaluated 132 patients aged >65 years who were hospitalized for pneumonia and who underwent a urinary sediment test on admission. The background characteristics, laboratory results and treatment regimens were documented, and the risk factors for the complication of bacterial pyuria and its association with 90-day mortality in pneumonia patients were elucidated.

RESULTS

A total of 37 (28%) of 132 patients were complicated by bacterial pyuria. The patients with bacterial pyuria were more often women, showed a poorer performance status, were more frequently fed by percutaneous endoscopic gastrostomy, and more frequently used diapers and/or a bladder catheter. Regarding first-line drugs, 82.6% of the patients received beta-lactamase inhibitors and extended-spectrum penicillins. The use of a bladder catheter and a poor performance status were associated with bacterial pyuria. A multivariate analysis showed that a poor performance status was the only factor associated with 90-day mortality.

CONCLUSIONS

Bacterial pyuria did not affect the prognosis of patients who were treated with penicillin-based regimens. Thus, broad-spectrum antibiotics are not necessarily required for elderly patients with pneumonia complicated by urinary tract infection. Geriatr Gerontol Int 2017; 17: 1076-1080.

Bacteraemic urinary tract infections may mimic respiratory infections: a nested case-control study

Daily practice suggests that respiratory signs may be observed in bacteraemic urinary infections (BUI). Our objective was to search for an association between the presence of respiratory symptoms and the bacteraemic nature of urinary tract infections (UTI). A nested case-control study was carried out based on our computerised dashboard from January 2011 to June 2015. Cases were defined as patients with a BUI due to Enterobacteriaceae species, identified in blood and urine cultures. Controls had fever and a positive urinary sample but sterile blood cultures (NBUI) and a final diagnosis of urinary infection. Patients from the BUI group were 1:1 matched to the NBUI group according to four parameters: age, gender, cardiovascular and pulmonary comorbid conditions. Subjects with cognitive impairment limiting clinical accuracy and those with healthcare-associated infections were excluded. We compared systematically recorded respiratory and urinary symptoms between groups: signs on auscultation, dyspnoea, chest pain, cough and sputum, dysuria with burning, pollakiuria, flank or costovertebral angle tenderness and ischuria. One hundred BUI were compared to 100 NBUI, both groups exhibiting a similar rate for all considered comorbid conditions. In the BUI group, 58 % showed at least one respiratory sign vs. 20 % in the NBUI group, p < 0.001, while urinary signs were less frequent: 54 % vs. 71 %, p = 0.013. In the multivariate analysis, BUI was associated with the presence of abnormal pulmonary auscultation [adjusted odds ratio (AOR), 5.91; p < 0.001] and a trend towards less urinary symptoms (AOR, 1.58; p = 0.058). Patients with BUI presented with significantly more respiratory signs, which overshadowed urinary symptoms, compared to those with non-bacteraemic UTI. Such observations impact clinical decision-making.

Urine Cultures among Hospitalized Veterans: Casting Too Broad a Net?

Since detection of asymptomatic bacteriuria among inpatients often leads to inappropriate antimicrobial treatment, we studied why urine cultures were ordered and correlates of treatment. Most cultures were obtained from patients without urinary complaints and a minority from asymptomatic patients. High-count bacteriuria, not clinical manifestations, appeared to trigger most antimicrobial use.

[Prognostic value of the primary diagnosis in elderly patients admitted to an acute geriatric unit at discharge and one year later]

OBJECTIVE

To analyse the relationship between the primary diagnosis on admission to an Acute Geriatric Unit (AGU) and the risk of hospital mortality and one year after discharge

MATERIAL AND METHODS

A longitudinal study was conducted on patients admitted to the Central Hospital AGU Red Cross in Madrid in 2009. The admission diagnosis was grouped by Diagnosis Related Groups (DRGs). The date of death was collected from the medical charts and the National Death Index Ministry of Health report. The main outcome of study was the association between diagnoses on admission and functional impairment at discharge (measured as a loss of 10 or more points between the Barthel Index at discharge and that on admission), mortality during hospitalization, at 3 months and one year after discharge. The multivariate analysis was adjusted for age, sex, comorbidity, functional and cognitive status, and serum albumin.

RESULTS

The study included1147 patients, with a mean age of 86.7 years (SD±6.7), and 66% were women. During admission, 10.1% of patients died and 36.6% had functional impairment at discharge. After discharge, 25.5% died at 3 months, and 42.2% at one year. The distribution of the primary diagnoses at admission (between parentheses hospital mortality and at year) were heart failure, 21.4% (8.1% and 37.4%), pneumonia,13.3% (12.3% and 46.4%), and aspiration pneumonia, 4.7% (27.5%, y 71%), respiratory diseases,13.3% (6.6% and 38.2%), urinary infection,10.2% (5.1% and 42.7%), and stroke (excluding AIT), 9.9% (13.3% and 46.9%). In the multivariate analysis, only admissions due to aspiration pneumonia were independently associated with increased risk of hospital mortality (odds ratio, 2.23; 95% CI=1.13 to 44.42), and stroke with increased risk of functional impairment at discharge (odds ratio, 6.01; 95% CI=3.42-10.57). No diagnosis was independently associated with increased risk of death at 3 months and at year

CONCLUSIONS

Admission from aspiration pneumonia carries an increased risk of death in elderly patients hospitalised for acute medical conditions. After discharge, the risk of death must be attributed to factors other than the admission diagnosis.

Febrile urinary tract infection in the emergency room

PURPOSE OF REVIEW

To review the recent advances in the diagnostic and therapeutic approach to adults presenting with febrile urinary tract infection (UTI) in the emergency department (ED).

RECENT FINDINGS

Recent research suggests overdiagnosis and therefore overtreatment of UTI in the ED, especially in the elderly. Antimicrobial pretreatment, an indwelling catheter, and malignancy are independent risk factors for bacteremia with uropathogens that cannot be cultured from urine. A simple clinical prediction rule can predict clinically relevant radiologic findings in patients with invasive UTI. Procalcitonin is a marker for bacteremia; pro-adrenomedullin predicts a complicated course and 30-day mortality in complicated UTI. Several reports have identified the risk factors for resistant uropathogens in community-acquired febrile UTI. Adherence to the guidelines and early culture-guided intravenous-to-oral switch reduces the length of hospitalization.

SUMMARY

An effective strategy is needed to improve the diagnosis of UTIs in acute care. Further research regarding biomarker-guided triage might improve the management of patients with febrile UTI. Future efforts should be directed toward the improvement of adherence to UTI treatment guidelines.

Treatment of uncomplicated symptomatic urinary tract infections: Resistance patterns and misuse of antibiotics

Introduction:

Uncomplicated but symptomatic urinary tract infections (UTIs) are a common problem seen in practice. The study was undertaken to assess the most common pathogens responsible for uncomplicated symptomatic UTIs and the antimicrobial resistance pattern in a hospital in Bangalore. The study also explores the issue of antibiotic usage for these patients.

Materials and Methods:

The study was conducted in the Medicine department of a tertiary hospital in Bangalore. In all, 196 patients presented with symptoms of UTI. Bacterial growth was determined by standard microbiology techniques on freshly voided mid-steam urine samples collected from recruited patients. Patients’ demographic data, urine culture results, resistance rates to antimicrobial agents and prescribed empiric antimicrobial therapy were analyzed.

Results:

The prevalence of UTI was 32.1%; majority (67.9%) of the symptomatic did not have UTI based on culture report. Gram-negative bacteria constituted the largest group with a prevalence of 84.1% (53/63), with Escherichia coli being the most common (70%) uropathogen. Gram-negative isolates showed high level of sensitivity to amikacin (90.6%) and nitrofurantoin (77.4%). Most of the gram-positive organisms were susceptible to nitrofurantoin (70%) and gentamicin (50%). Uropathogens isolated demonstrated high resistance to cotrimoxazole, fluoroquinolones, and beta-lactam antibiotics. It was found out that 30.1% of the patients were wrongly managed of which 14.7% were over treated.

Conclusion:

UTI can be over diagnosed and over treated on the basis of clinical signs, symptoms and urine microscopy. In the era of emerging anti-microbial resistance, effective counseling and delay in antibiotic initiation or empirical therapy with a short course of nitrofurantoin is highly recommended. Empirical therapy guidelines should be updated periodically to reflect changes in antimicrobial resistance of uropathogens.

Urinary tract infections and asymptomatic bacteriuria in older adults

Overuse of urinalysis in older adults to investigate vague changes in condition such as confusion, lethargy, and anorexia, has led to overtreatment of asymptomatic bacteriuria and associated antibiotic resistance.

Empirical Antimicrobial Prescriptions in Patients with Clostridium difficile Infection at Hospital Admission and Impact on Clinical Outcome

Objective.

To determine, among patients with Clostridium difficile infection (CDI) at hospital admission, the impact of concurrent use of systemic, non-CDI-related antimicrobials on clinical outcomes and the risk factors associated with unnecessary antimicrobial prescribing.

Design.

Retrospective cohort study.

Setting.

University-affiliated community hospital.

Methods.

We reviewed computerized medical records for all patients with CDI at hospital admission during a 24-month period (January 1, 2008, through December 31, 2009). Colectomy, discharge to hospice, and in-hospital mortality were considered to be adverse outcomes. Antimicrobial use was considered unnecessary in the absence of physical signs and laboratory or radiological findings suggestive of an infection other than CDI or in the absence of antimicrobial activity against the organism(s) recovered from clinical cultures.

Results.

Among the 94 patients with CDI at hospital admission, 62% received at least one non-CDI-related antimicrobial during their hospitalization for CDI. Severe complicated CDI (odds ratio [OR], 7.1 [95% confidence interval {CI}, 1.8–28.5]; P = .005), duration of non-CDI-related antimicrobial exposure (OR, 1.2 [95% CI, 1.03–1.36]; P = .016), and age (OR, 1.1 [95% CI, 1.0–1.1]; P = .043) were independent risk factors for adverse clinical outcomes. One-third of the patients received unnecessary antimicrobial therapy. Sepsis at hospital admission (OR, 5.3 [95% CI, 1.8–15.8]; P = .003) and clinical suspicion of urinary tract infection (OR, 9.7 [95% CI, 2.9–32.3]; P< .001) were independently associated with unnecessary antimicrobial prescriptions.

Conclusions.

Empirical use of non-CDI-related antimicrobials was common. Prolonged exposure to non-CDI-related antimicrobials was associated with adverse clinical outcomes, including increased in-hospital mortality. Minimizing non-CDI-related antimicrobial exposure in patients with CDI seems warranted.

Nosocomial bacteriuria in elderly inpatients may be leading to considerable antibiotic overuse: an audit of current management practice in a secondary level care hospital in New Zealand

Background

Bacteriuria in the form of symptomatic urinary tract infection (UTI) and asymptomatic bacteriuria (ASB) is common in the elderly. There is no clinical benefit obtained by treating elderly individuals with ASB. However, its high prevalence leads to the overdiagnosis of UTI and unnecessary antibiotic use, which can result in adverse events, including Clostridium difficile diarrhea and reinfection with antibiotic-resistant organisms.

Methods

This was a retrospective audit that assessed the management of nosocomial bacteriuria in elderly patients admitted to the over-65 years rehabilitation unit of a secondary level care hospital in New Zealand. Identified bacteriuria episodes had the timing of sample collection relative to admission, microbial etiology, antibiotic susceptibility profile, inflammatory marker level, and treatment determined. Episodes were classified into six different clinical groups based on the presence or absence of signs and symptoms, urinary catheter status, and systemic inflammatory response. The proportion of bacteriuria episodes by clinical grouping and the level of treatment by clinical group were determined, followed by assessment of the amount of overtreatment in terms of the number of unnecessary antibiotic courses and unnecessary antibiotic treatment days.

Results

Significant bacteriuria was identified in 30% of patients, with 35% of urine samples collected in the immediate postadmission period. Fifty-four percent of the bacteriuria episodes were ASB or catheter-associated ASB (CA-ASB) without an inflammatory response, 24% were ASB or CA-ASB with raised inflammatory markers, and 22% were UTI or CA-UTI. The most common cause of bacteriuria was Escherichia coli, although the etiology was diverse, especially after prolonged hospitalization or in catheterized patients. A large proportion of organisms were resistant to one or more of the commonly used oral antibiotics. Treatment of ASB and CA-ASB accounted for 43% of all antibiotic courses received. Furthermore, treatment of ASB and CA-ASB combined with unnecessarily prolonged treatment days for clinically relevant infections accounted for 55% of all antibiotic treatment days received.

Conclusion

The results suggest that inappropriate urine screening was occurring and that 43% of antibiotic courses and 55% of all antibiotic treatment days were unnecessary. Current practice is amenable to improvement by performing urine culture only when clinically indicated, focusing on clinical signs and symptoms to diagnose clinically significant UTI rather than a positive culture, and using, where possible, the ecologically least damaging antibiotic for the shortest duration required.

Challenges and proposed improvements for reviewing symptoms and catheter use to identify National Healthcare Safety Network catheter-associated urinary tract infections

BACKGROUND

Retrospective medical record review is used to categorize urinary tract infections (UTIs) as symptomatic, catheter-associated, and/or healthcare-associated to generate National Healthcare Safety Network (NHSN) surveillance and claims data. We assessed how often patients with UTI diagnoses in claims data had a catheter in place, had documented symptoms, or met the NHSN criteria for catheter-associated UTI (CAUTI).

METHODS

Two physicians retrospectively reviewed medical records for 294 randomly selected patients hospitalized with UTI as a secondary diagnosis, discharged between October 2008 and September 2009 from the University of Michigan. We applied a modification of recent NHSN criteria to estimate how often UTIs in claims data may be an NHSN CAUTI.

RESULTS

The 294 patients included 193 women (66%). The mean patient age was 63 years, and the median length of hospital stay was 7.5 days. Catheter use was noted for 216 of 294 postadmission records (74%), including 126 (43%) with a Foley catheter. NHSN symptoms were noted in 113 records (38%); 62 (21%) had symptoms other than fever. Of 136 hospitalizations meeting urine culture criteria, 17 (5.8%) met the criteria for a potential NHSN CAUTI.

CONCLUSIONS

Retrospective medical record review to identify symptoms and catheter use is complicated and resource-intensive. Requiring standard documentation of symptoms and catheter status when ordering urine cultures could simplify and improve CAUTI surveillance and its fidelity as a hospital quality indicator.

Role of body temperature in diagnosing bacterial infection in nursing home residents

OBJECTIVES

To provide empirically based recommendations for incorporating body temperature into clinical decision-making regarding diagnosing infection in nursing home (NH) residents.

DESIGN

Retrospective.

SETTING

Twelve North Carolina NHs.

PARTICIPANTS

NH residents (N = 1,007) with 1,858 randomly selected antibiotic prescribing episodes.

MEASUREMENTS

Maximum prescription-day temperature plus the three most recent nonillness temperatures were recorded for each prescribing episode. Two empirically based definitions of fever were developed: population-based (population mean nonillness temperature plus 2 population standard deviations (SDs)) and individualized (individual mean nonillness temperature plus 2 population SDs). These definitions were used along with previously published fever criteria and Infectious Diseases Society of America (IDSA) criteria to determine how often each prescribing episode was associated with a "fever" according to each definition.

RESULTS

Mean population nonillness temperature was 97.7 ± 0.5 ºF. If "normal" were defined as less than 2 SDs above the mean, fever would be defined as any temperature above 98.7 ºF, and the previously published fever cutpoints and the IDSA criteria are 4.8 SDs above this mean. Between 30% and 32% of the 1,858 prescribing episodes examined were associated with temperatures more than 2 SDs above the population mean nonillness temperature, whereas only 10% to 11% of episodes met the previously published and IDSA fever definitions.

CONCLUSION

Clinicians should apply empirically based definitions to assess fever in NH residents. Furthermore, low fever prevalence in residents treated with antibiotics according to all definitions suggests that some prescribing may not be associated with acute bacterial infection.

Antimicrobial treatment of asymptomatic bacteriuria in noncatheterized adults: a systematic review

Asymptomatic bacteriuria (ASB) is a common clinical finding characterized by the presence of bacteria in the urine of an individual without signs or symptoms suggestive of urinary tract infection. Despite available guidelines on the diagnosis and management of ASB, it is often managed inappropriately. We performed a systematic review of clinical trials evaluating antimicrobial therapy for ASB, identified translational barriers to evidence-based practice, and we offer strategies to optimize antimicrobial use for ASB. We conducted a systematic search of the PubMed, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health databases, and the Cochrane Library. Randomized controlled trials, cohort trials, case-control studies, and meta-analyses published in the English language were included in this review if they addressed treatment of ASB with at least one antimicrobial agent in nonpregnant adults. Articles were excluded if they evaluated patients with indwelling urinary catheters or were not clinical trials. Of the 304 articles identified from the search, 287 were excluded; thus 17 articles met the inclusion criteria. Although treatment of ASB with antimicrobial therapy may improve short-term microbiologic outcomes, the clinical significance is diminished because the effect is not sustained, there is no measurable improvement in morbidity or mortality, and some data indicate that therapy is deleterious. Several translational barriers that preclude adoption of evidence-based practice are identified. Treatment guidelines may not achieve their desired effect and underscore the need for additional methods to translate clinical trial data into practice. Clinical pharmacists are a core member of the antimicrobial stewardship team and in an important position to participate in initiatives that promote appropriate antimicrobial use. We suggest a multifaceted approach consisting of education and frequent routine prospective audits with feedback coupled with appropriate process and outcome measures.

Management of urinary tract infections in elderly patients: Strategies for improvement

Urinary tract infection (UTI) is one of the most common infections affecting the elderly. However, UTI is overdiagnosed and overtreated in this group. This project aimed to look into strategies for improving the management of UTI in elderly medical inpatients. A retrospective audit was performed on the case notes of medical inpatients in a district general hospital from December 2012 to April 2013. The target measures for improvement include increasing adherence to SIGN guidelines in the diagnosis of UTI, increasing the frequency and timeliness of urinary culture collection in suspected UTI, and increasing use of urine culture sensitivities to tailor antimicrobial treatments. Initial baseline measurement revealed 16 patients treated for UTI. 31.3% of these fulfilled SIGN criteria for UTI. 68.5% had urine cultures performed. 60% of patients with positive urine cultures had correct antibiotic therapy after sensitivity results. The mean time from the diagnosis of UTI to urine collection for culture was 4 days. Three further cycles were performed. Following each cycle, improvement measures were implemented to raise the awareness of medical staff about the management of UTI in the elderly. These comprised presentations to junior doctors at local teaching sessions; emails to ward managers with results of the previous audit cycle broken down by ward; and prominent display of guidelines on medical wards and ensuring availability of 'Newcastle pads' for taking sterile urine cultures from incontinent patients. In the final cycle, 19 patients were diagnosed with UTI. 42.1% of these fulfilled SIGN criteria for diagnosis of UTI. 89.5% had urine cultures sent. 86.7% of patients with a positive urine culture were treated with appropriate antibiotics after sensitivities became available. Mean time from UTI diagnosis to culture collection improved to zero days. In conclusion, continuous educational measures, performance feedback, and increased availability of specialist equipment are imperative for improving management of UTIs in the elderly.

A modern-day purgatory: older adults in the emergency department with nonoperative injuries

Older adults frequently present to the emergency department (ED) with injuries that do not require operative treatment but are sufficiently severe to make it unsafe for them to return home. These individuals typically do not meet criteria for hospital admission, but because of limited reimbursement for observation, admitting physicians are often reluctant to accept these individuals for observation. Admission to a skilled nursing or assisted living facility from the ED or rapid access to additional in-home care is also often difficult or impossible. As a result, older adults with nonoperative injuries often spend a long time in the ED waiting for an appropriate disposition. The challenges of identifying an appropriate disposition for these individuals, the consequences for patients, and some potential solutions to this commonly encountered problem are described.

Older women's experiences of suffering from urinary tract infections

AIMS AND OBJECTIVES

To describe and explore older women's experiences of having had repeated urinary tract infections (UTIs).

BACKGROUND

UTIs are one of the most common bacterial infections among older women. Approximately one-third of very old women suffer from at least one UTI each year. Despite the high incidence of UTI, little is known about the impact of UTI on health and daily life in older women.

DESIGN

A qualitative descriptive design.

METHODS

A qualitative study using semi-structured interviews was conducted with 20 Swedish women aged 67-96 years who suffered from repeated UTIs the preceding year. The data were analysed using qualitative content analysis.

RESULTS

Two main themes were identified: being in a state of manageable suffering and depending on alleviation. Being in a state of manageable suffering was described in terms of experiencing physical and psychological health problems, struggling to deal with the illness and being restricted in daily life. Depending on alleviation was illustrated in terms of having access to relief but also receiving inadequate care.

CONCLUSIONS

This study demonstrated that UTIs are a serious health problem among older women that not only affects both physical and mental health but also has serious social consequences. The women in this study described the physical and psychological health problems, struggling to deal with the illness, being restricted in daily life, depending on access to relief and receiving inadequate care.

RELEVANCE TO CLINICAL PRACTICE

It is important to improve the knowledge about how UTI affects the health of older women. This knowledge may help nurses develop strategies to support these women. One important part in the supportive strategies is that nurses can educate these women in self-care.

Evidence-based protocol: diagnosis and treatment of catheter-associated urinary tract infection within adult neurocritical care patient population

Evidence exists that patients requiring neurologic ICU admission have concomitant immunosuppression that makes them more prone to acquiring nosocomial infections. The risk of infection is highest in the acute phase after stroke, which may be attributed to stroke-induced immunodepression syndrome. Significant numbers of patients are being diagnosed inappropriately with catheter-associated urinary tract infection, for which they receive treatment that is not recommended. Protocol-based care enables providers to translate evidence into practice.

Clinician practice and the National Healthcare Safety Network definition for the diagnosis of catheter-associated urinary tract infection

BACKGROUND

The National Healthcare Safety Network (NHSN) definition for catheter-associated urinary tract infection (CAUTI) is used to evaluate improvements in CAUTI prevention efforts. We assessed whether clinician practice was reflective of the NHSN definition.

METHODS

We evaluated all adult inpatients hospitalized between July 2010 and June 2011, with a first positive urine culture > 48 hours of admission obtained while catheterized or within 48 hours of catheter discontinuation. Data comprised patients' signs, symptoms, and diagnostic tests; clinician's diagnosis; and the impression of the infectious diseases (ID) consultant. The clinician's practice was compared with the NHSN definition and the ID consultant's impression.

RESULTS

Antibiotics were initiated by clinicians to treat CAUTI in 216 of 387 (55.8%) cases, with 119 of 387 (30.7%) fitting the NHSN CAUTI definition, and 63 of 211 (29.9%) considered by ID to have a CAUTI. The sensitivity, specificity, and positive and negative predictive values of a clinician diagnosis of CAUTI were 62.2%, 47%, 34.3%, and 73.7% when compared with NHSN CAUTI definition (n = 387) and 100%, 57.4%, 50%, and 100% when compared with the ID consultant evaluation (n = 211), respectively. The positive predictive value of the NHSN CAUTI definition was 35.1% when compared with the ID consultant's impression (n = 211).

CONCLUSION

NHSN CAUTI definition did not reflect clinician or ID consultant practices. Our findings reflect the differences between surveillance definitions and clinical practice.

A survey of resident physicians' knowledge regarding urine testing and subsequent antimicrobial treatment

BACKGROUND

Asymptomatic bacteriuria is often treated with antimicrobials despite no benefit to patients, contributing to antimicrobial resistance and costs. Identifying knowledge deficits may improve physician training and antimicrobial stewardship efforts. We surveyed internal medicine and medicine-pediatrics resident physicians about their knowledge and attitudes regarding urine testing and subsequent management.

METHODS

We surveyed 280 resident physicians at Jackson Memorial Hospital/University of Miami Miller School of Medicine and the University of Minnesota Medical School, using patient management questions based on clinical vignettes. Overall knowledge, assessed by calculating the percentage of correct answers, was assessed for correlation with demographic information, training, and experience.

RESULTS

Of 100 responses (36% response rate), the mean percentage of correct answers was 48% (range for individual questions, 19%-85%). Experience and demographic factors demonstrated no association with overall knowledge. Training appeared to be associated with overall knowledge, with third-year residents having significantly higher percentages of correct answers compared with first-year residents (53% vs 40%; P = .03), but this was nonsignificant when adjusted for multiple comparisons (P = .18). Knowledge was significantly better for questions regarding surgical versus nonsurgical scenarios (63% vs 37%; P < .001), and for questions for which the correct answer was to start antimicrobials, versus withholding antimicrobials/limiting further testing (83% vs 39%; P < .001).

CONCLUSIONS

Knowledge deficits may contribute to unnecessary detection and treatment of asymptomatic bacteriuria.

Recurrent urinary tract infection in older women: an evidence-based approach

Ageing increases the risk of a woman developing a urinary tract infection (UTI). It also increases the risk of misdiagnosis and inappropriate antibiotic therapy being prescribed. Antibiotic therapy has costs as well as benefits and can lead to changes in gut and vaginal flora that further predispose older women to UTI. Antibiotic resistance is growing and those who do have a UTI may experience treatment failure because of resistance to commonly used antibiotics. Accurate diagnosis and effective evidence-based treatment becomes even more crucial in the face of an ageing population and increasing antimicrobial resistance. Furthermore, the need for specific evidence-based guidelines for UTI in older people is increasing.

How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions

Maintaining patient safety in acute hospitals is a global health challenge. Traditionally, patient safety measures have been concentrated on critical care and surgical patients. In this review the medical literature was reviewed over the last ten years on aspects of patient safety specifically related to patients with dementia. Patients with dementia do badly in hospital with frequent adverse events resulting in the geriatric syndromes of falls, delirium and loss of function with increased length of stay and increased mortality. Contributory factors include inadequate assessment and treatment, inappropriate intervention, discrimination, low staff levels and lack of staff training. Unfortunately there is no one simple solution to this problem, but what is needed is a multifactorial, multilevel approach at the seven levels of care - patient, task, staff, team, environment, organisation and institution. Improving safety and quality of care for patients with dementia in acute hospitals will benefit all patients and is an urgent priority for the NHS.

Diagnostic criteria for urinary tract infection in hospitalized elderly patients over 75 years of age: a multicenter cross-sectional study

INTRODUCTION

Urinary tract infection (UTI) is one of the most frequent infections in geriatric patients. Nevertheless, the diagnosis remains difficult because of the high prevalence of asymptomatic bacteriuria (AB). We studied the diagnosis criteria used by physicians in geriatric patients 75 years of age or more.

METHOD

A multicenter study was carried out in October 2009 in acute care wards (geriatrics, infectious diseases, internal medicine). During 1 week, the local investigator collected all positive urine microscopy and culture in geriatric patients 75 years of age or more and filled out a questionnaire on the final diagnosis (AB, cystitis, pyelonephritis, prostatitis), symptoms, clinical signs, and other infectious diagnosis.

RESULTS

Two hundred and forty-one questionnaires were filled out in 48 wards. Physicians diagnosed AB in 91 patients (37.8%), cystitis in 72 (29.9%), pyelonephritis in 48 (19.9%), prostatitis in 20 (8.3%). 28.2% of patients were asymptomatic; 35% presented with clinical signs. General signs were significantly associated with invasive infection and the absence of functional signs with AB. Among the patients presenting with an invasive UTI, 27.9% also presented with another infection. This other infection was not statistically associated with AB, cystitis, or invasive UTI.

CONCLUSION

Too many urine microscopy and culture procedures are not justified, and too many patients are diagnosed with several infections. Usual functional and clinical signs are important for the diagnosis but are infrequent. It seems necessary to review the range of clinical presentations and diagnostic criteria for UTI in geriatric patients.

American Geriatrics Society identifies five things that healthcare providers and patients should question

Given the American Geriatrics Society's (AGS) commitment to improving health care for older adults by, among other means, educating older people and their caregivers about their health and healthcare choices, the AGS was delighted when, in late 2011, the American Board of Internal Medicine Foundation invited the Society to join its "Choosing Wisely(®) " campaign. Choosing Wisely is designed to engage patients, healthcare professionals, and family caregivers in discussions about the safety and appropriateness of medical tests, medications, and procedures. Ideally, these discussions should examine whether the tests and procedures are evidence-based, whether any risks they pose might overshadow their potential benefits, whether they are redundant, and whether they are truly necessary. In addition to improving the quality of care, the initiative aims to rein in unneeded healthcare spending. According to a 2008 Congressional Budget Office report, as much as 30% of healthcare spending in the United States may be unnecessary.

Procalcitonin, pyuria and proadrenomedullin in the management of urinary tract infections--'triple p in uti': study protocol for a randomized controlled trial

Background

Urinary tract infections (UTIs) are among the most common infectious diseases and drivers of antibiotic use and in-hospital days. A reduction of antibiotic use potentially lowers the risk of antibiotic resistance. An early and adequate risk assessment combining medical, biopsychosocial and functional risk scores has the potential to optimize site-of-care decisions and thus allocation of limited health-care resources. The aim of this factorial design study is twofold: first, for Intervention A, it investigates antibiotic exposure of patients treated with a protocol based on the type of UTI, procalcitonin (PCT) and pyuria. Second, for Intervention B, it investigates the usefulness of the prognostic biomarker proadrenomedullin (ProADM) integrated into an interdisciplinary assessment bundle for site-of-care decisions.

Methods and design

This randomized controlled open-label trial has a factorial design (2 × 2). Randomization of patients will be based on a pre-specified computer-generated randomization list and independent for the two interventions. Adults with UTI presenting to the emergency department (ED) will be screened and enrolled after providing informed consent.

For our first Intervention (A), we developed a protocol based on previous observational research to recommend initiation and duration of antibiotic use based on the clinical presentation of UTI, pyuria and PCT levels. For our second intervention (B), an algorithm was developed to support site-of care decisions based on the prognostic marker ProADM and distinct nursing factors on days 1 and 3. Both interventions will be compared with a control group conforming to the guidelines.

The primary endpoints for the two interventions will be: (A) overall exposure to antibiotics and (B) length of physician-led hospitalization within a follow-up of 30 days. Endpoints are assessed at discharge from hospital, and 30 and 90 days after admission. We plan to screen 300 patients and enroll 250 for an anticipated estimated loss of follow-up of 20%. This will provide adequate power for the two interventions.

Discussion

This trial investigates two strategies for improved individualized medical care in patients with UTI. The minimally effective duration of antibiotic therapy is not known for UTIs, which is important for reducing the selection pressure for antibiotic resistance, costs and drug-related side effects. Triage decisions must be improved to reflect the true medical, biopsychosocial and functional risks in order to allocate patients to the most appropriate care setting and reduce hospital-acquired disability.

Trial registration

Trial registration number: ISRCTN13663741

Age, nursing home residence, and presentation of urinary tract infection in U.S. emergency departments, 2001-2008

OBJECTIVES

Current outpatient diagnostic algorithms for urinary tract infection (UTI) in older adults require the presence of classic signs and symptoms of UTI, such as fever and genitourinary symptoms. However, older adults with UTI may present with atypical signs and symptoms. The objective was to identify the associations of age and nursing home status with the clinical presentation of emergency department (ED) patients diagnosed with UTI.

METHODS

This was a retrospective, cross-sectional analysis of the 2001-2008 National Hospital Ambulatory Medical Care Survey (NHAMCS), ED component. Participants were adult ED patients diagnosed with UTI. Outcome variables were presence of fever, altered mental status, and urinary tract symptoms. Multivariable logistic regression models were constructed for each outcome. Age and nursing home status were the independent variables of interest. Age was divided into adults 18 to 64 years, older adults 65 to 84 years, and oldest adults 85 years of age and older.

RESULTS

There were 25.4 million ED visits in which UTI was diagnosed from 2001 through 2008, including 5.0 million in older adults and 2.2 million in the oldest adults. Fever was present in 13% of adults, 21% of older adults, and 19% of the oldest adults. Altered mental status was present in 1% of adults, 7% of older adults, and 13% of the oldest adults. Urinary tract symptoms were identified in 32% of adults, 24% of older adults, and 17% of the oldest adults. In multivariable analysis, altered mental status was more common in older adults (odds ratio [OR] = 1.94) and in the oldest adults (OR = 2.49). Urinary tract symptoms were less common in older adults (OR = 0.60) and the oldest adults (OR = 0.48). Nursing home residence was associated with increased fever (OR = 1.63) and altered mental status (OR = 4.79) and with decreased urinary tract symptoms (OR = 0.35).

CONCLUSIONS

Fever and urinary tract symptoms are absent in a large proportion of adults over 65 years of age diagnosed with UTI in the ED. Age over 65 years and nursing home residence are associated with increased presence of altered mental status and with lack of urinary tract symptoms. Nursing home residence is also associated with increased presence of fever. Emergency physicians (EPs) continue to diagnose UTI in patients without classic symptoms. Diagnostic criteria for UTI among adults 65 years and over specifically designed for use in the acute care setting should be developed and validated to prevent both inappropriate overdiagnosis and underdiagnosis of UTI.

Different patterns in use of antibiotics for lower urinary tract infection in institutionalized and home-dwelling elderly: a register-based study

PURPOSE

We compared the quality and pattern of use of antibiotics to treat urinary tract infection (UTI) between institutionalized and home-dwelling elderly.

METHODS

We analyzed the quality of use of UTI antibiotics in Swedish people aged ≥ 65 years at 30 September 2008 (1,260,843 home-dwelling and 86,721 institutionalized elderly). Data regarding drug use, age and sex were retrieved from the Swedish Prescribed Drug Register and information about type of housing from the Social Services Register. In women, we assessed: (1) the proportion who use quinolones (should be as low as possible); (2) the proportion treated with the recommended drugs (pivmecillinam, nitrofurantoin, or trimethoprim) (proportions should be about 40 %, 40 % and 15-20 %, respectively); In men, we assessed: (1) the proportion who used quinolones or trimethoprim (should be as high as possible).

RESULTS

The 1-day point prevalence for antibiotic use for UTI was 1.6 % among institutionalized and 0.9 % among home-dwelling elderly. Of these, about 15 % of institutionalized and 19 % of home-dwelling women used quinolones. The proportion of women treated with the recommended drugs pivmecillinam, nitrofurantoin or trimethoprim was 29 %, 27 % and 45 % in institutions and 40 %, 28 % and 34 % for home-dwellers. In men treated with antibiotics for UTI, quinolones or trimethoprim were used by about 76 % in institutions and 85 % in home-dwellers.

CONCLUSIONS

Our results indicate that recommendations for UTI treatment with antibiotics are not adequately followed. The high use of trimethoprim amongst institutionalized women and the low use of quinolones or trimethoprim among institutionalized men need further investigation.

Disagreement between emergency physician and inpatient physician diagnosis of infection in older adults admitted from the emergency department

OBJECTIVES

Older adults with infection are at increased risk of misdiagnosis while they are patients in the emergency department (ED) due to the common presence of nonspecific signs and symptoms. The primary objective was to determine the proportion of admitted older adult patients thought by the emergency physician (EP) to be infected, as compared with the diagnostic impression of inpatient physicians. The secondary objective was to determine the agreement between EP and inpatient physician diagnosis of specific infection types.

METHODS

The authors conducted a prospective, observational, convenience sampling of a cohort of ED patients ≥65 years old admitted to the hospital with diagnoses of acute infection. EPs noted at least one suspected source of infection. Inpatient diagnosis of infection was determined by chart review of the inpatient chart. Outcomes included the presence of any infection and of specific infectious sources diagnosed within 48 hours of admission. EP and inpatient diagnoses were compared using proportions, positive and negative likelihood ratios (LR+ and LR-), and the phi coefficient.

RESULTS

The study included 103 patients diagnosed with a suspected infection by the EP. Nineteen patients (18.4%, 95% confidence interval [CI] = 11.5% to 27.3%) were not diagnosed with any infection by the inpatient physician. For specific infection sources, ED diagnosis of bloodstream infection often did not agree with the inpatient diagnosis. Sensitivity was 40.0% and specificity 78.4% with an LR+ of 1.85 and LR- of 0.76. The phi coefficient was 0.15. EPs overdiagnosed pulmonary infection, with 72.1% specificity and an LR+ of 3.24. EP diagnosis had good accuracy for skin and soft tissue infection (sensitivity = 78.6% and specificity = 96.6%), with adequate LRs (LR+ of 23.3 and LR- of 0.22). Urinary tract infection (UTI) was underdiagnosed in the ED (sensitivity = 58.3%), but it is unclear if this is due to true ED underdiagnosis or due to overdiagnosis of UTI in the inpatient setting.

CONCLUSIONS

In older patients admitted from the ED, the provisional ED diagnosis and the inpatient diagnosis of an acute infection often disagree. In this sample, 18% of older ED patients diagnosed with infection during an ED stay were not diagnosed as infected by the inpatient physician. Regarding infection types, EPs were poor at diagnosing bacteremia and overdiagnosed pulmonary infections. EP diagnosis of skin and soft tissue infection generally agreed with the inpatient physician. There was also disagreement regarding presence of UTI, but the true nature of this difference is unclear from the data obtained in this study.

Diagnostic challenges and opportunities in older adults with infectious diseases

Infections remain a major threat to the well-being of our growing aged population. The correct and timely diagnosis of infections in older adults is increasingly important in the current age of antimicrobial resistance. Urinary tract infection, pneumonia, and bacteremia present particular challenges. In older patients with bacteremia, blood cultures have comparable yield as compared with younger patients. However, the routine triggers for ordering blood cultures may not be appropriate in older adults. In addition, resistance patterns of isolated pathogens may change with age. The main difficulties in diagnosing urinary tract infections in older adults are caused by an increased prevalence of asymptomatic bacteriuria and frequent use of urinary catheters. However, a combined noninvasive approach that includes history, physical examination, urinary dipstick testing, urine cultures, and simple blood tests can provide direction. In addition, specific guidelines for specific populations are available. In older patients suspected of bacterial pneumonia, bedside pulse oximetry and urinary antigen testing for Streptococcus pneumoniae and Legionella pneumophila provide direction for the clinician. Although infected older adults pose specific and unique diagnostic challenges, a thorough history and physical examination combined with minimally invasive testing will lead to the correct diagnosis in most older adults with infectious diseases, limiting the need for empiric antibiotics in this age group.