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Caterino JM, Kline DM, Leininger R, Southerland LT, Carpenter CR, Baugh CW, Pallin DJ, Hunold KM, Stevenson KB. Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department. J Am Geriatr Soc 2018; 67:484-492. [PMID: 30467825 DOI: 10.1111/jgs.15679] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/05/2018] [Accepted: 10/06/2018] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED). DESIGN Preplanned, secondary analysis of a prospective observational study. SETTING Tertiary care, academic ED. PARTICIPANTS A total of 424 patients in the ED, 65 years or older, including all chief complaints. MEASUREMENTS We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection. RESULTS Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40-2.53) or malaise/lethargy (PLR range, 1.25-1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15-18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79-0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms. CONCLUSIONS The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484-492, 2019.
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Affiliation(s)
- Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - David M Kline
- Department of Biomedical Informatics Center for Biostatistics, The Ohio State University, Columbus, Ohio
| | | | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Christopher R Carpenter
- Division of Emergency Medicine and Emergency Care Research Core, Washington University in St Louis, St Louis, Missouri
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kurt B Stevenson
- Department of Epidemiology and Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Sendi P, Borens O, Wahl P, Clauss M, Uçkay I. Management of Asymptomatic Bacteriuria, Urinary Catheters and Symptomatic Urinary Tract Infections in Patients Undergoing Surgery for Joint Replacement: A Position Paper of the Expert Group 'Infection' of swissorthopaedics. J Bone Jt Infect 2017; 2:154-159. [PMID: 28894690 PMCID: PMC5592375 DOI: 10.7150/jbji.20425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/23/2017] [Indexed: 12/31/2022] Open
Abstract
In this position paper, we review definitions related to this subject and the corresponding literature. Our recommendations include the following statements. Asymptomatic bacteriuria, asymptomatic leukocyturia, urine discolouration, odd smell or positive nitrite sediments are not an indication for antimicrobial treatment. Antimicrobial treatment of asymptomatic bacteriuria does not prevent periprosthetic joint infection, but is associated with adverse events, costs and antibiotic resistance development. Urine analyses or urine cultures in asymptomatic patients undergoing orthopaedic implants should be avoided. Indwelling urinary catheters are the most frequent reason for healthcare-associated urinary tract infections and should be avoided or removed as soon as possible.
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Affiliation(s)
- Parham Sendi
- Department of Infectious Diseases, Bern University Hospital, University of Bern.,Institute for Infectious Diseases, University of Bern
| | - Olivier Borens
- Orthopedic Septic Surgical Unit, Department of Surgery and Anaesthesiology, Lausanne University Hospital, Lausanne
| | - Peter Wahl
- Division for Orthopaedic and Trauma Surgery, Cantonal Hospital Winterthur, Switzerland
| | - Martin Clauss
- Clinic for Orthopedics and Trauma Surgery and Interdisciplinary Septic Surgical Unit, Kantonsspital Baselland Liestal, Switzerland
| | - Ilker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva.,Orthopedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Switzerland
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Caterino JM, Leininger R, Kline DM, Southerland LT, Khaliqdina S, Baugh CW, Pallin DJ, Stevenson KB. Accuracy of Current Diagnostic Criteria for Acute Bacterial Infection in Older Adults in the Emergency Department. J Am Geriatr Soc 2017; 65:1802-1809. [PMID: 28440855 DOI: 10.1111/jgs.14912] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Jeffrey M Caterino
- Department of Emergency Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Robert Leininger
- Division of Infectious Diseases, Wexner Medical Center, The Ohio State University, Columbus, OH, The Ohio State University, Columbus, Ohio
| | - David M Kline
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio
| | - Lauren T Southerland
- Department of Emergency Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Salman Khaliqdina
- Department of Emergency Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kurt B Stevenson
- Division of Infectious Diseases, Wexner Medical Center, The Ohio State University, Columbus, OH, The Ohio State University, Columbus, Ohio.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
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Abstract
Asymptomatic bacteriuria is very common. In healthy women, asymptomatic bacteriuria increases with age, from <1% in newborns to 10% to 20% of women age 80 years, but is uncommon in men until after age 50 years. Individuals with underlying genitourinary abnormalities, including indwelling devices, may also have a high frequency of asymptomatic bacteriuria, irrespective of age or gender. The prevalence is very high in residents of long-term-care facilities, from 25% to 50% of women and 15% to 40% of men. Escherichia coli is the most frequent organism isolated, but a wide variety of other organisms may occur. Bacteriuria may be transient or persist for a prolonged period. Pregnant women with asymptomatic bacteriuria identified in early pregnancy and who are untreated have a risk of pyelonephritis later in pregnancy of 20% to 30%. Bacteremia is frequent in bacteriuric subjects following mucosal trauma with bleeding, with 5% to 10% of patients developing severe sepsis or septic shock. These two groups with clear evidence of negative outcomes should be screened for bacteriuria and appropriately treated. Asymptomatic bacteriuria in other populations is benign and screening and treatment are not indicated. Antimicrobial treatment has no benefits but is associated with negative outcomes including reinfection with antimicrobial resistant organisms and a short-term increased frequency of symptomatic infection post-treatment. The observation of increased symptomatic infection post-treatment, however, has led to active investigation of bacterial interference as a strategy to prevent symptomatic episodes in selected high risk patients.
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Abstract
An increasing number of emergency departments (EDs) are providing extended care and monitoring of patients in ED observation units (EDOUs). EDOUs can be useful for older adults as an alternative to hospitalization and as a means of risk stratification for older adults with unclear presentations. They can also provide a period of therapeutic intervention and reassessment for older patients in whom the appropriateness and safety of immediate outpatient care are unclear. This article discusses the general characteristics of EDOUs, reviews appropriate entry and exclusion criteria for older adults in EDOUs, and discusses regulatory implications of observation status for patients with Medicare.
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Affiliation(s)
- Mark G. Moseley
- Associate Professor, Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Miles P. Hawley
- Assistant Professor, Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Jeffrey M. Caterino
- Associate Professor, Department of Emergency Medicine, The Ohio State University, Columbus, OH
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Lam B, Fang Z, Sargent EH, Kelley SO. Polymerase chain reaction-free, sample-to-answer bacterial detection in 30 minutes with integrated cell lysis. Anal Chem 2011; 84:21-5. [PMID: 22142422 DOI: 10.1021/ac202599b] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
An important goal for improved diagnosis and management of infectious disease is the development of rapid and accurate technologies for the decentralized detection of bacterial pathogens. Most current clinical methods that identify bacterial strains require time-consuming culture of the sample or procedures involving the polymerase chain reaction. Neither of these approaches has enabled testing at the point-of-need because of the requirement for skilled technicians and laboratory facilities. Here, we demonstrate the performance of an effective, integrated platform for the rapid detection of bacteria that combines a universal bacterial lysis approach and a sensitive nanostructured electrochemical biosensor. The lysis is rapid, is effective at releasing intercellular RNA from bacterial samples, and can be performed in a simple, cost-effective device integrated with an analysis chip. The platform was directly challenged with these unpurified lysates in buffer and urine. We successfully detected the presence of bacteria with high sensitivity and specificity and achieved a sample-to-answer turnaround time of 30 min. We have met the clinically relevant detection limit of 1 cfu/μL, indicating that uncultured samples can be analyzed. This advance will greatly reduce time to successful detection from days to minutes.
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Affiliation(s)
- Brian Lam
- Department of Chemistry, Faculty of Arts and Sciences, University of Toronto, Toronto, Ontario, Canada
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Kang Y, Crogan NL. An evidence-based review of infectious diseases. Geriatr Nurs 2009; 30:272-86. [PMID: 19673155 DOI: 10.1016/j.gerinurse.2009.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Caterino JM. Evaluation and Management of Geriatric Infections in the Emergency Department. Emerg Med Clin North Am 2008; 26:319-43, viii. [DOI: 10.1016/j.emc.2008.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Sims JB, de Lemos JA, Maewal P, Warner JJ, Peterson GE, McGuire DK. Urinary tract infection in patients with acute coronary syndrome: a potential systemic inflammatory connection. Am Heart J 2005; 149:1062-5. [PMID: 15976789 DOI: 10.1016/j.ahj.2004.08.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Inflammation has been linked with atherosclerotic disease development and instability. Contributors to systemic inflammation, such as subclinical infection, may trigger acute coronary syndromes (ACSs). METHODS Using a case-control study design, we evaluated the prevalence of urinary tract infection (UTI) among 100 consecutive ACS patients, compared with a contemporary control group undergoing elective coronary artery bypass graft (CABG) surgery. Cases were excluded if ACS was not confirmed by chart review or if a urinalysis was not obtained <or=6 hours of arrival. Patients excluded from the control group were those with myocardial infarction (MI) within 21 days before CABG or without a pre-CABG urinalysis. RESULTS The case and control groups were well matched, with the only significant differences being less congestive heart failure (OR 7.3, 95% CI 3.3-15.9) and more prior MI (OR 0.5, 95% CI 0.3-0.9) in the CABG control group. UTI was present in 27 of the ACS cases and 11 of the controls. Among ACS case patients, those with UTI tended to be older and more often women, with more diabetes, hyperlipidemia, hypertension, and renal insufficiency, and more commonly had non-ST elevation MI. In unadjusted analysis, UTI was 3 times more common in the cases versus controls (OR 3.0, 95% CI 1.4-6.4); results were similar after multivariable adjustment (OR 3.0, 95% CI 1.3-6.8). CONCLUSIONS Subclinical UTI is common among patients with ACS. Underlying infection may precipitate ACS via activation of systemic inflammation. This hypothesis should be explored in other data sets, and similar relationships with other bacterial and viral infections should be examined.
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Affiliation(s)
- John B Sims
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, USA
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Lerman-Garber I, Calva-Mercado JJ, Martínez-Sibaja C, del Castillo CF, Sánchez-Javier RM, Lara E, Villalobos I, Gómez-Pérez FJ. Leukocyturia in women with diabetes and its clinical implications. Arch Med Res 2000; 31:210-5. [PMID: 10880730 DOI: 10.1016/s0188-4409(00)00072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Urinalysis is one of the most common studies performed on the diabetic patient at every visit. The presence of leukocyturia is relatively common but it is not clear what the attitude of the physician toward this particular finding should be. The main objective of the present study was to investigate the clinical significance of leukocyturia in diabetic women. METHODS Ninety-eight diabetic women (84.7% type 2) aged 57 +/- 13 years who were being seen at the diabetic out-patient clinic were randomly selected. All patients underwent a clinical and gynecologic examination and a urinalysis. A Papanicolaou smear and a urine culture were also obtained. RESULTS The overall prevalence of leukocyturia (>5 cells/high power field (hpf)) was 46.5%. Patients with urinary tract infections (UTI) were 7.5 times more likely to have leukocyturia, while a leukocyte count <5cells/hpf predicted the absence of UTI in 96% of the women. In the comparison of patients with and without leukocyturia, we found that proteinuria (p = 0.06) and bacteriuria (p <0.002) were more common in the women with leukocyturia. A significant association with leukorrhea was not demonstrated. The empirical use of antibiotics was 12 times more frequent in the patients with leukocyturia. CONCLUSIONS A urinary culture should be requested in all diabetic patients with leukocyturia. The possibility of a UTI is remote when leukocyturia is absent.
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Affiliation(s)
- I Lerman-Garber
- Departamento de Diabetes y Metabolismo de Lípidos, Instituto Nacional de la Nutrición Salvador Zubirán, México, D.F., Mexico.
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