Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department

Clinical performance of existing diagnostic criteria for pneumonia in older emergency patients: A prospective cohort study

BACKGROUND

Pneumonia accounts for over half a million older adult emergency department (ED) visits annually, but ED pneumonia diagnosis is inaccurate. Geriatric-specific pneumonia diagnostic criteria exist for other settings; no prospective data exist to determine if application in the older adult ED population is feasible. The objective was to prospectively evaluate the utility of four current diagnostic criteria (Loeb; Modified McGeer; Infectious Disease Society of America/American Thoracic Society; American College of Emergency Physicians) in older adult ED patients.

METHODS

This was a prospective, observational cohort study of older adult ED patients ≥65 years of age in two U.S. EDs with suspected pneumonia defined as having chest radiography ordered and treating physician suspicion. The standard we used for defining the presence, absence, or inability to determine a diagnosis of pneumonia diagnosis was expert physician chart adjudication. We report the summary statistics for demographic characteristics and symptoms/exam findings and sensitivity, specificity, and likelihood ratios with 95% confidence intervals of the existing diagnostic criteria. Pre-specified cutoff values of a positive LR >10 and a negative LR <0.3 were considered clinically significant.

RESULTS

Of 135 patients enrolled, 27 had pneumonia by adjudicator review. Typical patient-reported pneumonia symptoms, such as fever (18.5%) and new/worse cough (51.9%), were not consistently present in pneumonia. The IDSA/ATS and ACEP criteria had positive LR >10 and negative LR <0.3; however, all confidence intervals included pre-specified cutoffs.

CONCLUSIONS

Older adults presented to the ED with low frequency of typical pneumonia symptoms. Although existing diagnostic definitions had promising test characteristics, they may not perform well enough for clinical application without refinement.

Diagnosis of urinary tract infections in the hospitalized older adult population in Alberta

BACKGROUND

Urinary tract infections (UTIs) are one of the most common infections reported in older adults, across all settings. Although a diagnosis of a UTI requires specific clinical and microbiological criteria, many older adults are diagnosed with a UTI without meeting the diagnostic criteria, resulting in unnecessary antibiotic treatment and their potential side effects, and a failure to find the true cause of their presentation to hospital.

OBJECTIVE

The aim of this study was to evaluate the accuracy of UTI diagnoses amongst hospitalized older adults based on clinical and microbiological findings, and their corresponding antibiotic treatment (including complications), in addition to identifying possible factors associated with a confirmed UTI diagnosis.

METHODS

A single-center retrospective cross-sectional study of older adult patients (n = 238) hospitalized at the University of Alberta Hospital with an admission diagnosis of UTI over a one-year period was performed.

RESULTS

44.6% (n = 106) of patients had a diagnosis of UTI which was supported by documents clinical and microbiological findings while 43.3% (n = 103) of patients had bacteriuria without documented symptoms. 54.2% (n = 129) of all patients were treated with antibiotics, despite not having evidence to support a diagnosis of a UTI, with 15.9% (n = 37) of those patients experiencing complications including diarrhea, Clostridioides difficile infection, and thrush. History of major neurocognitive disorder was significantly associated with diagnosis of UTI (p = 0.003).

CONCLUSION

UTIs are commonly misdiagnosed in hospitalized older adults by healthcare providers, resulting in the majority of such patients receiving unnecessary antibiotics, increasing the risk of complications. These findings will allow for initiatives to educate clinicians on the importance of UTI diagnosis in an older adult population and appropriately prescribing antibiotics to prevent unwanted complications.

Vaccines for the Elderly and Vaccination Programs in Europe and the United States

The share of the elderly population is growing worldwide as life expectancy increases. Immunosenescence and comorbidities increase infectious diseases' morbidity and mortality in older adults. Here, we aimed to summarize the latest findings on vaccines for the elderly against herpes zoster, influenza, respiratory syncytial virus (RSV), COVID-19, and pneumococcal disease and to examine vaccine recommendation differences for this age group in Europe and the United States. PubMed was searched using the keywords "elders" and "vaccine" alongside the disease/pathogen in question and paraphrased or synonymous terms. Vaccine recommendations were also sought in the European and US Centers for Disease Control and Prevention databases. Improved vaccines, tailored for the elderly, mainly by using novel adjuvants or by increasing antigen concentration, are now available. Significant differences exist between immunization policies, especially between European countries, in terms of the recipient's age, number of doses, vaccination schedule, and implementation (mandatory or recommended). Understanding the factors that influence the immune response to vaccination in the elderly may help to design vaccines that offer long-term protection for this vulnerable age group. A consensus-based strategy in Europe could help to fill the gaps in immunization policy in the elderly, particularly regarding vaccination against RSV and pneumococcus.

Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments

INTRODUCTION

Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening.

METHODS

We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds.

RESULTS

Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%.

CONCLUSIONS

The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.

Association between early manifestations of infection or sepsis and prognosis in a high complexity hospital in the city of Medellín

OBJECTIVE

To identify the first symptoms and signs of patients with suspected infection or sepsis and their association with the composite outcome of admission to the Intensive Care Unit (ICU) or mortality.

DESIGN

Prospective cohort study between June 2019 and March 2020.

SETTING

Hospital Universitario San Vicente Fundación, Colombia.

PATIENTS

Over 18 years of age with suspicion or confirmation of sepsis, which required hospitalization.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Symptoms and signs associated with infection, with their time of evolution, specified in the study.

RESULTS

From 1005 eligible patients, 261 were included. After multivariable adjustment with a logistic regression model, the main factors for ICU admission or mortality were heart rate (OR 1.04 with 95% CI 1.04-3.7), respiratory rate (OR 1.19 with 95% CI 1.0-1.4) and capillary refill time (OR 3.4 with 95% CI 1.9-6.1).

CONCLUSIONS

Heart rate, respiratory rate, and capillary refill may behave as early predictors of ICU admission and mortality in cases of sepsis.

Emergency department patient and physician survey accuracy compared to chart abstraction in patients with acute respiratory illness

BACKGROUND

High-quality research studies in older adults are needed. Unfortunately, the accuracy of chart review data in older adult patients has been called into question by previous studies. Little is known on this topic in patients with suspected pneumonia, a disease with 500,000 annual older adult U.S. emergency department (ED) visits that presents a diagnostic challenge to ED physicians. The study objective was to compare direct interview and chart abstraction as data sources.

METHODS

We present a preplanned secondary analysis of a prospective, observational cohort of ED patients ≥65 years of age with suspected pneumonia in two Midwest EDs. We describe the agreement between chart review and a criterion standard of prospective direct patient survey (symptoms) or direct physician survey (examination findings). Data were collected by chart review and from the patient and treating physician by survey.

RESULTS

The larger study enrolled 135 older adults; 134 with complete symptom data and 129 with complete examination data were included in this analysis. Pneumonia symptoms (confusion, malaise, rapid breathing, any cough, new/worse cough, any sputum production, change to sputum) had agreement between patient/legally authorized representative survey and chart review ranging from 47.8% (malaise) to 80.6% (confusion). All examination findings (rales, rhonchi, wheeze) had percent agreement between physician survey and chart review of ≥80%. However, all kappas except wheezing were less than 0.60, indicating weak agreement.

CONCLUSIONS

Both patient symptoms and examination findings demonstrated discrepancies between chart review and direct survey with larger discrepancies in symptoms reported. Researchers should consider these potential discrepancies during study design and data interpretation.

The role of Dutch guidelines in the diagnostic outcomes and treatment decisions of hospitalised older adults with a suspected urinary tract infection: a retrospective cohort study

PURPOSE

Urinary tract infections (UTIs) are highly prevalent and difficult to diagnose in older adults. We aimed to evaluate the applicability of Dutch Association of Urology (NVU) and Dutch Association of Elderly Care Physicians (Verenso) guidelines in terms of diagnostic outcomes and treatment decisions in hospitalised older adults with suspected UTIs.

METHODS

A retrospective cohort study was conducted on 225 geriatric patients with a urine culture taken in 2019, to determine conformity of the studied population to NVU and Verenso.

RESULTS

Of 225 patients with suspected UTI (mean age 86 years; 56.4% female), 67.6% had urinary tract-related symptoms, of whom 96 received antibiotics, including those with a negative urine dipstick (n = 12) or urine culture (n = 28). Hundred seventy-seven and 147 patients were assessed and treated conforming to the NVU and Verenso guidelines, respectively. The 38 patients who were assessed and treated non-conforming to NVU, including patients with negative urine diagnostics, received antibiotics more often compared with 177 patients treated conforming to NVU (p < 0.001). A large number of patients with negative urine tests were treated conforming to Verenso and antibiotics were withheld in 75.5% of the patients. The non-conforming Verenso-treated patients with prescribed antibiotics had significantly more negative dipstick results (p = 0.05), fewer urinary tract-related symptoms (p < 0.001) and more often a different infectious focus (p < 0.001).

CONCLUSION

The common practice performed on the studied geriatric population was more in accordance with the NVU guideline than Verenso. The results indicated that compliance with the guidelines might lead to fewer antibiotic prescriptions in the study population.

Effect of inpatient antibiotic treatment among older adults with delirium found with a positive urinalysis: a health record review

BACKGROUND

Among older adults with delirium and positive urinalysis, antibiotic treatment for urinary tract infection is common practice, but unsupported by literature or guidelines. We sought to: i) determine the rate of antibiotic treatment and the proportion of asymptomatic patients (other than delirium) in this patient population, and ii) examine the effect of antibiotic treatment on delirium resolution and adverse outcomes.

METHODS

A health record review was conducted at a tertiary academic centre from January to December 2020. Inclusion criteria were age ≥ 65, positive delirium screening assessment, positive urinalysis, and admission to general medical units. Outcomes included rates of antibiotic treatment, delirium on day 7 of admission, and 30-day adverse outcomes. We compared delirium and adverse outcome rates in antibiotic-treated vs. non-treated groups. We conducted subgroup analyses among asymptomatic patients.

RESULTS

We included 150 patients (57% female, mean age 85.4 years). Antibiotics were given to 86%. The asymptomatic subgroup (delirium without urinary symptoms or fever) comprised 38% and antibiotic treatment rate in this subgroup was 68%. There was no significant difference in delirium rate on day 7 between antibiotic-treated vs. non-treated groups, (entire cohort RR 0.94 [0.41-2.16] and asymptomatic subgroup RR 0.69 [0.22-2.15]) or in 30-day adverse outcomes.

CONCLUSIONS

Older adults with delirium and positive urinalysis in general medical inpatient units were frequently treated with antibiotics - often despite the absence of urinary or other infectious symptoms. We failed to find evidence that antibiotic treatment in this population is associated with delirium resolution on day 7 of admission.

Comparing skin surface temperature to clinical documentation of skin warmth in emergency department patients diagnosed with cellulitis

Objective

To compare clinical documentation of skin warmth to patient report and quantitative skin surface temperatures of patients diagnosed with cellulitis in the emergency department (ED).

Methods

Adult patients (≥18 years) presenting to the ED with an acute complaint involving visible erythema of the lower extremity were prospectively enrolled. Those diagnosed with cellulitis were included in this analysis. Participant report of skin warmth was recorded and skin surface temperature values were obtained from the affected and corresponding unaffected area of skin using thermal cameras. Average temperature (Tavg) was extracted from each image and the difference in Tavg between the affected and unaffected limb was calculated (Tgradient). Clinical documentation of skin warmth was compared to patient report and measured skin warmth (Tgradient >0°C).

Results

Among 126 participants diagnosed with cellulitis, 110 (87%) exhibited objective warmth (Tgradient >0°C) and 58 (53%) of these cases had warmth documented in the physical examination. Of those with objective warmth, 86 (78%) self-reported warmth and 7 (6%) had warmth documented in their history of present illness (HPI) (difference = 72%, 95% confidence interval [CI]: 62%-82%; P < 0.001). A significant difference was observed for Tavg affected when warmth was documented (32.1°C) versus not documented (31.0°C) in the physical examination (difference = 1.1°C, 95% CI: 0.29-1.94; P = 0.0083). No association was found between Tgradient and patient-reported or HPI-documented warmth.

Conclusions

The majority of ED-diagnosed cellulitis exhibited objective warmth, yet significant discordance was observed between patient-reported, clinician-documented, and measured warmth. This raises concerns over inadequate documentation practices and/or the poor sensitivity of touch as a reliable means to assess skin surface temperature. Introduction of objective temperature measurement tools could reduce subjectivity in the assessment of warmth in patients with suspected cellulitis.

Urinary Tract Infection Investigation and Treatment in Older Adults Presenting to the Emergency Department with Confusion: a Health Record Review of Local Practice Patterns

BACKGROUND

The rate of urinary tract infection (UTI) investigation and treatment in confused older emergency department (ED) patients has not been described in the literature. We aim to describe the pattern of practice in an academic tertiary care ED for this common presentation.

METHODS

A health record review was conducted on 499 adults aged ≥65 presenting to academic EDs with confusion. Exclusion criteria: Glasgow Coma Scale < 13, current treatment for UTI, indwelling catheters, nephrostomy tubes, transfer from another hospital. Outcomes were the prevalence of UTI investigation, diagnosis and antibiotic treatment.

RESULTS

64.9% received urine tests, 11.4% were diagnosed with UTI, and 35.2% were prescribed antibiotics. In the subgroup with no urinary symptoms, fever, or other obvious indication for antibiotics, these numbers were 58.2%, 7.6%, and 18.1%, respectively. Patients who had urine tests or received antibiotics were older than those who did not (p values < .01). Patients receiving antibiotics had higher admission rates and 30-day and six-month mortality (OR of 2.9 [2.0-4.3], 4.0 [1.6-11], and 2.8 [1.4-5.8], respectively).

CONCLUSION

Older patients presenting to ED with confusion were frequently investigated and treated for UTI, even in the absence of urinary symptoms. Antibiotic treatment was associated with higher hospitalization and mortality.

Frailty and associated prognosis among older emergency department patients with suspected infection: A prospective, observational cohort study

BACKGROUND

Prognosis and disposition among older emergency department (ED) patients with suspected infection remains challenging. Frailty is increasingly recognized as a predictor of poor prognosis among critically ill patients; however, its association with clinical outcomes among older ED patients with suspected infection is unknown.

METHODS

We conducted a multicenter prospective cohort study at two tertiary care EDs. We included older ED patients (≥75 years) with suspected infection. Frailty at baseline (before index illness) was explicitly measured for all patients by the treating physicians using the Clinical Frailty Scale (CFS). We defined frailty as a CFS 5-8. The primary outcome was 30-day mortality. We used multivariable logistic regression to adjust for known confounders. We also compared the prognostic accuracy of frailty with the Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) criteria.

RESULTS

We enrolled 203 patients, of whom 117 (57.6%) were frail. Frail patients were more likely to develop septic shock (adjusted odds ratio [aOR], 1.83; 95% confidence interval [CI], 1.08-2.51) and more likely to die within 30 days of ED presentation (aOR 2.05; 95% CI, 1.02-5.24). Sensitivity for mortality was highest among the CFS (73.1%; 95% CI, 52.2-88.4), compared with SIRS ≥ 2 (65.4%; 95% CI, 44.3-82.8) or qSOFA ≥ 2 (38.4; 95% CI, 20.2-59.4).

CONCLUSIONS

Frailty is a highly prevalent prognostic factor that can be used to risk-stratify older ED patients with suspected infection. ED clinicians should consider screening for frailty to optimize disposition in this population.

Factors affecting the risk of SARS-CoV-2 transmission to anesthesiologists performing endotracheal intubation in patients with SARS-CoV-2

BACKGROUND

In this study, we estimated the predictive factors of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in anesthesiologists performing endotracheal intubation in patients with confirmed SARS-CoV-2.

METHOD

We analyzed data from a survey conducted by the Chinese Society of Anesthesiology Task Force on Airway Management on endotracheal intubation in 98 patients with SARS-CoV-2 confirmed through nucleic acid testing and chest computed tomography. The multivariate logistic model with stepwise selection was used for selecting the predictive factors significantly associated with SARS-CoV-2 infection in the corresponding anesthesiologists.

RESULTS

SARS-CoV-2 prevalence in the corresponding anesthesiologists was 20.41% after intubation in patients with SARS-CoV-2. Univariate analysis indicated that intubation for elective treatment, intubation in an operating room or isolation ward, and routine rapid induction with continuous positive-pressure ventilation (PPV) for intubation were associated with a lower SARS-CoV-2 risk in the anesthesiologists. Multivariate analysis revealed that intubation for elective treatment was associated with a significantly decreased SARS-CoV-2 risk (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI]: 0.14-0.68, P < 0.0001), and coughing by patients during endotracheal intubation was associated with a significantly increased SARS-CoV-2 risk (aOR = 1.70, 95% CI: 1.39-2.97, P = 0.0404) in the anesthesiologists.

CONCLUSION

Endotracheal intubation for elective treatments, intubation in an operating room or isolation ward, and routine rapid induction with continuous PPV for patients with confirmed SARS-CoV-2 are associated with a lower risk of SARS-CoV-2 transmission in practicing anesthesiologists, and coughing by patients during intubation increases the risk.

Bloodstream infections in the elderly: what is the real goal?

Bloodstream infections (BSI) represent a serious bacterial infection with substantial morbidity and mortality. Population-based studies demonstrate an increased incidence, especially among elderly patients. Controversy exists regarding whether presentation of BSI are different in older patients compared to younger patients; our narrative review of the literature suggests that BSI in elderly patients would probably include one or more of the traditional symptoms/signs of fever, severe sepsis or septic shock, acute kidney injury, and/or leukocytosis. Sources of BSI in older adults are most commonly the urinary tract (more so than in younger adults) and the respiratory tract. Gram-negative bacteria are the most common isolates in the old (~ 40-60% of BSI); isolates from the elderly patient population show higher antibiotic resistance rates, with long-term care facilities serving as reservoirs for multidrug-resistant bacteria. BSI entail significantly higher rates of mortality in older age, both short and long term. Some of the risk factors for mortality are modifiable, such as the appropriateness of empirical antibiotic therapy and nosocomial acquisition of infection. Health-related quality of life issues regarding the elderly patient with BSI are not well addressed in the literature. Utilization of comprehensive geriatric assessment and comprehensive geriatric discharge planning need to be investigated further in this setting and might serve as key for improved results in this population. In this review, we address all these aspects of BSI in old patients with emphasis on future goals for management and research.

Management of Very Old Patients in Intensive Care Units

The global population is aging and the demand for critical care wards increasing. Aging is associated not only with physiological and cognitive vulnerability, but also with a decline in organ function. A new topic in geriatric care is how to appropriately use critical care resources and provide the best treatment plan for very old patients (VOPs). Our special geriatric intensive care unit has admitted nearly 500 VOPs. In this review, we share our VOP treatment strategy and summarize the key points as “ABCCDEFGHI bundles.” The aim is to help intensivists to provide more comprehensive therapy for VOPs in intensive care units.

Determining procalcitonin at point-of-care; A method comparison study of four commercial PCT assays

Objective

Procalcitonin (PCT) testing adds value in the early detection of infection and sepsis, as well as in management of antibiotic therapy. We determined the analytical and diagnostic performance of four PCT assays at POC.

Methods

PCT assays on AQT90 FLEX, Getein 1100, mLabs, and Finecare POC analyzers, in whole blood and plasma, were analyzed for repeatability, linearity, accuracy and concordance, by comparing with our reference PCT assay on the Cobas E602 system.

Results

For all assays precision was found higher in plasma than in whole blood. AQT90 showed good performance in all analytical and diagnostic areas, irrespective of test matrix and PCT concentration. The other POC assays demonstrated at least one analytical weakness. The Getein assay showed adequate precision only in plasma at high PCT levels, the mLabs assay only in plasma at low PCT levels. Accuracy, as demonstrated by Bland-Altman and Passing-Bablok analysis, was found adequate only for the AQT90 FLEX and Getein 1100 assay. Diagnostic concordance at 0.5 ​ng/mL was found excellent for the AQT90 FLEX, Getein 1100, and Finecare assays, much lower for the mLabs assay. At 0.25 ​ng/mL, only the AQT90 FLEX and Finecare assays showed excellent concordance with the reference assay.

Conclusions

The AQT90 FLEX PCT assay demonstrated excellent analytical performance and diagnostic agreement with the Cobas E602 assay, allowing both stand-alone and side-by-side testing. The other assays demonstrated some analytical deficiencies, potentially limiting their diagnostic use. Any clinical use of PCT results should always be in combination with all other clinical signs and diagnostic information.

Infections in Older Adults

Infections in elderly patients can prove diagnostically challenging. Age-related factors affecting the immune system in older individuals contribute to nonspecific presentations. Other age-related factors and chronic conditions have symptoms that may or may not point to an infectious diagnosis. Delay in administration of antimicrobials can lead to poor outcomes; however, unnecessary administration of antimicrobials can lead to increased morbidity and contribute to the emergence of multidrug-resistant organisms. Careful clinical assessment and consideration of patient history and risk factors is crucial. When necessary, antimicrobials should be chosen that are appropriate for the diagnosis and deescalated as soon as possible.

Co-circulation and misdiagnosis led to underestimation of the 2015-2017 Zika epidemic in the Americas

During the 2015-2017 Zika epidemic, dengue and chikungunya-two other viral diseases with the same vector as Zika-were also in circulation. Clinical presentation of these diseases can vary from person to person in terms of symptoms and severity, making it difficult to differentially diagnose them. Under these circumstances, it is possible that numerous cases of Zika could have been misdiagnosed as dengue or chikungunya, or vice versa. Given the importance of surveillance data for informing epidemiological analyses, our aim was to quantify the potential extent of misdiagnosis during this epidemic. Using basic principles of probability and empirical estimates of diagnostic sensitivity and specificity, we generated revised estimates of reported cases of Zika that accounted for the accuracy of diagnoses made on the basis of clinical presentation with or without laboratory confirmation. Applying this method to weekly reported case data from 43 countries throughout Latin America and the Caribbean, we estimated that 944,700 (95% CrI: 884,900-996,400) Zika cases occurred when assuming all confirmed cases were diagnosed using molecular methods versus 608,400 (95% CrI: 442,000-821,800) Zika cases that occurred when assuming all confirmed cases were diagnosed using serological methods. Our results imply that misdiagnosis was more common in countries with proportionally higher reported cases of dengue and chikungunya, such as Brazil. Given that Zika, dengue, and chikungunya appear likely to co-circulate in the Americas and elsewhere for years to come, our methodology has the potential to enhance the interpretation of passive surveillance data for these diseases going forward. Likewise, our methodology could also be used to help resolve transmission dynamics of other co-circulating diseases with similarities in symptomatology and potential for misdiagnosis.

The impact of health care provider relationships and communication dynamics on urinary tract infection management and antibiotic utilization for long-term care facility residents treated in the emergency department: A qualitative study

BACKGROUND

For older adults, over diagnosis of urinary tract infections (UTI) is a primary driver of inappropriate antibiotic use. This risk is increased for patients in long-term care facilities (LTCF), especially as they transition back and forth to emergency departments (ED). In this study, we aimed to understand how health care provider communication and relationship dynamics affect LTCF residents treated in the ED to identify barriers to antibiotic stewardship for UTIs.

METHODS

We conducted semi-structured interviews with nurses and physicians from LTCFs and EDs, guided by the Systems Engineering Initiative for Patient Safety framework. Data were systematically coded and underwent iterative, conventional, content analysis.

RESULTS

We interviewed 16 LTCF and 16 ED providers across Wisconsin. ED and LTCF nurses have a critical role in both intrafacility and interfacility communication. Fragmented communication and interprofessional power dynamics were identified barriers to optimal antibiotic prescribing for UTIs. Identified strategies to overcome these issues included using objective diagnostic criteria, development of communication scripts, and nurse-to-nurse education.

CONCLUSIONS

Our qualitative approach revealed important insights about how communication and relationship dynamics influence UTI diagnosis and optimal antibiotic stewardship for LTCF residents evaluated in the ED. Future interventions should strengthen communications between settings and across provider types, and address standardization of diagnostic and treatment communication pathways for LTCF residents with suspected infections transitioning between EDs and LTCFs.

COVID-19 Triage and Test Center: Safety, Feasibility, and Outcomes of Low-Threshold Testing

This prospective observational study evaluated the safety and feasibility of a low threshold testing process in a Triage and Test Center (TTC) during the early course of the coronavirus disease 19 (COVID-19) pandemic. In addition, we aimed to identify clinical predictors for a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) swab result. Patients underwent informal triage, standardized history taking, and physician evaluation, only where indicated. Patients were observed for 30 days. Safety was the primary outcome and was defined as a COVID-19-related 30 day re-presentation rate <5% and mortality rate <1% in patients presenting to the TTC. Feasibility was defined as an overruling of informal triage <5%. Among 4815 presentations, 572 (11.9%) were tested positive for SARS-CoV-2, and 4774 were discharged. Mortality at 30-days was 0.04% (2 patients, one of which related to COVID-19). Fever (OR 2.03 [95% CI 1.70;2.42]), myalgia (OR 1.94 [1.63;2.31]), chills (OR 1.77 [1.44;2.16]), headache (OR 1.61 [1.34;1.94]), cough (OR 1.50 [1.24;1.83]), weakness (OR 1.46 [1.21;1.76]), and confusion (OR 1.39 [1.06;1.80]) were associated with test positivity. Re-presentation rate was 8% overall and 1.4% in COVID-19 related re-presentation (69 of 4774). The overruling rate of informal triage was 1.5%. According to our study, a low-threshold testing process in a TTC appeared to be safe (low re-presentation and low mortality) and is feasible (low overruling of informal triage). A COVID-19 diagnosis based on clinical parameters only does not appear possible.

Covid-19 Infection in Older Adults: A Geriatrician's Perspective

The pandemic of the Covid-19 virus has become the main issue all over the world. In its current form, the disease is more severe in geriatric cases and individuals with chronic disease, even causing death. In older adults and atypical presentations, testing strategies for Covid-19, potential drug interactions of experimental Covid-19 therapies, and ageism are important issues in the course of the disease. Therefore, health-care professionals should be aware of these, and screening policies for Covid-19 should also include atypical presentations with or without classical symptoms of the illness in older adults. Furthermore, evaluation of individuals > 65 years of age from a geriatrician's perspective is very important, because Covid-19 is severe and fatal in seniors.

Timeliness of antibiotics for patients with sepsis and septic shock

For many years, sepsis guidelines have focused on early administration of antibiotics. While this practice may benefit some patients, for others it might have detrimental consequences. The increasingly shortened timeframes in which administration of antibiotics is recommended, have forced physicians to sacrifice diagnostic accuracy for speed, encouraging the overuse of antibiotics. The evidence supporting this practice is based on retrospective data, with all the limitations attached, while the only randomized trial on this subject does not show a mortality benefit from early administration of antibiotics in a population of patients with sepsis as often seen in the emergency department (ED). Physicians are challenged to treat patients suspected of having sepsis within a short period of time, while the real challenge should be to identify patients who would not be harmed by withholding treatment with antibiotics until the diagnosis of infection with a bacterial origin is confirmed and the appropriateness of a course of antibiotics can be evaluated more adequately. Therefore, in the general population of patients with sepsis, taking the time to gather additional data to confirm the diagnosis should be encouraged without a specific timeframe, although physicians should be encouraged to perform an adequate work-up as soon as possible. Patients with suspected sepsis and signs of shock should immediately be treated with antibiotics, as there is no margin for error.

Old subjects with sepsis in the emergency department: trend analysis of case fatality rate

Background

The burden of sepsis represents a global health care problem. We aimed to assess the case fatality rate (CFR) and its predictors in subjects with sepsis admitted to a general Italian hospital from 2009 to 2016, stratified by risk score.

Methods

We performed a retrospective analysis of all sepsis-related hospitalizations after Emergency Department (ED) visit in a public Italian hospital in an 8-year period. A risk score to predict CFR was computed by logistic regression analysis of selected variables in a training set (2009–2012), and then confirmed in the whole study population. A trend analysis of CFR during the study period was performed dividing patient as high-risk (upper tertile of risk score) or low-risk.

Results

Two thousand four hundred ninety-two subjects were included. Over time the incidental admission rate (no. of sepsis-related admissions per 100 total admissions) increased from 4.1% (2009–2010) to 5.4% (2015–2016); P < 0.001, accompanied by a reduced CFR (from 38.0 to 18.4%; P < 0.001). A group of 10 variables (admission to intensive care unit, cardio-vascular dysfunction, HIV infection, diabetes, age ≥ 80 years, respiratory diseases, number of organ dysfunction, digestive diseases, dementia and cancer) were selected by the logistic model to predict CFR with good accuracy: AUC 0.873 [0.009]. Along the years CFR decreased from 31.8% (2009–2010) to 25.0% (2015–2016); P = 0.007. The relative proportion of subjects ≥80 years (overall, 52.9% of cases) and classified as high-risk did not change along the years. CFR decreased only in low-risk subjects (from 13.3 to 5.2%; P < 0.001), and particularly in those aged ≥80 (from 18.2 to 6.6%; P = 0.003), but not in high-risk individuals (from 69.9 to 64.2%; P = 0.713).

Conclusion

Between 2009 and 2016 the incidence of sepsis-related hospitalization increased in a general Italian hospital, with a downward trend in CFR, only limited to low-risk patients and particularly to subjects ≥80 years.

Diagnosis of urinary tract infection in older persons in the emergency department: To pee or not to pee, that is the question

Doreen is a 79-year-old woman referred by her general practitioner to the ED for intravenous antibiotics for a urinary tract infection (UTI). She lives in a residential aged care facility (RACF) and staff report malodourous and cloudy urine. She denies dysuria or frequency. On examination Doreen is frail with vital signs of: temperature 37.7°C, pulse 87 bpm, blood pressure 130/70; there is no suprapubic or flank tenderness. Do you perform a dipstick test on Doreen’s urine for a suspected UTI?

Evidence-Informed Practice: Diagnostic Questions in Urinary Tract Infections in the Elderly

Introduction

Routine interventions in the practice of medicine often lack definitive evidence or are based on evidence that is either not high quality or of only modest-to-marginal effect sizes. An abnormal urinalysis in an elderly patient presenting to the emergency department (ED) with non-specific symptoms represents one condition that requires an evidence-informed approach to diagnosis and management of either asymptomatic bacteriuria or urinary tract infection (UTI). The emergency provider often will not have access to urine cultures, and the risks associated with antibiotic use in the elderly are not without potentially significant side effects.

Methods

We performed a historical and clinical review of the growing body of literature suggesting measurable differences in the systemic immune response manifest among patients with asymptomatic pyuria and UTI, including increases in the pro-inflammatory cytokine interleukin-6 and the acute phase reactant procalcitonin.

Results

Serum procalcitonin, a peptide that undergoes proteolysis into calcitonin, has been demonstrated to quickly and reliably rise in patients with severe bacterial infections, and may serve as a potentially sensitive and specific marker for identification of bacterial illness.

Conclusion

In the absence of validated risk scores for diagnosing UTI in elderly patients presenting to the ED, there may be a role for the use of procalcitonin in this patient population.