Mobility and other predictors of hospitalization for urinary tract infection: a retrospective cohort study

Nurse Staffing and Veteran Outcomes in the Veterans Health Administration's Community Living Centers

BACKGROUND

The demand for nursing care is rising in the long-term care setting. Nurse staffing is a crucial measure linked to health care quality measure outcomes.

PURPOSE

To assess for associations between nursing hours per patient day (NHPPD) and outcome measures in the Veterans Health Administration Community Living Centers.

METHODS

A retrospective data review of NHPPD and quality measures for 134 community living centers was conducted. Linear regression was used to assess for linear associations between average total NHPPD and 6 quality measures.

RESULTS

A significant linear association was found between average total NHPPD and falls with major injury ( P = .02) and help with activities of daily living ( P = .01). No associations were found between nurse staffing and 4 other quality measures.

CONCLUSIONS

This study adds to the body of literature regarding the impact of nurse staffing on quality measures.

Perioperative Dexamethasone Associated With Decreased Length of Stay After Total Hip and Knee Arthroplasty

INTRODUCTION

Dexamethasone is increasingly used after total joint arthroplasty (TJA) to reduce postoperative nausea and vomiting (PONV) and pain. The primary aim of this study was to examine the relationship between perioperative intravenous (IV) dexamethasone and length of stay (LOS) in patients undergoing primary, elective TJA.

METHODS

All patients who underwent TJA from 2015 to 2020 and received perioperative IV dexamethasone were queried from the Premier Healthcare Database. The cohort of patients who received dexamethasone was randomly truncated by a power of 10 and matched in a 1:2 ratio based on age and sex to patients who did not receive dexamethasone. Patient characteristics, hospital factors, comorbidities, 90-day postoperative complications, LOS, and postoperative morphine milligram equivalents were recorded for each cohort. Univariate and multivariate analyses were conducted to assess differences.

RESULTS

Overall, 190,974 matched patients were included, 63,658 (33.3%) of whom received dexamethasone and 127,316 (66.7%) did not. The dexamethasone cohort was composed of fewer patients with uncomplicated diabetes (11.6% vs. 17.5%, P < 0.001). Patients who received dexamethasone had significantly decreased mean LOS compared with patients who did not receive dexamethasone (1.66 vs. 2.03 days, P < 0.001). After controlling for confounding variables, dexamethasone was associated with significantly lower risk of pulmonary embolism (adjusted odds ratio [aOR]: 0.74, 95% CI: 0.61 to 0.90, P = 0.003), deep vein thrombosis (aOR: 0.78, 95% CI: 0.68 to 0.89, P < 0.001), PONV (aOR: 0.75, 95% CI: 0.70 to 0.80, P < 0.001), acute kidney injury (aOR: 0.82, 95% CI: 0.75 to 0.89, P < 0.001), and urinary tract infection (aOR: 0.77, 95% CI: 0.70 to 0.80, P < 0.001). In aggregate, dexamethasone was associated with similar postoperative opioid utilization between cohorts ( P = 0.061).

CONCLUSION

Perioperative dexamethasone was associated with reduced LOS and decreased postoperative complications including PONV, pulmonary embolism, deep vein thrombosis, acute kidney injury, and urinary tract infection after TJA. Although perioperative dexamethasone was not associated with notable reductions in postoperative opioid utilization, this study supports the use of dexamethasone to decrease LOS through multifactorial mechanisms beyond decreased pain.

Perioperative Outcomes, Comorbidities, and Complications following Total Shoulder Arthroplasty in Wheelchair Users: A Retrospective Cohort Analysis of a Nationwide Database

Impaired shoulder function hinders the ability of wheelchair users to maintain independence. The current state of the literature delineates the risks and benefits of surgical techniques for the management of shoulder pathologies. To the best of our knowledge, there is no study that has investigated complications following total shoulder arthroplasty (TSA) in wheelchair users. Utilizing the PearlDiver Mariner national administrative database, 72,108 patients were identified who underwent TSA with a concurrent diagnosis of a rotator cuff tear. Two matched cohorts, one of wheelchair users and one of non-wheelchair users, were created. Due to limitations within PearlDiver, one-year outcomes, including comorbidity and complication rates and readmission statistics, were compared between the two cohorts. Each matched cohort of 869 patients underwent TSA with a concurrent diagnosis of a rotator cuff tear. The rate of readmission in wheelchair users was greater than in non-wheelchair users (24.05% vs. 9.55%, OR: 3.00, CI: 2.279, 3.946). Patients in the wheelchair cohort exhibited higher rates of complications and comorbidities (p < 0.001). Among the most likely to be readmitted after TSA were patients with osteoarthritis, pulmonary heart disease, rheumatoid arthritis, and hypertension (p < 0.05). Significant differences in surgical outcomes existed between wheelchair and non-wheelchair users in terms of preoperative comorbidities, postoperative complications, and readmission rates.

Using evolutionary principles to make clinical decisions: a case series of urinary tract infections

The principles of evolutionary medicine have significant potential to be useful in a wide variety of clinical situations. Despite this, few demonstrations of clinical applications exist. To address this paucity, a case series applying evolutionary medicine principles to urinary tract infections, a common medical condition is presented. This series demonstrates how applying evolutionary medicine principles can be used to augment clinical decision-making.

Determinants of urinary tract infection in hospitalized patients with acute ischemic stroke

BACKGROUND

Stroke is a major cause of morbidity and mortality worldwide. Urinary tract infection (UTI) is a common post-acute ischemic stroke (AIS) complication. We assessed the incidence, determinant factors, infection characteristics, post-stroke complications, and outcomes of hospitalized AIS patients with UTI.

METHODS

This retrospective cohort study included AIS patients admitted within 7 days of stroke onset. The patients were divided into the UTI group and the non-UTI (control) group. Clinical data were collected and compared between the groups.

RESULTS

There were 342 AIS patients (31 with UTIs and 311 controls). The multivariate analysis showed that an initial National Institutes of Health Stroke Scale (NIHSS) score of ≥ 15 (odds ratio [OR] 5.00, 95% confidence interval [CI] 1.33-18.72) and Foley catheter retention (OR 14.10, 95% CI 3.25-61.28) were risk factors for UTI, whereas smoking (OR 0.08, 95% CI 0.01-0.50), an initial systolic blood pressure (SBP) of > 120 mmHg (OR 0.06, 95% CI 0.01-0.31), and statin use (OR 0.02, 95% CI 0.0006-0.42) were protective factors. Twenty cases (64.5%) were community-acquired and 11 cases (35.3%) were hospital-acquired. Ten patients (32.3%) had catheter-associated UTIs. The most common pathogen was Escherichia coli (13 patients, 41.9%). Post-stroke complications were significantly more common in the UTI group, including pneumonia, respiratory failure, sepsis, brain edema, seizure, symptomatic hemorrhagic transformation, congestive heart failure, atrial fibrillation with a rapid ventricular response, acute kidney injury, and hyponatremia. The median length of stay (LOS) in the UTI group was 12 days versus 3 days in the control group (p < 0.001). The median 3-month modified Rankin Scale score was higher (5 in UTI and 2 in control; p < 0.001) and the median 3-month Barthel Index was lower (0 in UTI and 100 in control; p < 0.001) in the UTI group than in the control group.

CONCLUSIONS

The risk factors for post-AIS UTI included severe stroke (NIHSS score ≥ 15) and urethral catheter indwelling. An initial SBP of > 120 mmHg and statin use were protective factors. The UTI group had significantly worse post-stroke complications, a longer LOS, and worse 3-month outcomes. Smoking was protective, which requires further investigation.

Association between osteoarthritis and urinary tract infection in older adults: A nationwide population-based cohort study

Osteoarthritis (OA) may increase urinary tract infection (UTI) in older adults. However, this issue remains unclear. We identified 8599 older patients (≥65 years) with OA, and an equal number of older patients without OA, matched by age, sex, and index date from the Taiwan National Health Insurance Research Database between 2001 and 2005. Past histories, including UTI and underlying comorbidities, were included in the analyses. Comparisons for any UTI, ≥1 hospitalization for UTI, and ≥3 hospitalizations for UTI between the 2 cohorts by following up until 2015 were performed. In both cohorts, the percentages of age subgroups were 65-74 years (65.7%), 75-84 years (30.1%), and ≥85 years (4.2%). The male sex was 42.4%. Patients with OA had an increased risk of any UTI compared with those without OA after adjusting for all past histories (adjusted hazard ratio [AHR]: 1.72; 95% confidence interval [CI]: 1.64-1.80). Compared with patients without OA, patients with OA also had an increased risk of ≥1 hospitalization for UTI and ≥3 hospitalizations for UTI (AHR: 1.13; 95% CI: 1.06-1.19 and AHR: 1.25; 95% CI: 1.13-1.38, respectively). In addition to OA, age 75-84 years, female sex, history of UTI, benign prostatic hyperplasia, indwelling urinary catheter, cerebrovascular disease, dementia, and urolithiasis were independent predictors for any UTI. This study showed that OA was associated with UTI in older adults. We suggest appropriately managing OA and controlling underlying comorbidities to prevent subsequent UTI.

Noncancerous Genitourinary Conditions as a Public Health Priority: Conceptualizing the Hidden Burden

OBJECTIVE

To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood.

METHODS

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden.

RESULTS

The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects).

CONCLUSION

NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.

Risk factors for the development of acute pyelonephritis in women with a positive urine culture

INTRODUCTION

In treating lower urinary tract symptoms (LUTS), the risk of overtreatment with antibiotics must be reconciled with the risk of an untreated urinary tract infection (UTI) progressing to acute pyelonephritis (APN). Using Cerner HealthFacts, a longitudinal clinical informatics database, we aimed to determine risk factors associated with the development of APN from UTI in an effort to guide the initiation of empiric antibiotics.

METHODS

We queried the Cerner HealthFacts database for women over age 18 with a positive urine culture. Any patient with an International Classification of Disease (ICD) code indicating chronic pyelonephritis was excluded. Development of APN within 30 days of the positive culture, specified by ICD coding, was our primary outcome. Patient and facility factors were assessed as potential risk factors for the development of APN using multivariable regression.

RESULTS

Out of 58 344 women with a positive urine culture, 3.9% (2296) developed APN. Mean patient age was 54.4 ± 25.3 years. Overall, 12 variables were predictive for APN and 11 variables were protective against APN. Presence of obstructive and reflux uropathies (OR 4.58), presentation to an acute care facility (OR 3.19), urinary retention (OR 2.30), history of UTI (OR 2.19), and renal comorbidities (OR 2.07) conferred the highest odds of APN development. The most protective variable against APN development was cognitive impairment (OR 0.49).

CONCLUSIONS

Identified risk factors associated with APN development may aid decisions regarding empiric antibiotic initiation for patients presenting with LUTS while awaiting urine culture results. The relationship between cognitive impairment and progression to APN deserves further study.

Long-term Risk of Parkinson Disease Following Influenza and Other Infections

Importance

Influenza has been associated with the risk of developing Parkinson disease, but the association is controversial.

Objective

To examine whether prior influenza and other infections are associated with Parkinson disease more than 10 years after infection.

Design, Setting, and Participants

This case-control study used data from 1977 to 2016 from the Danish National Patient Registry. All individuals with Parkinson disease, excluding those with drug-induced parkinsonism, were included and matched to 5 population controls on sex, age, and date of Parkinson diagnosis. Data were analyzed from December 2019 to September 2021.

Exposures

Infections were ascertained between 1977 and 2016 and categorized by time from infection to Parkinson disease diagnosis. To increase specificity of influenza diagnoses, influenza exposure was restricted to months of peak influenza activity.

Main Outcomes and Measures

Parkinson disease diagnoses were identified between January 1, 2000, and December 31, 2016. Crude and adjusted odds ratios (ORs) and 95% CIs were calculated by conditional logistic regression overall and stratified by time between infection and Parkinson disease (5 years or less, more than 5 to 10 years, more than 10 years).

Results

Of 61 626 included individuals, 23 826 (38.7%) were female, and 53 202 (86.3%) were older than 60 years. A total of 10 271 individuals with Parkinson disease and 51 355 controls were identified. Influenza diagnosed at any time during a calendar year was associated with Parkinson disease more than 10 years later (OR, 1.73; 95% CI, 1.11-2.71). When influenza exposure was restricted to months of highest influenza activity, an elevated OR with a wider confidence interval was found (OR, 1.52; 95% CI, 0.80-2.89). There was no evidence of an association with any type of infection more than 10 years prior to Parkinson disease (OR, 1.04; 95% CI, 0.98-1.10). Several specific infections yielded increased odds of Parkinson disease within 5 years of infection, but results were null when exposure occurred more than 10 years prior.

Conclusions and Relevance

In this case-control study, influenza was associated with diagnoses of Parkinson disease more than 10 years after infection. These observational data suggest a link between influenza and Parkinson disease but do not demonstrate causality. While other infections were associated with Parkinson disease diagnoses soon after infection, null associations after more than 10 years suggest these shorter-term associations are not causal.

Outcomes of COVID-19 infection in multiple sclerosis and related conditions: One-year pandemic experience of the multicenter New York COVID-19 Neuroimmunology Consortium (NYCNIC)

OBJECTIVE

To determine outcomes of COVID-19 in patients with Multiple Sclerosis (MS) and related conditions, and to determine predictors of these outcomes.

METHODS

This was a multicenter, observational cohort study of patients with MS or related CNS autoimmune disorders who developed confirmed or highly suspected COVID-19 infection from 2/1/2020 to 12/31/2020.

MAIN OUTCOME AND MEASURE

The primary outcome measure was hospitalization status due to COVID-19. Severity of infection was measured using a 4-point ordinal scale: 1. home care; 2. hospitalization without mechanical ventilation; 3. hospitalization and mechanical ventilation, and 4. death.

RESULTS

Of 474 patients in the study, 63.3% had confirmed COVID-19 infection and 93.9% were diagnosed with an MS phenotype. Mean age was 45 ± 13 (mean±SD) years, 72% were female, and 86% were treated with a DMT at the time of infection. 58 patients (12.2%) were hospitalized. 24 patients (5.1%) were critically ill (requiring ICU care or outcome of death), of which 15 patients (3.2%) died. Higher neurological disability and older age independently predicted hospitalization. 85% (102/120) of patients with known antibody results not treated with anti-CD20 therapies were seropositive while only 39.5% (17/43) of patients treated with anti-CD20 demonstrated seropositivity (p < 0.0001). Only 25% (2/8) of patients with PCR-confirmed COVID-19 being treated with anti-CD20 therapies demonstrated seropositivity.

CONCLUSIONS

Neurological disability and older age independently predicted hospitalization due to COVID-19. Additionally, the results demonstrate that anti-CD20 therapies significantly blunt humoral responses post-infection, a finding that carries implications with regards to natural or vaccine-mediated immunity.

Complications after intramedullary nail fixation of pathological versus non-pathological femoral shaft fractures: a retrospective cohort study in 233 patients

BACKGROUND

Postoperative adverse events after intramedullary nailing have been reported in patients with metastatic pathological and non-pathological femoral fractures. Other consequences to be considered are readmission and reoperation. Few studies have compared the risks of postoperative adverse events, reoperation, and readmission after intramedullary nailing of pathological and non-pathological femur fractures. This study was designed to test the hypothesis that patients with pathological femoral fractures had more adverse events, readmission, and reoperation following surgical fixation than non-pathological femoral fractures.

METHODS

This was a retrospective observational cohort study, conducted at an academic medical center in Thailand. The data from patients with femoral shaft fractures undergoing long intramedullary nailing, from June 1, 2006, to June 30, 2020, were included. Patients who had a pathological fracture from a primary bone tumor, metabolic bone disease, or inadequate/missing information were excluded. Patients with pathological fractures from metastatic bone disease were assigned to be the pathological group whereas those with traumatic fractures were assigned to be the non-pathological group. The primary outcome was the risk of inpatient adverse events as compared between the two groups. The secondary outcome was the risk of consequences after discharge as compared between the two groups. Outcomes were analyzed by using multivariate logistic regression analysis.

RESULTS

The total number of patients was 48 in the pathological fracture group and 185 in the non-pathological group. There were significantly higher rates of surgical and medical adverse events in patients with pathological fractures compared to patients with non-pathological fractures. After adjusting for potential confounding factors in multivariate regression analysis, patients with pathological fractures had higher odds of both adverse surgical (adjusted OR 2.43, 95 % CI 1.15-5.13) and medical adverse events (adjusted OR 2.81, 95 % CI 1.13-7.03).

CONCLUSIONS

Patients with metastatic pathological femoral shaft fractures undergoing intramedullary nailing were more likely to experience postoperative adverse events than patients with non-pathological fractures.

A prospective comparative study of the MNA-SF and GNRI nutritional screening tools in predicting infectious complications among elderly patients over 70 years undergoing posterior lumbar arthrodesis

Malnutrition is a risk factor for postoperative infectious complications of elderly patients undergoing posterior lumbar arthrodesis. At present, there is no gold standard for nutrition screening tools. We analyzed the value of predicting infectious complications among elderly patients over 70 years undergoing posterior lumbar arthrodesis by comparing the MNA-SF and GNRI. Demographic data, anthropometric measurements, serum albumin, surgical data and the occurrence of infectious complications and LOS were collected. Mini Nutritional Assessment short form (MNA-SF), Geriatric Nutritional Risk Index (GNRI) were performed within 24 h before surgery. Multivariable logistic regression analyses were used to identify predictors of infectious complications. The discriminatory performances of GNRI and MNA-SF scores for the occurrence of infectious complications were determined by receiver operating characteristic curves (ROC) analyses and the area under the curve (AUC). The study included 252 patients with a median age of 76.82 ± 6.41 years (range 70-84 years), and 142 patients (56.3%) were female. There were no significant differences in infectious complications (p = 0.236) and LOS (p = 0.580) among different GNRI categories. 27.3% malnourished patients evaluated by the MNA-SF suffered from infectious complications and 10.1% patients at risk of malnourished had infectious complications. Those patients had statistically significant higher prevalence of infectious complications (p = 0.002) and longer LOS (p = 0.023) than well-nourished patients. Multivariable analysis revealed that preoperative malnutrition and at risk of malnourished by the MNA-SF was significantly associated with infections. The area under the curve (AUC) of MNA-SF was 0.754, which was significantly high than AUC of GNRI (0.623) (Delong's test, p = 0.033). This study demonstrated that MNA-SF is a simple and effective tool for predicting the risk of infectious complications in elderly patients undergoing posterior lumbar arthrodesis.

Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA's Infection Advisory Subcommittee

The diagnosis and management of urinary tract infections (UTIs) among residents of post-acute and long-term care (PALTC) settings remains challenging. Nonspecific symptoms, complex medical conditions, insufficient awareness of diagnostic criteria, and unnecessary urine studies all contribute to the inappropriate diagnosis and treatment of UTIs in PALTC residents. In 2017, the Infection Advisory Subcommittee at AMDA-The Society for Post-Acute and Long-Term Care Medicine convened a workgroup comprised of experts in geriatrics and infectious diseases to review recent literature regarding UTIs in the PALTC population. The workgroup used evidence as well as their collective clinical expertise to develop this consensus statement with the goal of providing comprehensive guidance on the diagnosis, treatment, and prevention of UTIs in PALTC residents. The recommendations acknowledge limitations inherent to providing medical care for frail older adults, practicing within a resource limited setting, and prevention strategies tailored to PALTC populations. In addition, the consensus statement encourages integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and by prescribing clinicians as they care for residents with a suspected UTI.

Clostridioides difficile infection in patients with hematological malignancy: A multicenter study in Taiwan

BACKGROUND

Among the individuals with hematological malignancy (HM) complicated with Clostridioides difficile infection (CDI), the variables associated with in-hospital mortality and recurrence of CDI were investigated.

MATERIAL AND METHODS

Including adults with HM and those without malignancy suffering from CDI from January 2015 to December 2016 in three hospitals in Taiwan.

RESULTS

Totally 314 patients including 77 with HM and 237 patients without malignancy were included. HM patients more often had low leukocyte counts (<500 cells/mL: 28.6% vs. 2.1%) than those without malignancy and more patients without malignancy had severe CDI than patients with HM (31.6% vs. 14.3%, P = .003), according to the severity score of IDSA/SHEA. Patients with HM had a higher recurrence rate of CDI (14.3%, 11/77 vs. 7.2%, 17/237; P = .07) and longer hospital stay (47.2 ± 40.8 days vs. 33.3 ± 37.3 days; P = .006) than those without malignancy. In the multivariate analyses for those with HM and CDI, the in-hospital mortality was associated with vancomycin-resistant Enterococcus (VRE) colonization or infection (odds ratio [OR] 7.72; P = .01), and C. difficile ribotype 078 complex infection (OR 9.22; P = .03). Moreover underlying hematological malignancy (OR 2.74; P = .04) and VRE colonization/infection (OR 2.71; P = .02) were independently associated with CDI recurrence.

CONCLUSION

Patients with HM complicated with CDI were often regarded as non-severe infection, but had a similar in-hospital mortality rate as those without malignancy. CDI due to ribotype 078 complex isolates heralded a poor prognosis among HM patients.

Hospitalized Infections in People With Osteoarthritis: A National US Study

OBJECTIVE

To study the incidence, time trends, and outcomes of serious infections in people with osteoarthritis (OA).

METHODS

We used 1998-2016 US National Inpatient Sample (NIS) data. Using recommended weights, we examined the epidemiology of 5 types of serious infections requiring hospitalization in people with OA (opportunistic infections [OIs], skin and soft tissue infections [SSTIs], urinary tract infections [UTIs], pneumonia, and sepsis/bacteremia). We performed multivariable-adjusted logistic regression analyses to analyze factors associated with healthcare utilization (hospital charges, length of hospital stay, discharge to nonhome setting), and in-hospital mortality.

RESULTS

Of all serious infection hospitalizations, 46,708,154 were without OA and 3,258,416 had OA. People with OA were 16.4 years older, more likely to be female (52% vs 65%), White (59% vs 70%), have a Deyo-Charlson Comorbidity Index (DCCI) ≥ 2 (42% vs 51%), receive Medicare (54% vs 80%), and less likely to receive care at an urban teaching hospital (45% vs 39%). Serious infection rates per 100,000 NIS hospitalizations increased from the study period of 1998-2000 to 2015-2016: OI (from 4.5 to 7.2); SSTI (from 48.4 to 145.9); UTI (from 8.4 to 104.6); pneumonia (from 164.0 to 224.3); and sepsis (from 39.4 to 436.3). In multivariable-adjusted analyses, older age, higher DCCI, sepsis, northeast region, urban hospital, and medium or large hospital bed size were significantly associated with higher healthcare utilization outcomes and in-hospital mortality; Medicaid insurance, non-White race, and female sex were significantly associated with higher healthcare utilization.

CONCLUSION

Serious infection rates have increased in people with OA. Association of demographic, clinic, and hospital variables with serious infection outcomes identifies potential targets for future interventions.

Risk factors for infection in home health care: Analysis of national Outcome and Assessment Information Set data

Patients in home health care (HHC), a rapidly growing healthcare sector, are at high risk for infections. This study aimed to identify risk factors for infections among HHC patients using the Outcome and Assessment Information Set (OASIS) data. We used a 5% random sample of the 2013 national OASIS data. Infections were identified if records indicated that patients were hospitalized or received emergency care for one of three types of infections (respiratory, wound site, and urinary tract infection). Multivariate logistic regression models were used to identify risk factors for each individual infection type. The final analysis included 128,163 patients from 8,255 HHC agencies nationwide. Approximately 3.2% of the patients developed infections during their HHC stay that led to hospitalization or emergency care treatment. We found that associations between demographics and infection risk are specific to the type of infection. In general, a history of multiple hospitalizations in past 6 months, comorbidity, having a severe condition at HHC admission, and impaired physical functioning increased HHC patients' risk of infections. We also identified that HHC patients with caregivers who needed training in providing medical procedure or treatment are at higher risk for wound-site infections. Our findings suggest that patients with underlying medical conditions and limited physical function status are more likely to develop infection. The caregiver's lack of training in providing needed care at home also places HHC patients at high risk for infection. Education for patients and caregivers should be tailored based on their health literacy level to ensure complete understanding.

Validation of predictive factors for infection in adults with chronic leg ulcers: A prospective longitudinal study

AIMS AND OBJECTIVES

To validate the ability of factors to predict infection in adults with chronic leg ulcers over a 12-week period.

BACKGROUND

Leg ulcers affect ~3% of older adults and are often hard to heal. Infection is a leading contributor for delayed healing, causing delayed wound healing, increased hospitalisation, increased healthcare costs and reduced patient quality of life. The importance of early identification of infection has been highlighted for decades, yet little is known about factors that are associated with increased risk of infection in this specific population.

DESIGN

A longitudinal, prospective observational study in a single centre.

METHODS

Between August 2017 and May 2018, a total of 65 adults with chronic leg ulcers were prospectively observed for a 12-week period. Patients were recruited from an outpatient wound clinic at a tertiary hospital in Australia. Data were collected from recruitment (baseline) and each visit (weekly or fortnightly) up until 12 weeks. Descriptive statistics were calculated for all variables. A Cox proportional hazards regression model was used to identify predictive factors for infection. The TRIPOD guidelines for reporting were followed (See Data S1).

RESULTS

The sample consisted of 65 adults with chronic leg ulcers, and 9.2% of these had their ulcer infected at baseline. Two predictive factors, using walking aids and gout, were found to be significantly related to increased likelihood of developing infection within 12 weeks.

CONCLUSION

The present study showed that patients who either used walking aids or were diagnosed with gout were at greater risk of infection compared to those without these factors.

RELEVANCE TO CLINICAL PRACTICE

These findings provide new information for clinicians in early identification of patients at risk of infection, and for patients in enhancing their awareness of their own risk.

Preoperative Narcotic Use, Impaired Ambulation Status, and Increased Intraoperative Blood Loss Are Independent Risk Factors for Complications Following Posterior Cervical Laminectomy and Fusion Surgery

OBJECTIVE

This retrospective cohort study seeks to identify risk factors associated with complications following posterior cervical laminectomy and fusion (PCLF) surgery.

METHODS

Adults undergoing PCLF from 2012 through 2018 at a single center were identified. Demographic and radiographic data, surgical characteristics, and complication rates were compared. Multivariate logistic regression models identified independent predictors of complications following surgery.

RESULTS

A total of 196 patients met the inclusion criteria and were included in the study. The medical, surgical, and overall complication rates were 10.2%, 23.0%, and 29.1% respectively. Risk factors associated with medical complications in multivariate analysis included impaired ambulation status (odds ratio [OR], 2.27; p=0.02) and estimated blood loss over 500 mL (OR, 3.67; p=0.02). Multivariate analysis revealed preoperative narcotic use (OR, 2.43; p=0.02) and operative time (OR, 1.005; p=0.03) as risk factors for surgical complication, whereas antidepressant use was a protective factor (OR, 0.21; p=0.01). Overall complication was associated with preoperative narcotic use (OR, 1.97; p=0.04) and higher intraoperative blood loss (OR, 1.0007; p=0.03).

CONCLUSION

Preoperative narcotic use and estimated blood loss predicted the incidence of complications following PCLF for CSM. Ambulation status was a significant predictor of the development of a medical complication specifically. These results may help surgeons in counseling patients who may be at increased risk of complication following surgery.

Incidence and risk factors of non-device-associated urinary tract infections in an acute-care hospital

OBJECTIVE

To update current estimates of non-device-associated urinary tract infection (ND-UTI) rates and their frequency relative to catheter-associated UTIs (CA-UTIs) and to identify risk factors for ND-UTIs.

DESIGN

Cohort study.

SETTING

Academic teaching hospital.

PATIENTS

All adult hospitalizations between 2013 and 2017 were included. UTIs (device and non-device associated) were captured through comprehensive, hospital-wide active surveillance using Centers for Disease Control and Prevention case definitions and methodology.

RESULTS

From 2013 to 2017 there were 163,386 hospitalizations (97,485 unique patients) and 1,273 UTIs (715 ND-UTIs and 558 CA-UTIs). The rate of ND-UTIs remained stable, decreasing slightly from 6.14 to 5.57 ND-UTIs per 10,000 hospitalization days during the study period (P = .15). However, the proportion of UTIs that were non-device related increased from 52% to 72% (P < .0001). Female sex (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.50-2.50) and increasing age were associated with increased ND-UTI risk. Additionally, the following conditions were associated with increased risk: peptic ulcer disease (HR, 2.25; 95% CI, 1.04-4.86), immunosuppression (HR, 1.48; 95% CI, 1.15-1.91), trauma admissions (HR, 1.36; 95% CI, 1.02-1.81), total parenteral nutrition (HR, 1.99; 95% CI, 1.35-2.94) and opioid use (HR, 1.62; 95% CI, 1.10-2.32). Urinary retention (HR, 1.41; 95% CI, 0.96-2.07), suprapubic catheterization (HR, 2.28; 95% CI, 0.88-5.91), and nephrostomy tubes (HR, 2.02; 95% CI, 0.83-4.93) may also increase risk, but estimates were imprecise.

CONCLUSION

Greater than 70% of UTIs are now non-device associated. Current targeted surveillance practices should be reconsidered in light of this changing landscape. We identified several modifiable risk factors for ND-UTIs, and future research should explore the impact of prevention strategies that target these factors.

Urinary tract infection-related hospitalization among older adults receiving home health care

BACKGROUND

Urinary tract infection (UTI)- related hospitalizations are a poor patient outcome in the rapidly growing home health care (HHC) arena that serves a predominantly elderly population. We examined the association between activities of daily living (ADL) and risk of UTI-related hospitalization among this population.

METHODS

Using a retrospective cohort design, we conducted a secondary data analysis of a 5% random sample of a national HHC dataset, the Outcome and Assessment Information Set for the year 2013. Andersen's Behavioral Model of Health Service Utilization was used as a guiding framework for statistical modeling. We used logistic regression to examine the association between UTI-related hospitalization and predisposing, enabling, or need factors.

RESULTS

Among beneficiaries (n = 24,887) hospitalized in 2013, 1,133 had UTI-related hospitalizations. HHC patients with a UTI-related hospitalization were more likely to have severe ADL dependency, impaired decision making, and lower Charlson Comorbidity Index, than those with a non UTI-related hospitalization (P < .001). Risk factors for UTI-related hospitalization included female sex, (adjusted odds ratio [AOR], 1.44; 95% confidence interval [CI], 1.25-1.66), Medicaid recipient (AOR, 1.99; 95% CI, 1.09-3.64), severe ADL dependency (AOR, 1.50; 95% CI, 1.16-1.94), the presence of a caregiver to assist with supervision and safety (AOR, 1.26; 95% CI, 1.06-1.49), treatment for UTI in the previous 14 days (AOR, 2.85; 95% CI, 2.46-3.29), presence of a urinary catheter (AOR, 3.77; 95% CI, 2.98-4.77), and prior history of indwelling or suprapubic catheter (AOR, 1.44; 95% CI, 1.06-1.94).

CONCLUSIONS

ADL dependency levels are a potentially modifiable risk factor for UTI-related hospitalization on admission to HHC. ADL dependency levels can inform clinical interventions to ameliorate ADL dependency in HHC settings and identify groups of patients at high risk for UTI-related hospitalization.

Risk factors for infection in patients with chronic leg ulcers: A survival analysis

AIM

This study aimed to validate the relationships between possible predictive factors and clinically diagnosed infection in adult patients with chronic leg ulcers.

METHODS

This study used a sample of 636 adult participants whose ulcers were diagnosed as either venous, arterial or mixed aetiology leg ulcers and had no clinical signs of infection at recruitment. Data were extracted from recruitment to 12 weeks from six longitudinal prospective studies from 2004 to 2015. Survival analysis was used to investigate mean time-to-infection, including the Kaplan-Meier method and the Cox proportional-hazards regression model.

RESULTS

The sample included 74.7% venous, 19.6% mixed and 5.7% arterial leg ulcers. There were 101 (15.9%) participants diagnosed with infection at least once within 12 weeks of follow-up. Mean time-to-infection was 10.89 weeks (95% CI = 10.66-11.12). After adjustment for potential confounders, a Cox proportional hazards regression model found that depression, using walking aids, calf ankle ratio <1.3, wound area ≥10 cm² and ulcers with slough tissue at recruitment were significant risk factors for wound infection.

CONCLUSION

This study has validated the predictive ability of factors which have been found in a cross-sectional study to be significantly associated with infection in patients with leg ulcers, including venous leg ulcers, arterial leg ulcers and mixed aetiology leg ulcers. Results showed that patients with chronic leg ulcers, who either presented with depression, used walking aids, had a calf ankle ratio <1.3, a wound area ≥10 cm² or an ulcer with slough tissue, had greater likelihood of developing infection compared to those without these factors.

Nurses' knowledge and attitudes regarding major immobility complications among bedridden patients: A prospective multicentre study

AIMS AND OBJECTIVES

To gain insight into nurses' knowledge and attitudes regarding major immobility complications (pressure ulcers, pneumonia, deep vein thrombosis and urinary tract infections) and explore the correlation of nurses' knowledge and attitudes with the incidence of these complications.

BACKGROUND

Immobility complications have adverse consequences, and effective management requires appropriate knowledge, attitudes and skills. Evidence about nurses' knowledge and attitudes regarding immobility complications is lacking.

DESIGN

Cross-sectional study.

METHODS

A total of 3,903 nurses and 21,333 bedridden patients from 25 hospitals in China were surveyed. Nurses' knowledge and attitudes regarding major immobility complications were assessed using researcher-developed questionnaires. The content validity, reliability and internal consistency of the questionnaires were validated through expert review and a pilot study. The incidence of major immobility complications among bedridden patients from selected wards was surveyed by trained investigators. Correlations between knowledge, attitudes and the incidence of major immobility complications were evaluated with multilevel regression models.

RESULTS

Mean knowledge scores were 64.07% for pressure ulcers, 72.92% for deep vein thrombosis, 76.54% for pneumonia and 83.30% for urinary tract infections. Mean attitude scores for these complications were 86.25%, 84.31%, 85.00% and 84.53%, respectively. Knowledge and attitude scores were significantly higher among nurses with older age, longer employment duration, higher education level, previous training experience and those working in tertiary hospitals or critical care units. Nurses' knowledge about pressure ulcers was negatively related to the incidence of pressure ulcers, and attitude towards pneumonia was negatively correlated with the incidence of pneumonia.

CONCLUSION

Clinical nurses have relatively positive attitudes but inadequate knowledge regarding major immobility complications. Improved knowledge and attitudes regarding major immobility complications may contribute to reducing these complications.

RELEVANCE TO CLINICAL PRACTICE

Nursing managers should implement measures to improve nurses' knowledge and attitudes regarding major immobility complications to reduce the incidence of these complications in bedridden patients.

Infections Up to 76 Days After Stroke Increase Disability and Death

Early infection after stroke is associated with a poor outcome. We aimed to determine whether delayed infections (up to 76 days post-stroke) are associated with poor outcome at 90 days. Data came from the international Efficacy of Nitric Oxide Stroke (ENOS, ISRCTN99414122) trial. Post hoc data on infections were obtained from serious adverse events reports between 1 and 76 days following stroke in this large cohort of patients. Regression models accounting for baseline covariates were used to analyse fatalities and functional outcomes (modified Rankin Scale (mRS), Barthel Index, Euro-Qol-5D) at 90 days, in patients with infection compared to those without infection. Of 4011 patients, 242 (6.0%) developed one or more serious infections. Infections were associated with an increased risk of death (p < 0.001) and an increased likelihood of dependency (measured by mRS) compared to those of all other patients (p < 0.001). This remained when only surviving patients were analysed, indicating that the worsening of functional outcome is not due to mortality (p < 0.001). In addition, the timing of the infection after stroke did not alter its detrimental association with fatality (p = 0.14) or functional outcome (p = 0.47). In conclusion, severe post-stroke infections, whether occurring early or late after stroke, are associated with an increased risk of death and poorer functional outcome, independent of differences in baseline characteristics or treatment. Not only are strategies needed for reducing the risk of infection immediately after stroke, but also during the first 3 months following a stroke. This study is registered: ISRCTN registry, number ISRCTN99414122, ClinicalTrials.gov Identifier, NCT00989716.

[Urinary tract infections in the elderly]

Acute infection of the urinary tract is one of the most commonly encountered bacterial infections in the frail elderly population and is responsible for substantial morbidity and recurrent infections with antibiotic resistance. Although generally considered to be self-limiting without treatment or easily treated with a short antibiotic regime, urinary tract infections (UTIs) often have a dramatic history, associated with incomplete resolution and frequent recurrence. The biological complexity of the infections combined with a dramatic rise in antibiotic-resistant pathogens highlight the need for an anticipating strategy for therapy necessary for a rapid recovery. The first crucial step is the classification in asymptomatic bacteriuria or complicated pyelonephritis, on which the decision for the intensity of treatment and diagnostic effort is based. For the selection of empiric antibiotic therapy, knowledge about the predominant uropathogens as well as local resistance patterns is important. In this manner, most urinary tract infections in the elderly can be treated without greater expense.

Diagnosis and management of urinary tract infection in older adults

Urinary tract infection (UTI) is a commonly diagnosed infection in older adults. Despite consensus guidelines developed to assist providers in diagnosing UTI, distinguishing symptomatic UTI from asymptomatic bacteriuria (ASB) in older adults is problematic, as many older adults do not present with localized genitourinary symptoms. This article summarizes the recent literature and guidelines on the diagnosis and management of UTI and ASB in older adults.

The effect of increased mobility on morbidity in the neurointensive care unit

Object

The detrimental effects of immobility on intensive care unit (ICU) patients are well established. Limited studies involving medical ICUs have demonstrated the safety and benefit of mobility protocols. Currently no study has investigated the role of increased mobility in the neurointensive care unit population. This study was a single-institution prospective intervention trial to investigate the effectiveness of increased mobility among neurointensive care unit patients.

Methods

All patients admitted to the neurointensive care unit of a tertiary care center over a 16-month period (April 2010 through July 2011) were evaluated. The study consisted of a 10-month (8025 patient days) preintervention observation period followed by a 6-month (4455 patient days) postintervention period. The intervention was a comprehensive mobility initiative utilizing the Progressive Upright Mobility Protocol (PUMP) Plus.

Results

Implementation of the PUMP Plus increased mobility among neurointensive care unit patients by 300% (p < 0.0001). Initiation of this protocol also correlated with a reduction in neurointensive care unit length of stay (LOS; p < 0.004), hospital LOS (p < 0.004), hospital-acquired infections (p < 0.05), and ventilator-associated pneumonias (p < 0.001), and decreased the number of patient days in restraints (p < 0.05). Additionally, increased mobility did not lead to increases in adverse events as measured by falls or inadvertent line disconnections.

Conclusions

Among neurointensive care unit patients, increased mobility can be achieved quickly and safely with associated reductions in LOS and hospital-acquired infections using the PUMP Plus program.

Urinary Tract Infections in Older Adults Residing in Long-Term Care Facilities

Urinary tract infections (UTIs) are commonly suspected in residents of long-term care (LTC) facilities, and it has been common practice to prescribe antibiotics to these patients, even when they are asymptomatic. This approach, however, often does more harm than good, leading to increased rates of adverse drug effects and more recurrent infections with drug-resistant bacteria. It also does not improve genitourinary symptoms (eg, polyuria or malodorous urine) or lead to improved mortality rates; thus, distinguishing UTIs from asymptomatic bacteriuria is imperative in the LTC setting. This article provides a comprehensive overview of UTI in the LTC setting, outlining the epidemiology, risk factors and pathophysiology, microbiology, diagnosis, laboratory assessment, and management of symptomatic UTI.

Personality and reduced incidence of walking limitation in late life: findings from the Health, Aging, and Body Composition Study

OBJECTIVES

To examine the association between openness to experience and conscientiousness and incident reported walking limitation.

METHOD

The study population consisted of 786 men and women aged 71-81 years (M = 75 years, SD = 2.7) participating in the Health, Aging, and Body Composition-Cognitive Vitality Substudy.

RESULTS

Nearly 20% of participants (155/786) developed walking limitation during 6 years of follow-up. High openness was associated with a reduced risk of walking limitation (hazard ratio [HR] = 0.83, 95% confidence interval [CI] = 0.69-0.98), independent of sociodemographic factors, health conditions, and conscientiousness. This association was not mediated by lifestyle factors and was not substantially modified by other risk factors for functional disability. Conscientiousness was not associated with risk of walking limitation (HR = 0.91, 95% CI = 0.77-1.07).

DISCUSSION

Findings suggest that personality dimensions, specifically higher openness to experience, may contribute to functional resilience in late life.

Inappropriate use of urinary catheters: a prospective observational study

BACKGROUND

Despite the well-recognized role of urinary catheters in nosocomial urinary tract infections, data on risk factors associated with inappropriate urinary catheter use are scarce.

METHODS

A prospective review of electronic medical records of 436 patients admitted to an adult medical-surgical unit between October and December 2007 was performed to examine the appropriateness of urinary catheter use.

RESULTS

The use of 157 urinary catheters in 144 patients was observed. A total of 557 urinary catheter-days were recorded in these patients, of which 175 (31.4%) were found to be inappropriate based on the study criteria. The total number of catheters used and the total duration of catheterization were risk factors for inappropriate urinary catheter use (P < .05). Inappropriate catheter use was not associated with such adverse events as mortality, readmission, intensive care unit admission, catheter complications, or urine culture rates, but was associated with a trend toward longer duration of hospitalization.

CONCLUSIONS

Significant rates of inappropriate urinary catheter use and a trend toward longer duration of hospitalization with inappropriate catheter use were observed. These findings underscore the importance of establishing guidelines and effective policy implementation for the appropriate use of urinary catheters in hospitalized patients.