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Llor C, Moragas A, Ruppe G, Lykkegaard J, Hansen MP, Antsupova VS, Jensen JN, Theut AM, Petek D, Sodja N, Kowalczyk A, Bjerrum L. Diagnosing probable urinary tract infections in nursing home residents without indwelling catheters: A narrative review. Clin Microbiol Infect 2024:S1198-743X(24)00419-1. [PMID: 39209268 DOI: 10.1016/j.cmi.2024.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Revised: 08/18/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Overdiagnosis of urinary tract infections (UTIs) is one of the most common reasons for the unnecessary use of antibiotics in nursing homes, increasing the risk of missing serious conditions. Various decision tools and algorithms aim to aid in UTI diagnosis and the initiation of antibiotic therapy for residents. However, due to the lack of a clear gold standard, these tools vary widely and can be complex, with some requiring urine testing. As part of the European-funded IMAGINE project, aimed at improving antibiotic use for UTIs in nursing home residents, we have reviewed the recommendations. OBJECTIVES This review provides a comprehensive summary of the more relevant tools and algorithms aimed at identifying true UTIs among residents living in nursing homes and discusses the challenges in using these algorithms based on updated research. SOURCES The discussion is based on a relevant medical literature search and synthesis of the findings and published tools to provide an overview of the current state of improving the diagnosis of UTIs in nursing homes. CONTENT The following topics are covered: prevalence of asymptomatic bacteriuria, diagnostic challenges, clinical criteria, urinary testing, and algorithms to be implemented in nursing home facilities. IMPLICATIONS Diagnosing UTIs in residents is challenging due to the high prevalence of asymptomatic bacteriuria and non-specific urinary tract signs and symptoms among those with suspected UTIs. The fear of missing a UTI and the perceived antibiotic demands from residents and relatives might lead to overdiagnosis of this common condition. Despite their widespread use, urine dipsticks should not be recommended for geriatric patients. Patients who do not meet the minimum diagnostic criteria for UTIs should be evaluated for alternative conditions. Adherence to a simple algorithm can prevent unnecessary antibiotic courses without compromising resident safety.
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Affiliation(s)
- Carl Llor
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark; Primary Care Research Institute Jordi Gol (IDIAP), Barcelona, Spain; CIBER Enfermedades Infecciosas. Instituto de Salud Carlos III, Madrid, Spain.
| | - Ana Moragas
- Primary Care Research Institute Jordi Gol (IDIAP), Barcelona, Spain; CIBER Enfermedades Infecciosas. Instituto de Salud Carlos III, Madrid, Spain; Department of General Pathology. University Rovira i Virgili
| | - Georg Ruppe
- Austrian Interdisciplinary Platform on Ageing OEPIA, Austria
| | - Jesper Lykkegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Malene Plejdrup Hansen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark; Center for General Practice, Aalborg University, Aalborg, Denmark
| | - Valeria S Antsupova
- Department of Clinical Microbiology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Jette Nygaard Jensen
- Department of Clinical Microbiology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Anna Marie Theut
- Department of Clinical Microbiology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Davorina Petek
- Department of Family Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Nina Sodja
- Department of Family Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, the Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Lars Bjerrum
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Denmark
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Kristensen LH, Winther R, Colding-Jørgensen JT, Pottegård A, Nielsen H, Bodilsen J. Diagnostic accuracy of dipsticks for urinary tract infections in acutely hospitalised patients: a prospective population-based observational cohort study. BMJ Evid Based Med 2024:bmjebm-2024-112920. [PMID: 38997149 DOI: 10.1136/bmjebm-2024-112920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 07/14/2024]
Abstract
OBJECTIVE To determine the added diagnostic value of dipsticks for urinary tract infections (UTI) in acutely hospitalised individuals. DESIGN Prospective population-based cohort study. SETTING North Denmark. PARTICIPANTS All adults (≥18 years) examined with dipsticks at emergency departments in North Denmark Region from September 20 through 23 October 2021. MAIN OUTCOME MEASURES UTI was defined as ≥1 symptom of new-onset frequency, dysuria or suprapubic tenderness combined with a positive urine culture. Positive dipsticks were defined as any reaction for leucocyte esterase and/or nitrite. RESULTS Dipsticks were used in 1052/2495 (42%) of acutely hospitalised patients with a median age of 73 years (IQR 57-82) and 540 (51%) were female. Overall, 89/1052 (8%) fulfilled the UTI criteria and urine cultures were done in 607/1052 (58%) patients. Among patients examined with both dipstick and urine culture, sensitivity and specificity for UTI were 87% (95% CI 78% to 93%) and 45% (95% CI 41% to 50%). Positive and negative predictive values were 21% (95% CI 17% to 26%) and 95% (95% CI 92% to 98%), whereas positive and negative likelihood ratios were 1.58 (95% CI 1.41 to 1.77) and 0.30 (95% CI 0.18 to 0.51). Pretest probabilities of UTI ranged from 29% to 60% in participants with specific UTI symptoms with corresponding post-test probabilities of 35-69% if dipsticks were positive and 12-27% if dipsticks were negative. Results remained comparable if final clinical diagnosis was used as outcome among all patients examined with dipsticks. Modified Poisson regression yielded an adjusted relative risk of 4.41 (95% CI 2.40 to 8.11) for empirical antibiotics for UTI in participants without specific UTI symptoms and a positive dipstick. CONCLUSIONS Dipsticks yielded limited clinical decision support compared with a symptom-driven approach in this study and were independently associated with excess antibiotics for UTI.
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Affiliation(s)
| | - Rannva Winther
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | | | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Lui S, Carr F, Gibson W. Diagnosis of urinary tract infections in the hospitalized older adult population in Alberta. PLoS One 2024; 19:e0300564. [PMID: 38848404 PMCID: PMC11161040 DOI: 10.1371/journal.pone.0300564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/29/2024] [Indexed: 06/09/2024] Open
Abstract
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.
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Affiliation(s)
- Samantha Lui
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Frances Carr
- Division of Geriatric Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - William Gibson
- Division of Geriatric Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
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Bjørk E, Aabenhus R, Larsen SP, Ryg J, Henriksen DP, Lundby C, Pottegård A. Use of antibiotics for urinary tract infections up to and after care home admission in Denmark: a nationwide study. Eur Geriatr Med 2024; 15:797-805. [PMID: 38698277 PMCID: PMC11329397 DOI: 10.1007/s41999-024-00976-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 04/01/2024] [Indexed: 05/05/2024]
Abstract
PURPOSE Older people have the highest use of antibiotics for acute and chronic urinary tract infection (UTI), despite diagnostic uncertainty and the growing problem of antibiotic resistance. We aim to describe use-patterns of UTI antibiotics two years prior to and following care home admission in Denmark. METHODS This was a register-based nationwide drug-utilization study. In a cohort comprising all Danish residents admitted into a care home from 2015 to 2021, we described the use of UTI antibiotics, and examined differences between regions and individual care homes in rates of UTI antibiotic use. Further, we described trends in UTI-related contacts with hospitals in the two years prior to and following care home admission. RESULTS The cohort comprised 101,297 residents (61% female; median age 84 years). UTI antibiotic use doubled from 7 to 14 treatments/100 residents/month two months prior to care home admission and remained at 10 treatments/100 residents/month the following two years. Prescription of pivmecillinam (55%) was most common. Primary care practitioners prescribed the majority (92%) of UTI antibiotics. UTI-related hospital contacts peaked at two months prior to care home admission, with 6 admissions/100 residents/month, subsequently dropping to 2 admission/100 residents/month. We found considerable variation in UTI antibiotic use, with 10% of care homes responsible for 20% of treatments in 2021. CONCLUSION Use of UTI antibiotics increased prior to and remained at a stable high level following care home admission in Denmark. Despite variation in use across regions and individual care homes, an overall decrease was seen throughout the years 2016-2021.
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Affiliation(s)
- Emma Bjørk
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.
- Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, JB Winsløwsvej 19, 2, 5000, Odense C, Denmark.
- Odense Deprescribing Initiative (ODIN), Odense University Hospital, University of Southern Denmark, Odense C, Denmark.
| | - Rune Aabenhus
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Jesper Ryg
- Odense Deprescribing Initiative (ODIN), Odense University Hospital, University of Southern Denmark, Odense C, Denmark
- Department of Geriatric Medicine, Odense University Hospital, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Daniel P Henriksen
- Department of Clinical Pharmacology, Odense University Hospital, Odense C, Denmark
| | - Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark
- Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, JB Winsløwsvej 19, 2, 5000, Odense C, Denmark
- Odense Deprescribing Initiative (ODIN), Odense University Hospital, University of Southern Denmark, Odense C, Denmark
- Department of Public Health, Research Unit of General Practice, University of Southern, Odense C, Denmark
| | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark
- Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, JB Winsløwsvej 19, 2, 5000, Odense C, Denmark
- Odense Deprescribing Initiative (ODIN), Odense University Hospital, University of Southern Denmark, Odense C, Denmark
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Redwood R, Claeys KC. The Diagnosis and Treatment of Adult Urinary Tract Infections in the Emergency Department. Emerg Med Clin North Am 2024; 42:209-230. [PMID: 38641388 DOI: 10.1016/j.emc.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Emergency medicine has been called the art of "making complicated clinical decisions with limited information." This description is particularly relevant in the case of diagnosis and treatment of urinary tract infections (UTIs). Although common, UTIs are often challenging to diagnose given the presence of non-specific signs and symptoms and over-reliance on laboratory findings. This review provides an interdisciplinary interpretation of the primary literature and practice guidelines, with a focus on diagnostic and antimicrobial stewardship in the emergency department.
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Affiliation(s)
- Robert Redwood
- Bozeman Health Emergency Department, 915 Highland Avenue, Bozeman, MT 59715, USA
| | - Kimberly C Claeys
- Department of Pharmacy Science and Health Outcomes Research, University of Maryland School of Pharmacy, 20 N Pine Street, Baltimore, MD 21201, USA.
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Nejadsadeghi E, gorji EE, Vakili-Basir A, Norouzi S, Dehghani SL, Papi S. The impact of theory-based education on promoting urinary tract infection prevention behaviours among elderly diabetic women - experimental study. PRZEGLAD MENOPAUZALNY = MENOPAUSE REVIEW 2024; 23:41-52. [PMID: 38690068 PMCID: PMC11056722 DOI: 10.5114/pm.2024.136963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/27/2024] [Indexed: 05/02/2024]
Abstract
Introduction Urinary tract infection (UTI) is a prevalent infection among the elderly population, often culminating in more severe and life-threatening complications. The prevalence of diabetes among elderly individuals is markedly on the rise, with UTI emerging as the most prevalent infectious ailment in this diabetic cohort. This study aims to ascertain the influence of theory-based education on promoting UTI prevention behaviours among elderly diabetic women. Material and methods In this experimental study, 100 elderly women with diabetes who sought care at comprehensive health service centres in Miandoab City between January and May 2022 were assessed. Multistage random sampling was employed, and an educational intervention was designed according to the health belief model (HBM) constructs. Data collected before and one month after the educational intervention were analysed with a validated and reliable researcher-designed questionnaire. Results The participants had a mean age of 62.30 ±7.63 years. There was significant disparity between the experimental and control groups concerning the mean scores for knowledge, HBM constructs, and behaviour, with adjustments made for baseline differences. In essence, the intervention had significant affects, resulting in heightened levels of knowledge, improvements in HBM constructs, and more favourable behavioural changes. The effect size was moderate for perceived benefits and severity, while it was large for other variables (p < 0.05). Conclusions The research findings validate the effectiveness of an intervention grounded in HBM for fostering UTI prevention behaviours among elderly diabetic women. Consequently, such an approach is recommended for enhancing the overall health of elderly diabetic women.
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Affiliation(s)
| | - Elham Eshaghi gorji
- Department of Geriatric Nursing, School of Nursing and Midwifery, Shahid Sadoughi University of Medical Science, Yazd, Iran
| | - Ahmad Vakili-Basir
- Department of Epidemiology and Biostatics, school of Public Health, Tehran university of Medical Sciences, Tehran, Iran
| | - Samaneh Norouzi
- Department of Health Education and Health Promotion, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | | | - Shahab Papi
- Department of Geriatric Health, School of Health, Mazandaran University of Medical Sciences, Sari, Iran
- Dental Research Center, Mazandaran University of Medical Sciences, Sari, Iran
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Stoltzner P, Duncan C. Casting shadows of perception: An exploration of visual hallucinations. Nurse Pract 2024; 49:20-28. [PMID: 38271146 DOI: 10.1097/01.npr.0000000000000139] [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: 01/27/2024]
Abstract
ABSTRACT Hallucinations can be caused by biological, psychological, neurological, ophthalmological, and environmental factors. This article discusses a selection of the various conditions that can present with visual disturbances and hallucinations including schizophrenia, HIV, neurosyphilis, hyperammonemia, migraine, substance use, brain tumors, sleep disturbances, thyroid disorders, delirium, ophthalmologic conditions, and Lewy body dementia, providing an overview of the differential diagnosis of visual hallucinations. The mechanisms by which these conditions can lead to hallucinations are also discussed, and insight into the recommended medical workup for each is provided.
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Fésüs A, Matuz M, Papfalvi E, Hambalek H, Ruzsa R, Tánczos B, Bácskay I, Lekli I, Illés Á, Benkő R. Evaluation of the Diagnosis and Antibiotic Prescription Pattern in Patients Hospitalized with Urinary Tract Infections: Single-Center Study from a University-Affiliated Hospital. Antibiotics (Basel) 2023; 12:1689. [PMID: 38136723 PMCID: PMC10741002 DOI: 10.3390/antibiotics12121689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/21/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
UTIs (urinary tract infections) are common bacterial infections with a non-negligible hospitalization rate. The diagnosis of UTIs remains a challenge for prescribers and a common source of misdiagnosis. This retrospective observational study aimed to evaluate whether recorded diagnosis by clinicians and empirical antibiotic therapy met the EAU (European Association of Urology) guideline in patients hospitalized with UTI. The study was conducted at an internal medicine unit of a tertiary care medical center in Hungary. The diagnosis was assessed based on clinical presentation, physical examination, and laboratory (including microbiological) results, considering all the potential risk factors. Diagnosis was considered misdiagnosis when not confirmed by clinical presentation or clinical signs and symptoms. Evaluation of empirical antibiotic therapy was performed only for confirmed UTIs. Empirical treatment was considered guideline-adherent when complying with the relevant recommendations. Out of 185 patients, 41.6% failed to meet EAU-based UTI diagnosis criteria, of which 27.6% were misdiagnosed and 14.1% were ABU (asymptomatic bacteriuria). The diagnosis of urosepsis recorded at admission (9.7%, 18/185) was not confirmed either by clinical or microbiological tests in five (5/18) cases. The initial empirical therapies for UTI showed a relatively low rate (45.4%) of guideline adherence regarding agent selection. The most common guideline-non-adherent therapies were combinations with metronidazole (16.7%). Dosage appropriateness assessments showed a guideline adherence rate of 36.1%, and underdosing due to high body weight was common (9.3%). Overall (agent, route of administration, dose, duration) guideline adherence was found to be substantially low (10.2%). We found a relatively high rate of misdiagnosed UTIs. Written protocols on the ward may be crucial in reducing misdiagnosis and in optimizing antibiotic use.
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Affiliation(s)
- Adina Fésüs
- Department of Pharmacology, Faculty of Pharmacy, University of Debrecen, H-4032 Debrecen, Hungary; (A.F.); (B.T.); (I.L.)
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, H-4032 Debrecen, Hungary;
- Institute of Healthcare Industry, University of Debrecen, H-4032 Debrecen, Hungary
| | - Mária Matuz
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Szeged, H-6725 Szeged, Hungary; (M.M.); (E.P.); (H.H.); (R.R.)
- Central Pharmacy, Albert Szent Györgyi Medical Center, University of Szeged, H-6725 Szeged, Hungary
| | - Erika Papfalvi
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Szeged, H-6725 Szeged, Hungary; (M.M.); (E.P.); (H.H.); (R.R.)
- Department of Emergency Medicine, Albert Szent Györgyi Medical Center, University of Szeged, H-6725 Szeged, Hungary
| | - Helga Hambalek
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Szeged, H-6725 Szeged, Hungary; (M.M.); (E.P.); (H.H.); (R.R.)
| | - Roxána Ruzsa
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Szeged, H-6725 Szeged, Hungary; (M.M.); (E.P.); (H.H.); (R.R.)
| | - Bence Tánczos
- Department of Pharmacology, Faculty of Pharmacy, University of Debrecen, H-4032 Debrecen, Hungary; (A.F.); (B.T.); (I.L.)
| | - Ildikó Bácskay
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, H-4032 Debrecen, Hungary;
- Institute of Healthcare Industry, University of Debrecen, H-4032 Debrecen, Hungary
| | - István Lekli
- Department of Pharmacology, Faculty of Pharmacy, University of Debrecen, H-4032 Debrecen, Hungary; (A.F.); (B.T.); (I.L.)
| | - Árpád Illés
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary;
| | - Ria Benkő
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Szeged, H-6725 Szeged, Hungary; (M.M.); (E.P.); (H.H.); (R.R.)
- Central Pharmacy, Albert Szent Györgyi Medical Center, University of Szeged, H-6725 Szeged, Hungary
- Department of Emergency Medicine, Albert Szent Györgyi Medical Center, University of Szeged, H-6725 Szeged, Hungary
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Mylotte JM. Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents. J Am Med Dir Assoc 2023; 24:1619-1628. [PMID: 37572691 DOI: 10.1016/j.jamda.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/14/2023]
Abstract
One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use in nursing home residents.
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Affiliation(s)
- Joseph M Mylotte
- Division of Infectious Diseases, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY.
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Tingström P, Karlsson N, Grodzinsky E, Sund Levander M. The value of fever assessment in addition to the Early Detection Infection Scale (EDIS). A validation study in nursing home residents in Sweden. BMC Geriatr 2023; 23:585. [PMID: 37737163 PMCID: PMC10515033 DOI: 10.1186/s12877-023-04266-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 08/30/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND In order to improve detection of suspected infections in frail elderly there is an urgent need for development of decision support tools, that can be used in the daily work of all healthcare professionals for assessing non-specific and specific changes. The aim was to study non-specific signs and symptoms and fever temperature for early detection of ongoing infection in frail elderly, and how these correlates to provide the instrument, the Early Detection Infection Scale (EDIS), which is used to assess changes in health condition in frail elderly. METHODS This was an explorative, prospective cohort study, including 45 nursing home residents, 76 to 99 years, in Sweden. Nursing assistants measured morning ear body temperature twice a week and used the EDIS to assess individual health condition daily for six months. The outcome comprised events of suspected infection, compiled from nursing and medical patient records. Factor analysis and multivariate logistic regression analysis were performed to analyse data. RESULTS Fifteen residents were diagnosed with at least one infection during the six-month follow-up and 189 observations related to 72 events of suspected infection were recorded. The first factor analysis revealed that the components, change in cognitive and physical function, general signs and symptoms of illness, increased tenderness, change in eye expression and food intake and change in emotions explained 61% of the variance. The second factor analysis, adding temperature assessed as fever to > 1.0 °C from individual normal, resulted in change in physical function and food intake, confusion and signs and symptoms from respiratory and urinary tract, general signs and symptoms of illness and fever and increased tenderness, explaining 59% of the variance. In the first regression analysis, increased tenderness and change in eye expression and food intake, and in the second change in physical function and food intake, general signs and symptoms of illness and fever (> 1.0 °C from individual normal) and increased tenderness were significantly associated with increased risk for ongoing infection. CONCLUSION No items in the EDIS should be removed at present, and assessment of fever as > 1.0 °C from individual normal is a valuable addition. The EDIS has the potential to make it easier for first line caregivers to systematically assess changes in health condition in fragile elderly people and helps observations to be communicated in a standardised way throughout the care process. The EDIS thus contributes to ensuring that the decisions not being taken at the wrong level of care.
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Affiliation(s)
- Pia Tingström
- Medical Faculty, Linköping University, Linköping, Sweden.
| | | | - Ewa Grodzinsky
- Medical Faculty, Linköping University, Linköping, Sweden
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Wilcox CR, Worswick L, Muller I, Moore A, Hayward G, Lown M, Moore M, Little P, Francis N. Feasibility of a placebo-controlled trial of antibiotics for possible urinary tract infection in care homes: a qualitative interview study. BJGP Open 2023; 7:BJGPO.2023.0014. [PMID: 37225255 PMCID: PMC10646207 DOI: 10.3399/bjgpo.2023.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/16/2023] [Accepted: 04/25/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Diagnosis of suspected urinary tract infection (UTI) in care and nursing home residents is commonly based on vague non-localising symptoms (for example, confusion), potentially leading to inappropriate antibiotic prescription. The safety of withholding antibiotics in such cases could be addressed by a randomised controlled trial (RCT); however, this would require close monitoring of residents, and support from care home staff, clinicians, residents, and families. AIM To explore the views of residential care and nursing home staff (herein referred to as care home staff) and primary care clinicians on the feasibility and design of a potential RCT of antibiotics for suspected UTI in care home residents, with no localising urinary symptoms. DESIGN & SETTING A qualitative interview study with primary care clinicians and care home staff in the UK. METHOD Semi-structured interviews with 16 care home staff and 11 primary care clinicians were thematically analysed. RESULTS Participants were broadly supportive of the proposed RCT. The safety of residents was a priority and there was strong support for using the RESTORE2 (Recognise Early Soft Signs, Take Observations, Respond, Escalate) assessment tool to monitor residents; however, there were concerns about associated training requirements, especially for night and temporary staff. Effective communication (with residents, families, and staff) was deemed essential, and carers were confident that residents and families would be supportive of the RCT if the rationale was clearly explained and safety systems were robust. There were mixed views on a placebo-controlled design. The perceived additional burden was seen as a potential barrier, and the use of temporary staff and the out-of-hours period were highlighted as potential risk areas. CONCLUSION The support for this potential trial was encouraging. Future development will need to prioritise resident safety (especially in the out-of-hours period), effective communication, and minimising additional burden on staff to optimise recruitment.
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Affiliation(s)
- Christopher R Wilcox
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Louise Worswick
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Ingrid Muller
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Abigail Moore
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Lown
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Little
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nick Francis
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
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12
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Zukowska A, Kaczmarczyk M, Listewnik M, Zukowski M. The Association of Infection with Delirium in the Post-Operative Period after Elective CABG Surgery. J Clin Med 2023; 12:4736. [PMID: 37510851 PMCID: PMC10380657 DOI: 10.3390/jcm12144736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/12/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023] Open
Abstract
Delirium is one of the most common complications of coronary artery by-pass graft (CABG) surgery. The identification of patients at increased risk of delirium and the implementation of preventive measures to reduce the risk of postoperative delirium is necessary to improve treatment outcomes after CABG. The aim of this study was to assess the association between postoperative delirium and postoperative infection and 10-year mortality in patients undergoing CABG surgery. This is a retrospective, observational cohort study of patients undergoing planned on-pump CABG between April 2010 and December 2012. We analysed a group of 3098 patients operated on in our cardiac surgery centre, from whom we selected a cohort of patients undergoing planned CABG surgery. All patients were assessed for postoperative infection, such as pneumonia, bloodstream infections (BSIs) and surgical site infections (SSIs). Patients who experienced postoperative delirium were significantly more likely to have infection (7.4% vs. 22%; p = 0.0037). As regards particular types of infection, significant differences were only found for pneumonia and sternal SSIs. Patients who experienced postoperative delirium had significantly lower 5-year (p = 0.0136) and 10-year (p = 0.0134) survival. Postoperative delirium significantly increases long-term mortality in patients undergoing CABG surgery. Pneumonia and sternal SSIs significantly increase the risk of postoperative delirium in cardiac surgery patients.
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Affiliation(s)
- Agnieszka Zukowska
- Department of Infection Control, Regional Hospital Stargard, 73-110 Stargard, Poland
| | | | - Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Maciej Zukowski
- Department of Anesthesiology, Intensive Care and Acute Intoxication, Pomeranian Medical University, 70-111 Szczecin, Poland
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13
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Rockenschaub P, Gill MJ, McNulty D, Carroll O, Freemantle N, Shallcross L. Can the application of machine learning to electronic health records guide antibiotic prescribing decisions for suspected urinary tract infection in the Emergency Department? PLOS DIGITAL HEALTH 2023; 2:e0000261. [PMID: 37310941 DOI: 10.1371/journal.pdig.0000261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 04/25/2023] [Indexed: 06/15/2023]
Abstract
Urinary tract infections (UTIs) are a major cause of emergency hospital admissions, but it remains challenging to diagnose them reliably. Application of machine learning (ML) to routine patient data could support clinical decision-making. We developed a ML model predicting bacteriuria in the ED and evaluated its performance in key patient groups to determine scope for its future use to improve UTI diagnosis and thus guide antibiotic prescribing decisions in clinical practice. We used retrospective electronic health records from a large UK hospital (2011-2019). Non-pregnant adults who attended the ED and had a urine sample cultured were eligible for inclusion. The primary outcome was predominant bacterial growth ≥104 cfu/mL in urine. Predictors included demography, medical history, ED diagnoses, blood tests, and urine flow cytometry. Linear and tree-based models were trained via repeated cross-validation, re-calibrated, and validated on data from 2018/19. Changes in performance were investigated by age, sex, ethnicity, and suspected ED diagnosis, and compared to clinical judgement. Among 12,680 included samples, 4,677 (36.9%) showed bacterial growth. Relying primarily on flow cytometry parameters, our best model achieved an area under the ROC curve (AUC) of 0.813 (95% CI 0.792-0.834) in the test data, and achieved both higher sensitivity and specificity compared to proxies of clinician's judgement. Performance remained stable for white and non-white patients but was lower during a period of laboratory procedure change in 2015, in patients ≥65 years (AUC 0.783, 95% CI 0.752-0.815), and in men (AUC 0.758, 95% CI 0.717-0.798). Performance was also slightly reduced in patients with recorded suspicion of UTI (AUC 0.797, 95% CI 0.765-0.828). Our results suggest scope for use of ML to inform antibiotic prescribing decisions by improving diagnosis of suspected UTI in the ED, but performance varied with patient characteristics. Clinical utility of predictive models for UTI is therefore likely to differ for important patient subgroups including women <65 years, women ≥65 years, and men. Tailored models and decision thresholds may be required that account for differences in achievable performance, background incidence, and risks of infectious complications in these groups.
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Affiliation(s)
- Patrick Rockenschaub
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Martin J Gill
- Department of Clinical Microbiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Dave McNulty
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Orlagh Carroll
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London, United Kingdom
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14
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Saust LT, Siersma VD, Bjerrum L, Hansen MP. Development of quality indicators for the diagnosis and treatment of urinary tract infections in general practice: a RAND appropriateness method. BMJ Open Qual 2023; 12:bmjoq-2022-002156. [PMID: 37230738 DOI: 10.1136/bmjoq-2022-002156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 05/07/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE To develop a set of quality indicators for the diagnosis and antibiotic treatment of adult patients with suspected urinary tract infections in general practice. DESIGN A Research and Development/University of California Los Angeles appropriateness method was used. SETTING Danish general practice. SUBJECTS A panel of nine experts, mainly general practitioners, was asked to rate the relevance of 27 preliminary quality indicators. The set of indicators was based on the most recent Danish guidelines for the management of patients with suspected urinary tract infection. An online meeting was held to resolve misinterpretations and achieve consensus. MAIN OUTCOME MEASURES The experts were asked to rate the indicators on a nine-point Likert scale. Consensus of appropriateness was reached if the overall panel median rating was 7-9 with agreement. Agreement was defined as: no more than one expert rated the indicator outside the three-point region (1-3, 4-6 and 7-9) containing the median. RESULTS A total of 23 of the 27 proposed quality indicators attained consensus. One additional indicator was proposed by the panel of experts, leading to a final set of 24 quality indicators. All indicators focusing on the diagnostic process achieved consensus of appropriateness, while the experts agreed on three quarters of the proposed quality indicators concerning either the treatment decision or the choice of antibiotics. CONCLUSION This set of quality indicators may be used to strengthen general practice's focus on the management of patients with a possible urinary tract infection and to identify potential quality problems.
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Affiliation(s)
- Laura Trolle Saust
- Department of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Center for General Practice, Aalborg University, Aalborg, Denmark
| | - Volkert Dirk Siersma
- Department of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bjerrum
- Department of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Malene Plejdrup Hansen
- Department of Clinical Medicine, Center for General Practice, Aalborg University, Aalborg, Denmark
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Rochford B, Pendse S, Kumar N, De Choudhury M. Leveraging Symptom Search Data to Understand Disparities in US Mental Health Care: Demographic Analysis of Search Engine Trace Data. JMIR Ment Health 2023; 10:e43253. [PMID: 36716082 PMCID: PMC9926343 DOI: 10.2196/43253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/16/2022] [Accepted: 11/20/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In the United States, 1 out of every 3 people lives in a mental health professional shortage area. Shortage areas tend to be rural, have higher levels of poverty, and have poor mental health outcomes. Previous work has demonstrated that these poor outcomes may arise from interactions between a lack of resources and lack of recognition of mental illness by medical professionals. OBJECTIVE We aimed to understand the differences in how people in shortage and nonshortage areas search for information about mental health on the web. METHODS We analyzed search engine log data related to health from 2017-2021 and examined the differences in mental health search behavior between shortage and nonshortage areas. We analyzed several axes of difference, including shortage versus nonshortage comparisons, urban versus rural comparisons, and temporal comparisons. RESULTS We found specific differences in search behavior between shortage and nonshortage areas. In shortage areas, broader and more general mental health symptom categories, namely anxiety (mean 2.03%, SD 0.44%), depression (mean 1.15%, SD 0.27%), fatigue (mean 1.21%, SD 0.28%), and headache (mean 1.03%, SD 0.23%), were searched significantly more often (Q<.0003). In contrast, specific symptom categories and mental health disorders such as binge eating (mean 0.02%, SD 0.02%), psychosis (mean 0.37%, SD 0.06%), and attention-deficit/hyperactivity disorder (mean 0.77%, SD 0.10%) were searched significantly more often (Q<.0009) in nonshortage areas. Although suicide rates are consistently known to be higher in shortage and rural areas, we see that the rates of suicide-related searching are lower in shortage areas (mean 0.05%, SD 0.04%) than in nonshortage areas (mean 0.10%, SD 0.03%; Q<.0003), more so when a shortage area is rural (mean 0.024%, SD 0.029%; Q<2 × 10-12). CONCLUSIONS This study demonstrates differences in how people from geographically marginalized groups search on the web for mental health. One main implication of this work is the influence that search engine ranking algorithms and interface design might have on the kinds of resources that individuals use when in distress. Our results support the idea that search engine algorithm designers should be conscientious of the role that structural factors play in expressions of distress and they should attempt to design search engine algorithms and interfaces to close gaps in care.
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Affiliation(s)
- Ben Rochford
- School of Interactive Computing, College of Computing, Georgia Institute of Technology, Atlanta, GA, United States
| | - Sachin Pendse
- School of Interactive Computing, College of Computing, Georgia Institute of Technology, Atlanta, GA, United States
| | - Neha Kumar
- School of Interactive Computing, College of Computing, Georgia Institute of Technology, Atlanta, GA, United States
| | - Munmun De Choudhury
- School of Interactive Computing, College of Computing, Georgia Institute of Technology, Atlanta, GA, United States
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16
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Appropriateness of antibiotic use in patients with and without altered mental status diagnosed with a urinary tract infection. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e198. [PMID: 36712472 PMCID: PMC9879859 DOI: 10.1017/ash.2022.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 12/15/2022]
Abstract
Objective The objective of this study was to determine antibiotic appropriateness based on Loeb minimum criteria (LMC) in patients with and without altered mental status (AMS). Design Retrospective, quasi-experimental study assessing pooled data from 3 periods pertaining to the implementation of a UTI management guideline. Setting Academic medical center in Lexington, Kentucky. Patients Adult patients aged ≥18 years with a collected urinalysis receiving antimicrobial therapy for a UTI indication. Methods Appropriateness of UTI management was assessed in patients prior to an institutional UTI guideline, after guideline introduction and education, and after implementation of a prospective audit-and-feedback stewardship intervention from September to November 2017-2019. Patient data were pooled and compared between patients noted to have AMS versus those with classic UTI symptoms. Loeb minimum criteria were used to determine whether UTI diagnosis and treatment was warranted. Results In total, 600 patients were included in the study. AMS was one of the most common indications for testing across the 3 periods (19%-30.5%). Among those with AMS, 25 patients (16.7%) met LMC, significantly less than the 151 points (33.6%) without AMS (P < .001). Conclusions Patients with AMS are prescribed antibiotic therapy without symptoms indicative of UTI at a higher rate than those without AMS, according to LMC. Further antimicrobial stewardship efforts should focus on prescriber education and development of clearly defined criteria for patients with and without AMS.
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17
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Muacevic A, Adler JR, Paul S, Abbas MS, Nassar ST, Tasha T, Desai A, Bajgain A, Ali A, Mohammed L. Urinary Tract Infection Induced Delirium in Elderly Patients: A Systematic Review. Cureus 2022; 14:e32321. [PMID: 36632270 PMCID: PMC9827929 DOI: 10.7759/cureus.32321] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/08/2022] [Indexed: 12/13/2022] Open
Abstract
Urinary tract infection (UTI) is common in older adults, mainly due to several age-related risk factors. Symptoms of UTI are atypical in the elderly population, like hypotension, tachycardia, urinary incontinence, poor appetite, drowsiness, frequent falls, and delirium. UTI manifests more commonly and specifically for this age group as delirium or confusion in the absence of a fever. This systematic review aims to highlight the relationship between UTI and delirium in the elderly population by understanding the pathologies individually and collectively. A systematic review is conducted by searching PubMed with regular keywords and major Medical Subject Heading (MeSH) keywords, Science Direct, and Google Scholar. The inclusion criteria consisted of studies based on male and female human populations above the age of 65 in the English language, available in full text published between 2017 and 2022. However, the exclusion criteria were animal studies, clinical trials, literature published before 2017, and papers published in any other language except English. A total of 106 articles were identified, and nine final studies were selected after a quality assessment, following which a valid relationship between delirium and UTI was identified in this systematic review.
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18
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Eecen C, Vreeswijk R, Souverein D, Euser SM, Kalisvaart KJ. 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. Eur Geriatr Med 2022; 13:1391-1401. [PMID: 36309951 DOI: 10.1007/s41999-022-00708-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/11/2022] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- C Eecen
- Department of Geriatrics, Spaarne Gasthuis, Location Haarlem-Zuid, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands.
| | - R Vreeswijk
- Department of Geriatrics, Spaarne Gasthuis, Location Haarlem-Zuid, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands
| | - D Souverein
- Department of Epidemiology, Regional Public Health Laboratory Kennemerland, Boerhaavelaan 26, 2035 RC, Haarlem, The Netherlands
| | - S M Euser
- Department of Epidemiology, Regional Public Health Laboratory Kennemerland, Boerhaavelaan 26, 2035 RC, Haarlem, The Netherlands
| | - K J Kalisvaart
- Department of Geriatrics, Spaarne Gasthuis, Location Haarlem-Zuid, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands
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19
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Effect of inpatient antibiotic treatment among older adults with delirium found with a positive urinalysis: a health record review. BMC Geriatr 2022; 22:916. [PMID: 36447157 PMCID: PMC9706880 DOI: 10.1186/s12877-022-03549-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/20/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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20
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Cheng B, Zaman M, Cox W. Correlation of Pyuria and Bacteriuria in Acute Care. Am J Med 2022; 135:e353-e358. [PMID: 35580716 DOI: 10.1016/j.amjmed.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 04/01/2022] [Accepted: 04/12/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Pyuria is often used as an import marker in the diagnosis of urinary tract infection. The interpretation of pyuria may be especially important in patients with nonspecific complaints. There is a paucity of data to demonstrate the utility of pyuria alone in the diagnosis of bacteriuria or urinary tract infection. This study aims to further define the relationship of pyuria and positive bacterial growth in urine culture, as well as the diagnostic utility of different urine white blood cell cutoff points. METHOD A total of 46,127 patients older than the age of 18 were selected from the inpatient population of HCA Healthcare System Capital Division. Urine microscopy results were stratified by white blood cell count and correlated with positivity of urine culture bacterial growth. The optimal urine white blood cell cutoff was derived based on the receiver operating characteristic curve plot. RESULTS Urine microscopy finding of white blood cell 0-5 cell/hpf, 5-10 cell/hpf, 10-25 cell/hpf, and higher than 25 cell/hpf was associated with 25.4%, 28.2%, 33%, and 53.8% rates of bacteriuria, respectively. The receiver operating characteristic curve plot demonstrated that pyuria alone did not provide adequate diagnostic accuracy to predict bacteriuria. The optimal cutoff point for the best combination of sensitivity and specificity was found to be 25 cell/hpf. CONCLUSION Pyuria alone provides inadequate diagnostic accuracy for predicting bacteriuria. Urine white blood cell count greater than 25 cell/hpf was found to be the optimal cutoff to detect bacteriuria. The result of this study supports the current guideline recommendation against antibiotic treatment based on urine analysis alone. It also informs future design of randomized controlled trial that investigates interventional strategies for patients with pyuria and nonspecific complaints.
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Affiliation(s)
- Bo Cheng
- LewisGale Hospital Montgomery, Blacksburg, Va.
| | | | - William Cox
- LewisGale Hospital Montgomery, Blacksburg, Va
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21
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Jones AE, Nagle C, Ahern T, Smyth W. Evidence for a nurse-led protocol for removing urinary catheters: A scoping review. Collegian 2022. [DOI: 10.1016/j.colegn.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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22
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Antibiotic postprescribing modification opportunities among nursing home residents treated for urinary tract infection. Infect Control Hosp Epidemiol 2022:1-6. [DOI: 10.1017/ice.2022.202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Abstract
Objective:
To characterize opportunities to postprescriptively modify antibiotic prescriptions initiated for treatment of suspected urinary tract infection (UTI) in nursing homes.
Design:
Cross-sectional cohort study.
Methods:
Data from the health records of residents treated for UTI between 2013 and 2014 in 5 Wisconsin nursing homes were abstracted using a structured approach. Explicit definitions were used to identify whether the prescribed antibiotic could have been stopped, shortened, or changed to a nonfluoroquinolone alternative. Antibiotic treatments appropriately modified by study nursing home providers in real time were not considered modifiable. Identification of >1 potential modification opportunity (eg, stop and shorten) per antibiotic treatment event was permitted.
Results:
In total, 356 eligible antibiotic treatment courses among 249 unique residents were identified. Only 59 antibiotic courses prescribed for treatment of suspected UTI (16.6%) were not amenable to any modification. Discontinuation of treatment due to lack of signs or symptoms of infection was the most frequently identified potential modification opportunity (66.2%). Although less common, substantial numbers of antibiotic treatment courses were potentially amenable to shortening (34%) or agent change (19%) modifications. If applied in concert at 72 hours after antibiotic initiation, stop and shorten modifications could eradicate up to 1,326 avoidable antibiotic days, and change modifications could remove a 32 remaining avoidable fluoroquinolone days.
Conclusions:
Substantial opportunity exists to enhance the quality of antibiotic prescribing for treatment of suspected UTI in nursing homes through postprescriptive review interventions. Additional studies examining how to best design and implement postprescriptive review interventions in nursing homes are needed.
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Urinary Tract Infections Impair Adult Hippocampal Neurogenesis. BIOLOGY 2022; 11:biology11060891. [PMID: 35741412 PMCID: PMC9220213 DOI: 10.3390/biology11060891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 11/20/2022]
Abstract
Simple Summary Urinary tract infections are associated with features of cognitive decline and memory deficits, where the underlying correlation or mechanism is still not clear. In this study, we investigate the effect of urinary tract infections on cognitive functions in rodents and whether it is associated with adult hippocampal neurogenesis, a process that is detrimental for memory formation. We have shown that urinary tract infection affects the time spent exploring a novel arm in the Y-maze test. This was accompanied with a decrease in the proliferation of neural stem cells at an early time point post infection and a persistent decrease in neurogenesis at a later time point (34 days). We also detected decreased levels of neurotrophic factors important for neurogenesis and an elevated expression of interleukin 1β in the hippocampus. Treatment with either anti-inflammatory drugs or anti-biotics does not recover proliferation of neural stem cells. Here, we present hippocampal neurogenesis as a possible contributor to cognitive changes associated with urinary tract infections. Given the significant increase in urinary tract infection occurrence, it is important to address some of the detrimental effects that such an infection can have at the level of the brain. Abstract Previous studies have suggested a link between urinary tract infections (UTIs) and cognitive impairment. One possible contributing factor for UTI-induced cognitive changes that has not yet been investigated is a potential alteration in hippocampal neurogenesis. In this study, we aim to investigate the effect of UTI on brain plasticity by specifically examining alterations in neurogenesis. Adult male Sprague Dawley rats received an intra-urethral injection of an Escherichia coli (E. coli) clinical isolate (108 CFU/mL). We found that rats with a UTI (CFU/mL ≥ 105) had reduced proliferation of neural stem cells (NSCs) at an early time point post infection (day 4) and neurogenesis at a later time point (day 34). This was associated with the decreased expression in mRNA of BDNF, NGF, and FGF2, and elevated expression of IL-1β in the hippocampus at 6 h post infection, but with no changes in optical intensity of the microglia and astrocytes. In addition, infected rats spent less time exploring a novel arm in the Y-maze test. Treatment with an anti-inflammatory drug did not revert the effect on NSCs, while treatment with antibiotics further decreased the basal level of their proliferation. This study presents novel findings on the impact of urinary tract infections on hippocampal neurogenesis that could be correlated with cognitive impairment.
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MacRae V, Holland S, MacLeod R. Diagnosing, managing and preventing urinary tract infections in older people with dementia in hospital. Nurs Older People 2022; 34:28-33. [PMID: 35441502 DOI: 10.7748/nop.2022.e1392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/09/2022]
Abstract
Urinary tract infections (UTIs) are common in older people and are frequently more complicated to diagnose than in younger adults. There are often challenges associated with distinguishing symptomatic UTIs from asymptomatic bacteriuria, particularly in people with cognitive impairment. Older people with dementia are at increased risk of developing a UTI because dementia can lead to voiding issues, impede personal hygiene and increase the need for urinary catheterisation. Furthermore, while a UTI is usually diagnosed based on an individual's physical signs and symptoms, people with dementia may only exhibit signs of sudden altered mental status such as increased confusion, agitation or withdrawal, making diagnosis challenging. This article discusses the main considerations regarding UTIs in people with dementia in hospital and outlines prevention strategies that nurses can implement in their practice.
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Affiliation(s)
- Vicky MacRae
- University Hospital Crosshouse, NHS Ayrshire and Arran, Ayrshire, Scotland
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25
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Gungabissoon U, Perera G, Galwey NW, Stewart R. Potentially avoidable causes of hospitalisation in people with dementia: contemporaneous associations by stage of dementia in a South London clinical cohort. BMJ Open 2022; 12:e055447. [PMID: 35383067 PMCID: PMC8984034 DOI: 10.1136/bmjopen-2021-055447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To estimate the frequency of all-cause and ambulatory care sensitive condition (ACSCs)-related hospitalisations among individuals with dementia. In addition, to investigate differences by stage of dementia based on recorded cognitive function. SETTING Data from a large London dementia care clinical case register, linked to a national hospitalisation database. PARTICIPANTS Individuals aged ≥65 years with a confirmed dementia diagnosis with recorded cognitive function. OUTCOME MEASURES Acute general hospital admissions were evaluated within 6 months of a randomly selected cognitive function score in patients with a clinical diagnosis of dementia. To evaluate associations between ACSC-related hospital admissions (overall and individual ACSCs) and stage of dementia, an ordinal regression was performed, modelling stage of dementia as the dependant variable (to facilitate efficient model selection, with no implication concerning the direction of causality). RESULTS Of the 5294 people with dementia, 2993 (56.5%) had at least one hospitalisation during a 12-month period of evaluation, and 1192 (22.5%) had an ACSC-related admission. Proportions with an all-cause or ACSC-related hospitalisation were greater in the groups with more advanced dementia (all-cause 53.9%, 57.1% and 60.9%, p 0.002; ACSC-related 19.5%, 24.0% and 25.3%, p<0.0001 in the mild, moderate and severe groups, respectively). An ACSC-related admission was associated with 1.3-fold (95% CI 1.1 to 1.5) increased odds of more severe dementia after adjusting for demographic factors. Concerning admissions for individual ACSCs, the most common ACSC was urinary tract infection /pyelonephritis (9.8% of hospitalised patients) followed by pneumonia (7.1%); in an adjusted model, these were each associated with 1.4-fold increased odds of more severe dementia (95% CI 1.2 to 1.7 and 1.1 to 1.7, respectively). CONCLUSIONS Potentially avoidable hospitalisations were common in people with dementia, particularly in those with greater cognitive impairment. Our results call for greater attention to the extent of cognitive status impairment, and not just dementia diagnosis, when evaluating measures to reduce the risk of potentially avoidable hospitalisations.
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Affiliation(s)
- Usha Gungabissoon
- Epidemiology (Value Evidence and Outcomes), GSK, Brentford, London, UK
- Psychological Medicine, King's College London, Institute of Psychiatry Psychology and Neuroscience, London, UK
| | - Gayan Perera
- Psychological Medicine, King's College London, Institute of Psychiatry Psychology and Neuroscience, London, UK
| | | | - Robert Stewart
- Psychological Medicine, King's College London, Institute of Psychiatry Psychology and Neuroscience, London, UK
- Mental Health of Older Adults, South London and Maudsley NHS Foundation Trust, London, UK
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Latour K, De Lepeleire J, Catry B, Buntinx F. Nursing home residents with suspected urinary tract infections: a diagnostic accuracy study. BMC Geriatr 2022; 22:187. [PMID: 35255822 PMCID: PMC8903673 DOI: 10.1186/s12877-022-02866-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 02/10/2022] [Indexed: 12/02/2022] Open
Abstract
Background Urinary tract infections (UTIs) are one of the most common infections in nursing homes (NHs). A high error rate of a UTI diagnosis based solely on clinical criteria is to be expected in older persons as they often present infections in an atypical way. A study was set up to assess the diagnostic value of signs/symptoms and urine dipstick testing in identifying UTIs in NH residents and to explore whether C-reactive protein (CRP) measured by point-of-care testing (POCT) can help in the diagnosis. Methods During a three month prospective multicentre study, urine sampling for culture, POCT CRP and urinary dipstick testing were performed in each NH resident with a suspected UTI. UTIs were defined according to Stone et al., i.e. criteria based upon the presence of a set of signs/symptoms and a positive urine culture. Results Eleven NHs and 1 263 residents participated. Sixteen out of 137 recorded UTI suspicions were confirmed. Acute dysuria (positive likelihood ratio (LR +): 7.56, 95% confidence interval (CI): 3.94–14.5) and acute suprapubic pain (LR + : 11.4, 95% CI: 3.58–35.9) were found to be significant predictors. The combined nitrite and leucocyte esterase urine dipstick test (one or both positive) had a 96.0% negative predictive value (95% CI: 80.5–99.3%). The sensitivity of a positive CRP test (≥ 5 mg/L) was 60.0% (95% CI: 32.3–83.7%). Antimicrobials were prescribed in 60.2% of suspected but unconfirmed UTIs and in 92.3% of confirmed UTIs. Conclusions Using a stringent definition, only 11.7% of our suspicions were confirmed. Besides acute dysuria and suprapubic pain, we were not able to prove that any other clinical sign/symptom or POCT CPR adds useful information to the UTI diagnosis. We confirmed the findings of earlier research that urine dipstick tests are useful in ruling out UTIs and identified a potential overuse of antimicrobials in our NH population. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-02866-2.
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Affiliation(s)
- Katrien Latour
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium. .,Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Boudewijn Catry
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium.,Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Frank Buntinx
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Department of General Practice, Maastricht University, Maastricht, The Netherlands
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Laguë A, Boucher V, Joo P, Yadav K, Morasse C, Émond M. Investigation and treatment of asymptomatic bacteriuria in older patients with delirium: a cross-sectional survey of Canadian physicians. CAN J EMERG MED 2022; 24:61-67. [PMID: 34181215 DOI: 10.1007/s43678-021-00148-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/11/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Current guidelines suggest assessing non-infectious causes and careful observation before giving antibiotics to delirious patients with asymptomatic bacteriuria. Our study aims to describe the current practice of Canadian physicians regarding the investigation and treatment of asymptomatic bacteriuria in delirious older patients (aged ≥ 65 years). METHODS Our team of medical experts designed and reviewed a cross-sectional online survey. Study participants were physicians who conduct their clinical practice in Canada and care for older patients with delirium in their current practice. Potential study participants were reached through Canadian associations: Canadian Geriatrics Society, the Canadian Association of Emergency Physicians, the Association des Médecins d'Urgence du Québec and members of Choosing Wisely Canada. RESULTS 297 physicians were included. The main results show 79.4% of our participants request a urine dipstick or urinalysis in delirious patients and 52.4% immediately order a urine culture with the urinalysis. If bacteriuria is found in delirious but afebrile patients without urinary symptoms, 38% of physicians immediately treat with antibiotics, 33.8% wait for culture before initiating treatment, 14.4% treat if no other cause is found for delirium and only 13.7% would refrain from giving antibiotics. Results from respondents were similar for delirious patients with known cognitive impairment. Participants were almost unanimous (92.5%) in saying they need clear guidelines regarding the treatment of bacteriuria in older delirious patients. CONCLUSIONS This survey highlights the heterogeneous clinical management of asymptomatic bacteriuria in delirious patients and the need for clear guidelines for patients.
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Affiliation(s)
- Antoine Laguë
- Axe Santé Des Populations Et Pratiques Optimales en Santé, Centre de recherche du CHU de Québec - Université Laval, 1401, 18ièmerue, Québec, QC, G1J 1Z4, Canada
- VITAM - Centre de Recherche en Santé Durable, Québec, QC, Canada
- Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Valérie Boucher
- Axe Santé Des Populations Et Pratiques Optimales en Santé, Centre de recherche du CHU de Québec - Université Laval, 1401, 18ièmerue, Québec, QC, G1J 1Z4, Canada
- VITAM - Centre de Recherche en Santé Durable, Québec, QC, Canada
- Faculté de Médecine, Université Laval, Québec, QC, Canada
- Centre D'Excellence Sur Le Vieillissement de Québec, Québec, QC, Canada
| | - Pil Joo
- University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Marcel Émond
- Axe Santé Des Populations Et Pratiques Optimales en Santé, Centre de recherche du CHU de Québec - Université Laval, 1401, 18ièmerue, Québec, QC, G1J 1Z4, Canada.
- VITAM - Centre de Recherche en Santé Durable, Québec, QC, Canada.
- Faculté de Médecine, Université Laval, Québec, QC, Canada.
- Centre D'Excellence Sur Le Vieillissement de Québec, Québec, QC, Canada.
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Goebel MC, Trautner BW, Grigoryan L. The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections. Clin Microbiol Rev 2021; 34:e0000320. [PMID: 34431702 PMCID: PMC8404614 DOI: 10.1128/cmr.00003-20] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Urinary tract infections (UTI) are one of the most common indications for antibiotic prescriptions in the outpatient setting. Given rising rates of antibiotic resistance among uropathogens, antibiotic stewardship is critically needed to improve outpatient antibiotic use, including in outpatient clinics (primary care and specialty clinics) and emergency departments. Outpatient clinics are in general a neglected practice area in antibiotic stewardship programs, yet most antibiotic use in the United States is in the outpatient setting. This article provides a comprehensive review of antibiotic stewardship strategies for outpatient UTI in the adult population, with a focus on the "five Ds" of stewardship for UTI, including right diagnosis, right drug, right dose, right duration, and de-escalation. Stewardship interventions that have shown success for improving prescribing for outpatient UTI are discussed, including diagnostic stewardship strategies, such as reflex urine cultures, computerized decision support systems, and modified reporting of urine culture results. Among the many challenges to achieving stewardship for UTI in the outpatient setting, some of the most important are diagnostic uncertainty, increasing antibiotic resistance, limitations of guidelines, and time constraints of stewardship personnel and front-line providers. This article presents a stewardship framework, built on current evidence and expert opinion, that clinicians can use to guide their own outpatient management of UTI.
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Affiliation(s)
- Melanie C. Goebel
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
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Hernández-Hernández D, Padilla-Fernández B, Ortega-González MY, Castro-Díaz DM. Recurrent Urinary Tract Infections and Asymptomatic Bacteriuria in Adults. CURRENT BLADDER DYSFUNCTION REPORTS 2021; 17:1-12. [PMID: 34868442 PMCID: PMC8634747 DOI: 10.1007/s11884-021-00638-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 12/14/2022]
Abstract
Purpose of review Our goal was to summarize recent evidence regarding recurrent urinary tract infections and asymptomatic bacteriuria in different adult populations. Recent findings Several research groups are focused on the description of resident bacterial flora in the bladder and urinary dysbiosis in the microbiome era. Even the definitions might change in light of these discoveries. However, the role of urinary microbiome and bacterial interference has still to be determined. Summary Systematic treatment of asymptomatic bacteriuria is not recommended and even classic indications such as asymptomatic bacteriuria in pregnant women are controversial. In fact, its treatment is associated with a higher probability of symptomatic UTI and a higher prevalence of antibiotic-resistant bacteria. Improving the diagnosis of asymptomatic bacteriuria and optimizing the management of recurrent urinary tract infections, especially through non-antibiotics measures, are needed in order to minimise antimicrobial resistance.
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Affiliation(s)
| | - Bárbara Padilla-Fernández
- Department of Urology, Complejo Hospitalario Universitario de Canarias, La Laguna, Tenerife Spain.,Departamento de Cirugía, Facultad de Medicina, Universidad de La Laguna, Tenerife, Spain
| | | | - David Manuel Castro-Díaz
- Department of Urology, Complejo Hospitalario Universitario de Canarias, La Laguna, Tenerife Spain.,Departamento de Cirugía, Facultad de Medicina, Universidad de La Laguna, Tenerife, Spain
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Pinnell RAM, Ramsay T, Wang H, Joo P. Urinary Tract Infection Investigation and Treatment in Older Adults Presenting to the Emergency Department with Confusion: a Health Record Review of Local Practice Patterns. Can Geriatr J 2021; 24:341-350. [PMID: 34912489 PMCID: PMC8629500 DOI: 10.5770/cgj.24.518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
| | - Tim Ramsay
- Ottawa Hospital Research, Institute, Ottawa, ON
| | - Han Wang
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Pil Joo
- Ottawa Hospital Research, Institute, Ottawa, ON
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
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31
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Cooper DL, Buterakos R, Wagner LM, Tith J, Lee SYD. A retrospective comparison of guidelines to assess hospital-diagnosed urinary tract infection in nursing home residents. Am J Infect Control 2021; 49:1354-1358. [PMID: 33872686 DOI: 10.1016/j.ajic.2021.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Inappropriate antibiotic treatments for urinary tract infection (UTI) in nursing home (NH) residents are common and contribute to antibiotic resistance. Published guidelines aim to improve accurate assessment, diagnosis, and treatment of UTIs. This study assessed whether records from hospitalized NH residents diagnosed with UTI, while comparing the Cooper Tool and Stone criteria, supported appropriate treatment. METHODS A retrospective chart review was conducted using electronic medical record (EMR) data from residents of 3 NHs who were diagnosed with UTI when hospitalized over a 3-year period. The Cooper Tool and Stone criteria were used to assess treatment appropriateness. RESULTS Of 79 hospitalized residents treated for UTI, 11 (13.9%) were appropriately treated according to the Cooper Tool and 9 (11.4%) according to Stone. The 2 criteria agreed in 9 of the cases including 100% of those with catheters. Urinalysis was documented in 72% of residents and 24% had documentation of culture and sensitivity. CONCLUSIONS Appropriate UTI treatment rates using both tools were low but much higher in those with catheters. Future research is necessary to validate the use of these tools in the hospital setting which have the potential to improve treatment accuracy and reduce unnecessary antibiotics use.
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Hartman EAR, Groen WG, Heltveit-Olsen SR, Lindbaek M, Hoye S, Sundvall PD, Gunnarsson R, Skoglund I, Snaebjörnsson Arnljots E, Godycki-Cwirko M, Kowalczyk A, Platteel TN, Zuithoff NPA, Monnier AA, Verheij TJM, Hertogh CMPM, van de Pol AC. Multifaceted antibiotic stewardship intervention using a participatory-action-research approach to improve antibiotic prescribing for urinary tract infections in frail elderly (ImpresU): study protocol for a European qualitative study followed by a pragmatic cluster randomised controlled trial. BMJ Open 2021; 11:e052552. [PMID: 34620666 PMCID: PMC8499316 DOI: 10.1136/bmjopen-2021-052552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Almost 60% of antibiotics in frail elderly are prescribed for alleged urinary tract infections (UTIs). A substantial part of this comprises prescriptions in case of non-specific symptoms or asymptomatic bacteriuria, for which the latest guidelines promote restrictiveness with antibiotics. We aim to reduce inappropriate antibiotic use for UTIs through an antibiotic stewardship intervention (ASI) that encourages to prescribe according to these guidelines. To develop an effective ASI, we first need a better understanding of the complex decision-making process concerning suspected UTIs in frail elderly. Moreover, the implementation approach requires tailoring to the heterogeneous elderly care setting. METHODS AND ANALYSIS First, we conduct a qualitative study to explore factors contributing to antibiotic prescribing for UTIs in frail elderly, using semi-structured interviews with general practitioners, nursing staff, patients and informal caregivers. Next, we perform a pragmatic cluster randomised controlled trial in elderly care organisations. A multifaceted ASI is implemented in the intervention group; the control group receives care as usual. The ASI is centred around a decision tool that promotes restrictive antibiotic use, supported by a toolbox with educational materials. For the implementation, we use a modified participatory-action-research approach, guided by the results of the qualitative study. The primary outcome is the number of antibiotic prescriptions for suspected UTIs. We aim to recruit 34 clusters with in total 680 frail elderly residents ≥70 years. Data collection takes place during a 5-month baseline period and a 7-month follow-up period. Finally, we perform a process evaluation. The study has been delayed for 6 months due to COVID-19 and is expected to end in July 2021. ETHICS AND DISSEMINATION Ethical approvals and/or waivers were obtained from the ethical committees in Poland, the Netherlands, Norway and Sweden. The results will be disseminated through publication in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER NCT03970356.
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Affiliation(s)
- Esther A R Hartman
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wim G Groen
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Silje Rebekka Heltveit-Olsen
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Lindbaek
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sigurd Hoye
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Ronny Gunnarsson
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Ingmarie Skoglund
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Egill Snaebjörnsson Arnljots
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Maciej Godycki-Cwirko
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Tamara N Platteel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Annelie A Monnier
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alma C van de Pol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Krinitski D, Kasina R, Klöppel S, Lenouvel E. Associations of delirium with urinary tract infections and asymptomatic bacteriuria in adults aged 65 and older: A systematic review and meta-analysis. J Am Geriatr Soc 2021; 69:3312-3323. [PMID: 34448496 PMCID: PMC9292354 DOI: 10.1111/jgs.17418] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/21/2021] [Accepted: 06/27/2021] [Indexed: 12/29/2022]
Abstract
Objective To determine the associations of delirium with urinary tract infection (UTI) and asymptomatic bacteriuria (AB) in individuals aged 65 and older. Methods The protocol for this systematic review and meta‐analysis was published on PROSPERO (CRD42020164341). Electronic databases were searched for relevant studies, professional associations and experts in the field were additionally contacted. Studies with control groups reporting associations between delirium and UTI as well as delirium and AB in older adults were included. The random effects model meta‐analysis was conducted using odds ratios (ORs) with 95% confidence intervals (CIs) as effect size measures. The Newcastle‐Ottawa scale was used to rate the studies' quality. Heterogeneity was assessed using the Q and I2 tests. The effects of potential moderators were investigated by both subgroup and meta‐regression analyses. The risk of publication bias was evaluated using the funnel plot and Egger's test. Results Twenty nine relevant studies (16,618 participants) examining the association between delirium and UTI in older adults were identified. The association between delirium and UTI was found to be significant (OR 2.67; 95% CI 2.12–3.36; p < 0.001) and persisted regardless of potential confounders. The association between delirium and AB in older adults in the only eligible study found (192 participants) was insignificant (OR 1.62; 95% CI 0.57–4.65; p = 0.37). All included studies were of moderate quality. Conclusion The results of this study support the association between delirium and UTI in older adults. Insufficient evidence was found to conclude on an association between delirium and AB in this age group. These findings are limited due to the moderate quality of the included studies and a lack of available research on the association between delirium and AB. Future studies should use the highest quality approaches for defining both delirium and UTI and consider AB in their investigations.
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Affiliation(s)
- Damir Krinitski
- Faculty of Medicine, University of Bern, Bern, Switzerland.,Integrated Psychiatry Winterthur, Winterthur, Switzerland
| | - Rafal Kasina
- Faculty of Medicine, University of Bern, Bern, Switzerland.,Monvia Health Centre, Wallisellen, Switzerland
| | - Stefan Klöppel
- Faculty of Medicine, University of Bern, Bern, Switzerland.,University Hospital of Old Age Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Eric Lenouvel
- Faculty of Medicine, University of Bern, Bern, Switzerland.,University Hospital of Old Age Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
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Memari M, Mendoza MA, Shukla B, O'Rourke P. Things We Do for No Reason™: Obtaining Urine Testing in Older Adults With Delirium Without Signs or Symptoms of Urinary Tract Infection. J Hosp Med 2021; 16:jhm.3620. [PMID: 34328841 DOI: 10.12788/jhm.3620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/16/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Milad Memari
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Maria A Mendoza
- University of Miami, Miller School of Medicine, Miami, Florida
- Jackson Memorial Hospital, Miami, Florida
| | - Bhavarth Shukla
- University of Miami, Miller School of Medicine, Miami, Florida
| | - Paul O'Rourke
- Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland
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35
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Arnold SH, Nygaard Jensen J, Bjerrum L, Siersma V, Winther Bang C, Brostrøm Kousgaard M, Holm A. Effectiveness of a tailored intervention to reduce antibiotics for urinary tract infections in nursing home residents: a cluster, randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2021; 21:1549-1556. [PMID: 34303417 DOI: 10.1016/s1473-3099(21)00001-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/20/2020] [Accepted: 01/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND When suspecting a urinary tract infection (UTI), the nursing home staff contacts a physician with clinical information on behalf of the resident; hence, poor understanding of UTI or a lack of clinical communicative skills can cause overtreatment with antibiotics. We investigated whether a tailored intervention that improves knowledge about UTI and communication skills in nursing home staff influences antibiotic prescriptions for UTI. METHODS This open-label, parallel-group, cluster randomised controlled trial was done at 22 participating nursing homes in Denmark. Patients were eligible if they were nursing home residents aged 65 years or older, had the nursing home listed as their permanent address, and resided in a living space designated for those with dementia or somatic health-care needs. We included nursing homes that were not participating in other UTI projects and those in which staff were present at all hours. Using computer-generated random numbers and stratification by municipality, a statistician randomised the nursing homes (1:1) to receive either interactive educational sessions and use of a dialogue tool or to continue standard practice. The statistical analysis was blinded. Staff attended 75 min sessions over 8 weeks to learn how to distinguish between UTIs and asymptomatic bacteriuria, evaluate non-specific symptoms, and use the dialogue tool. The primary outcome was the number of antibiotic prescriptions for acute UTI per resident per days at risk, defined as the number of days the resident had been present at the nursing home during the trial period. The trial is registered at ClinicalTrials.gov, NCT03715062. FINDINGS Between June 1, 2017, and June 1, 2018, 22 of 68 invited nursing homes were recruited. Of 22 randomised nursing homes (n=1625 residents), 11 received the intervention (770 [92·2%] of 835 allocated residents) and 11 were in the control group (705 [89·2%] of 790 allocated residents). The standardised number of nursing home staff was 572 in the intervention group and 535 in the control group. All nursing homes completed the trial. 65 residents were excluded from data collection in the intervention group and 85 were excluded in the control group. 1470 residents (intervention n=765; control n=705) were analysed for the primary endpoint. The number of antibiotic prescriptions for UTI per resident was 134 per 84 035 days at risk in the intervention group and 228 per 77817 days at risk in the control group. The rate ratio (RR) of receiving an antibiotic for UTI was 0·51 (95% CI 0·37-0·71) in the unadjusted model and 0·42 (0·31-0·57) in the adjusted model. Of 140 diary entries of suspected UTIs, no deaths were reported. 421 (28·5%) of 1475 residents were admitted to hospital. The risk of all-cause hospitalisation increased in the intervention group (adjusted model RR 1·28, 95% CI 0·95-1·74), whereas all-cause mortality was lower in the intervention group (0·91, 0·62-1·33). INTERPRETATION The intervention effectively reduced antibiotic prescriptions and inappropriate treatments for UTI without substantially influencing all-cause hospitalisations and mortality. FUNDING Danish Ministry of Health and the Velux Foundation.
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Affiliation(s)
- Sif Helene Arnold
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark.
| | - Jette Nygaard Jensen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Lars Bjerrum
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Anne Holm
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Punko D, Hogan C, Quinn D, Kontos N. C-L Case Conference: A 73-Year-Old Man With "Altered Mental Status" and Agitation. J Acad Consult Liaison Psychiatry 2021; 62:485-492. [PMID: 34256179 DOI: 10.1016/j.jaclp.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/22/2021] [Accepted: 05/26/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Diana Punko
- The Avery D. Weisman Psychiatry Consultation Service, Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
| | - Charlotte Hogan
- The Avery D. Weisman Psychiatry Consultation Service, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Davin Quinn
- Division of Behavioral Health Consultation and Integration, Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM
| | - Nicholas Kontos
- The Avery D. Weisman Psychiatry Consultation Service, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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Helmke N. Risk of Cognitive Bias Associated With the Treatment of Urinary Tract Infection in Patients With Psychiatric Disorders. J Acad Consult Liaison Psychiatry 2021; 62:555-556. [PMID: 34083159 DOI: 10.1016/j.jaclp.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/21/2021] [Accepted: 03/25/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Nicole Helmke
- Department of Psychiatry and Behavioral Sciences and Department of Medicine, Duke University School of Medicine, Durham, NC.
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38
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Asymptomatic bacterisputia: Rethinking diagnostic stewardship in pneumonia. Infect Control Hosp Epidemiol 2021; 42:737-739. [PMID: 33934730 DOI: 10.1017/ice.2021.109] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Dexter J, Mortimore G. The management of urinary tract infections in older patients within an urgent care out-of-hours setting. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2021; 30:334-342. [PMID: 33769881 DOI: 10.12968/bjon.2021.30.6.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This article critically analyses the prevalence, assessment and management of urinary tract infections (UTIs) in patients over the age of 65, in an urgent care out-of-hours service in order to enhance care. It is undertaken from the perspective of working as an Advanced Nurse Practitioner (ANP). A synopsis of UTI is presented, examining the epidemiology and aetiology. The process of assessment, diagnosis and management of UTI in older people is appraised based on current evidence. Difficulties associated with the recognition of UTI in elderly are evaluated. Finally, recommendations are made for the improvement of future practice as an ANP.
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Affiliation(s)
- Justine Dexter
- Advanced Nurse Practitioner, Urgent Care, South Derbyshire, DHU Health Care
| | - Gerri Mortimore
- Senior Lecturer in Advanced Practice, Department of Health and Social Care, University of Derby
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40
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Schoevaerdts D, Sibille FX, Gavazzi G. Infections in the older population: what do we know? Aging Clin Exp Res 2021; 33:689-701. [PMID: 31656032 DOI: 10.1007/s40520-019-01375-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 10/04/2019] [Indexed: 12/20/2022]
Abstract
The incidence of infections increases with age and results in a higher risk of morbidity and mortality. This rise is not mainly related to chronological age per se but has been linked mostly to individual factors such as immunosenescence; the presence of comorbidities; the occurrence of geriatric syndromes such as poor nutrition, polypharmacy, and cognitive disorders; and the presence of functional impairment concomitant with environmental, healthcare-related and microbiological factors such as the increasing risk of multidrug-resistant microorganisms. The geriatric concept of frailty introduces a new approach for considering the risk of infection; this concept highlights the importance of functional status and is a more comprehensive and multicomponent approach that may help to reverse the vulnerability to stress. The aim of this article is to provide some typical hallmarks of infections among older adults in comparison to younger individuals. The main differences among the older population that are presented are an increased prevalence of infections and potential risk factors, a higher risk of carrying multidrug-resistant microorganisms, an increase in barriers to a prompt diagnosis related to atypical presentations and challenges with diagnostic tools, a higher risk of under- and over-diagnosis, a worse prognosis with a higher risk of acute and chronic complications and a particular need for better communication among all healthcare sectors as they are closely linked together.
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Affiliation(s)
- Didier Schoevaerdts
- Geriatric Department, CHU UCL Namur, Site Godinne, Avenue Dr. Gaston Thérasse, 1, B-5530, Yvoir, Belgium.
| | - François-Xavier Sibille
- Geriatric Department, CHU UCL Namur, Site Godinne, Avenue Dr. Gaston Thérasse, 1, B-5530, Yvoir, Belgium
| | - Gaetan Gavazzi
- Geriatric Department, CHU UCL Namur, Site Godinne, Avenue Dr. Gaston Thérasse, 1, B-5530, Yvoir, Belgium
- Service Gériatrie Clinique, Centre Hospitalo-Universitaire Grenoble-Alpes, Avenue Central 621, 38400, Saint-Martin-d'Hères, France
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41
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Romero-Ortuno R. Infection in dementia and delirium in frailty. NATURE AGING 2021; 1:157-158. [PMID: 37118625 DOI: 10.1038/s43587-021-00031-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Roman Romero-Ortuno
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland.
- Mercer's Institute for Successful Ageing (MISA), St. James's Hospital, Dublin, Ireland.
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland.
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42
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Petty LA, Vaughn VM, Flanders SA, Patel T, Malani AN, Ratz D, Kaye KS, Pogue JM, Dumkow LE, Thyagarajan R, Hsaiky LM, Osterholzer D, Kronick SL, McLaughlin E, Gandhi TN. Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department. Open Forum Infect Dis 2020; 7:ofaa537. [PMID: 33324723 PMCID: PMC7724506 DOI: 10.1093/ofid/ofaa537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/29/2020] [Indexed: 02/04/2023] Open
Abstract
Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018-February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08-1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.
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Affiliation(s)
- Lindsay A Petty
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Valerie M Vaughn
- Internal Medicine, Division of General Internal Medicine, University of Utah Medical School, Salt Lake City, Utah, USA
| | - Scott A Flanders
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Twisha Patel
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Internal Medicine, Division of Infectious Diseases, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - David Ratz
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Keith S Kaye
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason M Pogue
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa E Dumkow
- Department of Pharmacy, Mercy Health Saint Mary's, Grand Rapids, Michigan, USA
| | | | - Lama M Hsaiky
- Department of Pharmacy, Beaumont Hospital, Dearborn, Michigan, USA
| | - Danielle Osterholzer
- Internal Medicine, Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan, USA
| | - Steven L Kronick
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth McLaughlin
- Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
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Crawford AH, Cardy TJA. Is there a link between bacteriuria and a reversible encephalopathy in dogs and cats? J Small Anim Pract 2020; 61:467-474. [PMID: 32743843 DOI: 10.1111/jsap.13178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/02/2020] [Accepted: 04/21/2020] [Indexed: 11/29/2022]
Abstract
Bacteriuria has been associated with abnormal neurological status in humans, especially geriatric patients. In this report, we review 11 cases (seven dogs and four cats) that suggest an association between bacteriuria and abnormal neurological status in veterinary medicine. These cases showed diffuse forebrain signs with or without brainstem signs, but primary brain disease was excluded by MRI and cerebrospinal fluid analysis. Bacteriological culture of urine was positive in each animal and neurological deficits improved or resolved with initiation of antibiosis ± fluid therapy and levetiracetam. While further studies are needed to definitively confirm or refute the link between bacteriuria and a reversible encephalopathy, urine bacteriological culture should be considered in veterinary patients presented with acute onset forebrain neuro-anatomical localisation, even in the absence of clinical signs of lower urinary tract inflammation.
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Affiliation(s)
- A H Crawford
- Clinical Science and Services, Royal Veterinary College, University of London, Hawkshead Lane, North Mymms, Hatfield, Herts, AL9 7TA, UK
| | - T J A Cardy
- Clinical Science and Services, Royal Veterinary College, University of London, Hawkshead Lane, North Mymms, Hatfield, Herts, AL9 7TA, UK
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Petty LA, Vaughn VM, Gandhi TN. Web Exclusive. Annals for Hospitalists Inpatient Notes - Innocent Bystander: Leaving Asymptomatic Bacteriuria Alone in Hospitalized Patients. Ann Intern Med 2020; 173:HO2-HO3. [PMID: 32687754 DOI: 10.7326/m20-4261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Lindsay A Petty
- University of Michigan, Ann Arbor, Michigan (L.A.P., V.M.V., T.N.G.)
| | - Valerie M Vaughn
- University of Michigan, Ann Arbor, Michigan (L.A.P., V.M.V., T.N.G.)
| | - Tejal N Gandhi
- University of Michigan, Ann Arbor, Michigan (L.A.P., V.M.V., T.N.G.)
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Arnold SH, Olesen JA, Jensen JN, Bjerrum L, Holm A, Kousgaard MB. Development of a Tailored, Complex Intervention for Clinical Reflection and Communication about Suspected Urinary Tract Infections in Nursing Home Residents. Antibiotics (Basel) 2020; 9:E360. [PMID: 32630549 PMCID: PMC7345997 DOI: 10.3390/antibiotics9060360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Inappropriate antibiotic treatments for urinary tract infections (UTIs) in nursing homes cause the development of resistant bacteria. Nonspecific symptoms and asymptomatic bacteriuria are drivers of overtreatment. Nursing home staff provide general practice with information about ailing residents; therefore, their knowledge and communication skills influence prescribing. This paper describes the development of a tailored, complex intervention for a cluster-randomised trial that targets the knowledge of UTI and communication skills in nursing home staff to reduce antibiotic prescriptions. METHODS A dialogue tool was drafted, drawing on participatory observations in nursing homes, interviews with stakeholders, and a survey in general practice. The tool was tailored through a five-phase process that included stakeholders. Finally, the tool and a case-based educational session were tested in a pilot study. RESULTS The main barriers were that complex patients were evaluated by healthcare staff with limited knowledge about disease and clinical reasoning; findings reported to general practice were insignificant and included vague descriptions; there was evidence of previous opinion bias; nonspecific symptoms were interpreted as UTI; intuitive reasoning led to the inappropriate suspicion of UTI. CONCLUSION Sustainable change in antibiotic-prescribing behaviour in nursing homes requires a change in nursing home staff's beliefs about and management of UTIs.
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Affiliation(s)
- Sif H. Arnold
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark; (J.A.O.); (L.B.); (A.H.); (M.B.K.)
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark;
| | - Julie A. Olesen
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark; (J.A.O.); (L.B.); (A.H.); (M.B.K.)
| | - Jette N. Jensen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark;
| | - Lars Bjerrum
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark; (J.A.O.); (L.B.); (A.H.); (M.B.K.)
| | - Anne Holm
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark; (J.A.O.); (L.B.); (A.H.); (M.B.K.)
| | - Marius B. Kousgaard
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 24 Q, K 1353 Copenhagen, Denmark; (J.A.O.); (L.B.); (A.H.); (M.B.K.)
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46
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Godbole GP, Cerruto N, Chavada R. Principles of assessment and management of urinary tract infections in older adults. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2020. [DOI: 10.1002/jppr.1650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Gauri P. Godbole
- Pharmacy Department Gosford Hospital, NSW Health Gosford Australia
| | - Nicole Cerruto
- Pharmacy Department Gosford Hospital, NSW Health Gosford Australia
| | - Ruchir Chavada
- Department of Microbiology and Infectious Diseases NSW Health Pathology Central Coast Newcastle Australia
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Arnold SH, Jensen JN, Kousgaard MB, Siersma V, Bjerrum L, Holm A. Reducing Antibiotic Prescriptions for Urinary Tract Infection in Nursing Homes Using a Complex Tailored Intervention Targeting Nursing Home Staff: Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e17710. [PMID: 32383679 PMCID: PMC7244999 DOI: 10.2196/17710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Urinary tract infection (UTI) is the most common reason for antibiotic prescription in nursing homes. Overprescription causes antibiotic-related harms in those who are treated and others residing within the nursing home. The diagnostic process in nursing homes is complicated with both challenging issues related to the elderly population and the nursing home setting. A physician rarely visits a nursing home for suspected UTI. Consequently, the knowledge of UTI and communication skills of staff influence the diagnosis. OBJECTIVE The objective of this study is to describe a cluster randomized controlled trial with a tailored complex intervention for improving the knowledge of UTI and communication skills of nursing home staff in order to decrease the number of antibiotic prescriptions for UTI in nursing home residents, without changing hospitalization and mortality. METHODS The study describes an open-label cluster randomized controlled trial with two parallel groups and a 1:1 allocation ratio. Twenty-two eligible nursing homes are sampled from the Capital Region of Denmark, corresponding to 1274 nursing home residents. The intervention group receives a dialogue tool, and all nursing home staff attend a workshop on UTI. The main outcomes of the study are the antibiotic prescription rate for UTI, all-cause hospitalization, all-cause mortality, and suspected UTI during the trial period. RESULTS The trial ended in April 2019. Data have been collected and are being analyzed. We expect the results of the trial to be published in a peer-reviewed journal in the fall of 2020. CONCLUSIONS The greatest strengths of this study are the randomized design, tailored development of the intervention, and access to medical records. The potential limitations are the hierarchy in the prescription process, Hawthorne effect, and biased access to data on signs and symptoms through a UTI diary. The results of this trial could offer a strategy to overcome some of the challenges of increased antibiotic resistance and could have implications in terms of how to handle cases of suspected UTI. TRIAL REGISTRATION ClinicalTrials.gov NCT03715062; https://clinicaltrials.gov/ct2/show/NCT03715062. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/17710.
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Affiliation(s)
- Sif Helene Arnold
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Jette Nygaard Jensen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Marius Brostrøm Kousgaard
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bjerrum
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anne Holm
- The Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Burkett E, Carpenter CR, Arendts G, Hullick C, Paterson DL, Caterino JM. Diagnosis of urinary tract infection in older persons in the emergency department: To pee or not to pee, that is the question. Emerg Med Australas 2019; 31:856-862. [PMID: 31478344 PMCID: PMC10509932 DOI: 10.1111/1742-6723.13376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 07/16/2019] [Indexed: 01/26/2023]
Abstract
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?
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Affiliation(s)
- Ellen Burkett
- Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Healthcare Improvement Unit, Clinical Excellence Queensland, Brisbane, Queensland, Australia
| | | | - Glenn Arendts
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Emergency Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Carolyn Hullick
- Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia
- Faculty of Health and Medicine, The University of Newcastle, Newcastle, New South Wales, Australia
| | - David L Paterson
- Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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