Investigation and treatment of asymptomatic bacteriuria in older patients with delirium: a cross-sectional survey of Canadian physicians

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.

Current practice for primary headache disorders and perspectives on peripheral nerve blocks among emergency physicians in Canada: A national survey

“…We used rigorous methodologies in our postal survey and anticipated a 50% response rate based on previous surveys using similar methods 29,30 . Postal surveys typically have a higher response rate compared with electronic surveys; recent surveys among emergency physicians using email have response rates of less than 35% 31–33 . Regarding emergency physician demographics, most physicians had been in practice for 10 or more years; however, this population may be less likely to perform newer or different techniques, such as PNBs.…”

“…29,30 Postal surveys typically have a higher response rate compared with electronic surveys; recent surveys among emergency physicians using email have response rates of less than 35%. [31][32][33] Regarding emergency physician demographics, most physicians had been in practice for 10 or more years; however, this population may be less likely to perform newer or different techniques, such as PNBs. Most physicians practiced in an academic health center or community teaching general hospital; thus, physicians in rural or non-teaching hospital settings are under-represented.…”

Delirium in older adults, if you think it’s the urine, think again

“…While there are many presentations for which older adults are seen in the ED, urine studies are commonly (almost reflexively) included in the work-up for these patients regardless of urinary symptoms. In this issue of CJEM, Laguë et al [1] published a cross-sectional survey of the current practice of Canadian physicians regarding investigations and treatment of asymptomatic bacteriuria in older patients. The investigators should be applauded for their efforts to draw attention to Canadian physician practice patterns on this important clinical topic.…”

“…79.4% of participants reported to frequently request a urine dipstick or urinalysis in patients with delirium and 52.4% immediately order a urine culture with the urinalysis. Furthermore, if bacteriuria was found in a patient with delirium who was afebrile and had no urinary symptoms, 38% of physicians immediately treated with antibiotics [1]. Treatment of asymptomatic bacteriuria in older patients with delirium has failed to demonstrate benefit and comes with risk [2].…”

“…There was considerable variation among study participants on the definition of asymptomatic bacteriuria, with 47% of respondents defining bacteriuria in an afebrile patient with new onset of confusion and no urinary or systemic signs or symptoms incorrectly as a urinary tract infection, rather than asymptomatic bacteriuria [1]. Asymptomatic bacteriuria is clearly defined in the literature as bacteriuria [isolation of urinary pathogen(s) at ≥ 10 5 CFU/mL in midstream urine] in the absence of genitourinary signs or symptoms.…”