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

Caterino, Jeffrey M.; Kline, David; Leininger, Robert; Southerland, Lauren T.; Carpenter, Christopher R.; Baugh, Christopher W.; Pallin, Daniel J.; Hunold, Katherine M.; Stevenson, Kurt B.

doi:10.1111/jgs.15679

Cited by 45 publications

(42 citation statements)

References 50 publications

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“…The clinical conundrum of the abnormal urinalysis in an elderly patient presenting with non-specific symptoms is a common occurrence 14. While it is well-known that UTIs can cause malaise and mental status changes in elderly populations,15 consistent clinical data suggest that the overwhelming percentage of “positive” urinalyses (UA) represent asymptomatic bacteriuria, and are neither truly indicative of UTI nor related to the patient’s non-specific complaints 16. Additionally, fixating on the “positive” UA can often cause clinicians to reach premature diagnostic closure and stop further investigations.…”

Section: Resultsmentioning

confidence: 99%

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

Pescatore

Niforatos

Rezaie³

et al. 2019

WestJEM

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An abnormal urinalysis in an elderly patient presenting to the emergency department (ED) with non-specific symptoms represents one condition that requires an evidence-informed approach to diagnosis and management of either asymptomatic bacteriuria or urinary tract infection (UTI). The emergency provider often will not have access to urine cultures, and the risks associated with antibiotic use in the elderly are not without potentially significant side effects. Methods: We performed a historical and clinical review of the growing body of literature suggesting measurable differences in the systemic immune response manifest among patients with asymptomatic pyuria and UTI, including increases in the pro-inflammatory cytokine interleukin-6 and the acute phase reactant procalcitonin. Results: Serum procalcitonin, a peptide that undergoes proteolysis into calcitonin, has been demonstrated to quickly and reliably rise in patients with severe bacterial infections, and may serve as a potentially sensitive and specific marker for identification of bacterial illness. Conclusion: In the absence of validated risk scores for diagnosing UTI in elderly patients presenting to the ED, there may be a role for the use of procalcitonin in this patient population.

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Section: Resultsmentioning

confidence: 99%

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

Pescatore

Niforatos

Rezaie³

et al. 2019

WestJEM

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“…Even though certain markers defining influenza-like illness, such as fever, myalgia, chills, and cough, were somewhat predictive of positive swab results in our setting, nonspecific symptoms, such as weakness and confusion [ 16 ] were similarly predictive. Although we previously demonstrated that nonspecific symptoms such as weakness are associated with unfavorable prognosis [ 17 ], these symptoms do not generally increase the probability of infection in (older) adults in the ED [ 18 , 19 ]. These symptoms appear to be unable to distinguish COVID-19 from other (infectious) illness.…”

Section: Discussionmentioning

confidence: 99%

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

Mansella

Rueegg

Widmer

et al. 2020

JCM

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

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“…Limitations: first, although we included a comprehensive set of diagnostic codes of infectious disease to define sepsis, the incidence of sepsis in the elderly population might be nonetheless underestimated. Because of immune failure and functional decline, conventional clinical symptoms of inflammatory response may be lacking in older patients, or they might occur with atypical manifestations, like delirium or falls [26], which are frequent confounders for the rapid diagnosis of sepsis. Second, we used the all-cause mortality rather than sepsis-related mortality as primary endpoint of our study.…”

Section: Discussionmentioning

confidence: 99%

Old subjects with sepsis: trend analysis of case fatality rate in the Emergency Department

Fabbri

Marchesini

Benazzi

et al. 2019

Preprint

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Background: The burden of sepsis represents a global health care problem. We aimed to assess the case fatality rate (CFR) and its predictors in subjects with sepsis admitted to a general Italian hospital from 2009 to 2016, stratified by risk score.Methods: We performed a retrospective analysis of all sepsis-related hospitalizations after Emergency Department (ED) visit in a public Italian hospital in an 8-year period. A risk score to predict CFR was computed by logistic regression analysis of selected variables in a training set (2009-2012), and then confirmed in the whole study population. A trend analysis of CFR during the study period was performed dividing patient as high-risk (upper tertile of risk score) or low-risk . Results: 2,492 subjects were included. Over time the incidental admission rate (no. of sepsis-related admissions per 100 total admissions) increased from 4.1% (2009-2010) to 5.4% (2015-2016); P<0.001, accompanied by a reduced CFR (from 38.0% to 18.4%; P<0.001). A group of 10 variables (admission in intensive care unit, cardio-vascular dysfunction, HIV infection, diabetes, age ≥80 years, respiratory diseases, number of organ dysfunction, digestive diseases, dementia and cancer) were selected by the logistic model to predict CFR with good accuracy: AUC 0.873 [0.009]. Along the years CFR decreased from 31.8% (2009-2010) to 25.0% (2015-2016); P = 0.007. The relative proportion of subjects ≥80 years (overall, 52.9% of cases) and classified as high-risk did not change along the years. CFR decreased only in low-risk subjects (from 13.3% to 5.2%; P<0.001), and particularly in those aged ≥80 (from 18.2% to 6.6%; P=0.003), but not in high-risk individuals (from 69.9% to 64.2%; P=0.713). Conclusion: Between 2009 and 2016 the incidence of sepsis-related hospitalization increased in a general Italian hospital, with a downward trend in CFR, only limited to low-risk patients and particularly to subjects ≥80 years.

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

Cited by 45 publications

References 50 publications

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

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

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

Old subjects with sepsis: trend analysis of case fatality rate in the Emergency Department

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