Treatment of asymptomatic UTI in older delirious medical in-patients: A prospective cohort study

Dasgupta, Monidipa; Brymer, Chris; Elsayed, Sameer

doi:10.1016/j.archger.2017.05.010

Cited by 34 publications

(35 citation statements)

References 51 publications

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“…The proportion of asymptomatic patients who received antibiotics in our study (18%) was slightly lower than the 27% of confused patients treated for ASB in a previous study involving in-patients. ( 25 ) This variation may be due to the shorter time course of ED treatment, as 35–40% of the patients treated for ASB in the in-patient study received their treatment after the first week of admission. ( 25 )…”

Section: Discussionmentioning

confidence: 99%

“…No such data were published from any Canadian EDs to our knowledge. To date, studies have reported on nursing home and inpatient UTI care patterns, the appropriateness of UTI investigation and treatment in older adults, ( 14 , 15 , 22 – 25 ) ED patterns of UTI investigation in young patients, ( 26 ) and ED antibiotic prescription for UTI in all older women. ( 16 ) The last of these found that only one-third of patients diagnosed with UTI had urinary symptoms, and that many presented with confusion instead, but the study did not specifically investigate this link.…”

Section: Introductionmentioning

confidence: 99%

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

Pinnell¹,

Ramsay²,

Wang³

et al. 2021

Can Geriatr J

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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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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

Pinnell¹,

Ramsay²,

Wang³

et al. 2021

Can Geriatr J

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“…᭺ An outstanding question is whether a time-limited trial of antibiotics should be undertaken in patients with delirium and no evidence of infection. A prospective cohort study of older medical inpatients with delirium and asymptomatic bacteriuria examined the effect of a test treatment with antibiotics, hypothesising that a urinary tract infection could be responsible for the clinical picture [90]. The older patients treated in this way obtained worse percentages of functional recovery and a higher incidence of Clostridium difficile infections, questioning the benefit of a time-limited trial of antibiotics in older patients with delirium and asymptomatic bacteriuria [90].…”

Section: Recommendationmentioning

confidence: 99%

Delirium in adult cancer patients: ESMO Clinical Practice Guidelines

et al. 2018

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“…Yet many older patients, particularly those with cognitive impairments where history-taking is clinically challenging, are often subjected to frequent, but needless antibiotic treatment regimens that do not cure or eradicate the bacteriuria, but actually drive microbial resistance [11]. However, the clinical dilemma is considerable because leaving a suspected UTI untreated in such patients may allow the infection to progress resulting in pyelonephritis, septicaemia and in some cases death [2, 12], but if treated unnecessarily can predispose individuals to opportunistic infections such as Clostridium difficile antibiotic induced diarrhoea [11]. This conundrum illustrates the need for further investigations in older patient groups, specifically focussing on host-microbial interactions during periods of bacteriuria or asymptomatic carriage and infection.…”

Section: Introductionmentioning

confidence: 99%

Elevated urine IL-10 concentrations associate with Escherichia coli persistence in older patients susceptible to recurrent urinary tract infections

et al. 2019

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Background Age is a significant risk factor for recurrent urinary tract (rUTI) infections, but the clinical picture is often confused in older patients who also present with asymptomatic bacteriuria (ASB). Yet, how bacteriuria establishes in such patients and the factors underpinning and/or driving symptomatic UTI episodes are still not understood. To explore this further a pilot study was completed in which 30 male and female community based older patients (mean age 75y) presenting clinically with ASB / rUTIs and 15 control volunteers (72y) were recruited and monitored for up to 6 months. During this period symptomatic UTI episodes were recorded and urines collected for urinary cytokine and uropathogenic Escherichia coli (UPEC) analyses. Results Eighty-six per cent of patients carried E. coli (10 2 ≥ 10 5 CFU/ml urine) at some point throughout the study and molecular typing identified 26 different E. coli strains in total. Analyses of urine samples for ten different cytokines identified substantial patient variability. However, when examined longitudinally the pro-inflammatory markers, IL-1 and IL-8, and the anti-inflammatory markers, IL-5 and IL-10, were significantly different in the patient urines compared to those of the controls ( P < 0.0001). Furthermore, analysing the cytokine data of the rUTI susceptible cohort in relation to E. coli carriage, showed the mean IL-10 concentration to be significantly elevated ( P = 0.04), in patients displaying E. coli numbers ≥10 5 CFU/ml. Conclusions These pilot study data suggest that bacteriuria, characteristic of older rUTI patients, is associated with an immune homeostasis in the urinary tract involving the synthesis and activities of the pro and anti-inflammatory cytokines IL-1, IL-5, IL-8 and IL-10. Data also suggests a role for IL-10 in regulating bacterial persistence.

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Treatment of asymptomatic UTI in older delirious medical in-patients: A prospective cohort study

Cited by 34 publications

References 51 publications

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

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

Delirium in adult cancer patients: ESMO Clinical Practice Guidelines

Elevated urine IL-10 concentrations associate with Escherichia coli persistence in older patients susceptible to recurrent urinary tract infections

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