When comparing these data to available national statistics that estimate participation in youth soccer, true injury rates may actually be decreasing for boys and girls. Young children should be closely supervised because of risk of head injuries and rate of hospitalization. The establishment of a national database of soccer participation and injury data is needed to better identify injury risks.

Objectives To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED). Design Preplanned, secondary analysis of a prospective observational study. Setting Tertiary care, academic ED. Participants A total of 424 patients in the ED, 65 years or older, including all chief complaints. Measurements We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection. Results Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40‐2.53) or malaise/lethargy (PLR range, 1.25‐1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15‐18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79‐0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms. Conclusions The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484–492, 2019.

Objectives To evaluate the accuracy of emergency department (ED) physicians’, the Loeb criteria, and CDC guideline diagnoses of acute bacterial infection in older adults compared to a gold standard expert review. Design Prospective, observational study. Setting Urban, tertiary-care ED. Participants ED patients aged ≥65 years, excluding those incarcerated, traumas, non-English speaking, or unable to consent. Measurements Two physician experts identified bacterial infections using clinical judgement, patient surveys, and medical records; a third adjudicated in cases of disagreement. Agreement and test characteristics were measured for ED physician diagnosis, Loeb criteria, and CDC surveillance guidelines. Results Gold-standard review identified bacterial infection in 77/424 patients (18%): 18(4.2%) lower respiratory, 19(4.5%) urinary tract (UTI), 22(5.2%) gastrointestinal, and 15(3.5%) skin/soft tissue. ED physicians diagnosed infection in 71 (17%), but there were 33 with under- and 27 with over-diagnosis. Physician agreement with the gold standard was moderate for infection overall and each infection type (kappa [k] 0.48–0.59), but sensitivity was low (<67%), and negative likelihood ratio (LR[−]) >0.30 for all infections. Loeb criteria had poor sensitivity, agreement, and LR(−) for lower respiratory (50%; k=0.55; 0.51) and UTI (26%; k=0.34; 0.74), but 87% sensitivity (k=0.78; LR[−] 0.14) for skin/soft tissue infection. CDC guidelines had moderate agreement, but poor sensitivity and LR(−). Conclusions Infections are often under- and over-diagnosed by emergency physicians in older adults. The Loeb criteria are useful only for diagnosing skin/soft tissue infections. CDC guidelines are inadequate in the ED. New criteria are needed to aid ED physicians in accurately diagnosing infection in older adults.

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