Age, Nursing Home Residence, and Presentation of Urinary Tract Infection in U.S. Emergency Departments, 2001–2008

Abstract

Objectives: Current outpatient diagnostic algorithms for urinary tract infection (UTI) in older adults require the presence of classic signs and symptoms of UTI, such as fever and genitourinary symptoms. However, older adults with UTI may present with atypical signs and symptoms. The objective was to identify the associations of age and nursing home status with the clinical presentation of emergency department (ED) patients diagnosed with UTI.Methods: This was a retrospective, cross-sectional analysis of the 2001-2008 National Hospital Ambulatory Medical Care Survey (NHAMCS), ED component. Participants were adult ED patients diagnosed with UTI. Outcome variables were presence of fever, altered mental status, and urinary tract symptoms. Multivariable logistic regression models were constructed for each outcome. Age and nursing home status were the independent variables of interest. Age was divided into adults 18 to 64 years, older adults 65 to 84 years, and oldest adults 85 years of age and older.Results: There were 25.4 million ED visits in which UTI was diagnosed from 2001 through 2008, including 5.0 million in older adults and 2.2 million in the oldest adults. Fever was present in 13% of adults, 21% of older adults, and 19% of the oldest adults. Altered mental status was present in 1% of adults, 7% of older adults, and 13% of the oldest adults. Urinary tract symptoms were identified in 32% of adults, 24% of older adults, and 17% of the oldest adults. In multivariable analysis, altered mental status was more common in older adults (odds ratio [OR] = 1.94) and in the oldest adults (OR = 2.49). Urinary tract symptoms were less common in older adults (OR = 0.60) and the oldest adults (OR = 0.48). Nursing home residence was associated with increased fever (OR = 1.63) and altered mental status (OR = 4.79) and with decreased urinary tract symptoms (OR = 0.35).Conclusions: Fever and urinary tract symptoms are absent in a large proportion of adults over 65 years of age diagnosed with UTI in the ED. Age over 65 years and nursing home residence are associated with increased presence of altered mental status and with lack of urinary tract symptoms. Nursing home residence is also associated with increased presence of fever. Emergency physicians (EPs) continue to diagnose UTI in patients without classic symptoms. Diagnostic criteria for UTI among adults 65 years and over specifically designed for use in the acute care setting should be developed and validated to prevent both inappropriate overdiagnosis and underdiagnosis of UTI.

Differential characteristics of healthcare-associated compared to community-acquired febrile urinary tract infections in males

“…As in previous studies, males with HCA-FUTI had a lower frequency of mictional symptoms, spontaneous flank pain and lumbar tenderness [3]. These observations are consistent with those found by Caterino et al regarding a decreased frequency of specific urinary symptoms in patients aged over 65 years, particularly among those living in nursing home residences [18]. The diagnosis of UTI in elderly is challenging as they frequently present with atypical symptoms, although the presence of atypical symptoms is not always indicative of UTI.…”

Escherichia coli antibiotic resistance in emergency departments. Do local resistance rates matter?

“…Grouping months across the 6 years of the study period, median number of isolates per month was 1,442 (1,415-1,486). Lowest and highest numbers of isolates were obtained respectively in February (1,259) and in August (1,704). Overall, susceptibility rates to amoxicillin, amoxicillin-clavulanate, cefotaxime, ciprofloxacin, gentamicin and cotrimoxazole were 56.7 % (55.9-57.4 %), 69.…”

“…Urinary tract infections (UTIs) account for a major proportion of Emergency Department (ED) visits and antibacterial therapy in the ED [1,2]. Most of antibacterial therapies for UTI are started on an empirical basis, i.e.…”

Urinary Tract Infections in the Elderly

“…UTI is a significant cause of mortality, with bacteraemic UTI carrying a mortality of up to 33 % in older adults [1]. The diagnosis of UTI in older persons is often challenging, with older patients being less likely to present with classical symptoms or fever [2] and with asymptomatic bacteriuria being highly prevalent [3][4][5]. It has been estimated that in hospitalised older people, up to half of diagnoses of UTI are incorrect [6].…”