Improving Management of Urinary Tract Infections in Older Adults: A Paradigm Shift or Therapeutic Nihilism?

Crnich, Christopher; Jump, Robin L.P.; Nace, David A.

doi:10.1111/jgs.14961

Cited by 8 publications

(9 citation statements)

References 25 publications

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“…UTI is the second most common diagnosis for which empirical antibiotics are prescribed in both primary and secondary care, with more than 50% of the antibiotics prescribed for a suspected UTI in older adults being considered unnecessary. 9 10 11 With the spread of antibiotic resistance and its increasing threat to public health (about 30% of urinary isolates of E coli are now resistant to trimethoprim), national guidelines and antimicrobial stewardship programmes have been proposed to combat these challenges. 12 13 14 15 16 NHS England, for example, released the Quality Premium to incentivise Clinical Commissioning Groups to reduce antibiotic use in primary care.…”

Section: Introductionmentioning

confidence: 99%

Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study

Gharbi

Drysdale

Lishman

et al. 2019

BMJ

158

137

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Objective To evaluate the association between antibiotic treatment for urinary tract infection (UTI) and severe adverse outcomes in elderly patients in primary care. Design Retrospective population based cohort study. Setting Clinical Practice Research Datalink (2007-15) primary care records linked to hospital episode statistics and death records in England. Participants 157 264 adults aged 65 years or older presenting to a general practitioner with at least one diagnosis of suspected or confirmed lower UTI from November 2007 to May 2015. Main outcome measures Bloodstream infection, hospital admission, and all cause mortality within 60 days after the index UTI diagnosis. Results Among 312 896 UTI episodes (157 264 unique patients), 7.2% (n=22 534) did not have a record of antibiotics being prescribed and 6.2% (n=19 292) showed a delay in antibiotic prescribing. 1539 episodes of bloodstream infection (0.5%) were recorded within 60 days after the initial UTI. The rate of bloodstream infection was significantly higher among those patients not prescribed an antibiotic (2.9%; n=647) and those recorded as revisiting the general practitioner within seven days of the initial consultation for an antibiotic prescription compared with those given a prescription for an antibiotic at the initial consultation (2.2% v 0.2%; P=0.001). After adjustment for covariates, patients were significantly more likely to experience a bloodstream infection in the deferred antibiotics group (adjusted odds ratio 7.12, 95% confidence interval 6.22 to 8.14) and no antibiotics group (8.08, 7.12 to 9.16) compared with the immediate antibiotics group. The number needed to harm (NNH) for occurrence of bloodstream infection was lower (greater risk) for the no antibiotics group (NNH=37) than for the deferred antibiotics group (NNH=51) compared with the immediate antibiotics group. The rate of hospital admissions was about double among cases with no antibiotics (27.0%) and deferred antibiotics (26.8%) compared with those prescribed immediate antibiotics (14.8%; P=0.001). The risk of all cause mortality was significantly higher with deferred antibiotics and no antibiotics than with immediate antibiotics at any time during the 60 days follow-up (adjusted hazard ratio 1.16, 95% confidence interval 1.06 to 1.27 and 2.18, 2.04 to 2.33, respectively). Men older than 85 years were particularly at risk for both bloodstream infection and 60 day all cause mortality. Conclusions In elderly patients with a diagnosis of UTI in primary care, no antibiotics and deferred antibiotics were associated with a significant increase in bloodstream infection and all cause mortality compared with immediate antibiotics. In the context of an increase of Escherichia coli bloodstream infections in England, early initiation of recommended first line antibiotics for UTI in the older population is advocated.

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Section: Introductionmentioning

confidence: 99%

Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study

Gharbi

Drysdale

Lishman

et al. 2019

BMJ

158

137

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show abstract

“…7,39,40 Avoiding antibiotics in ASB has been included in the Choosing Wisely campaign, and there have been calls to adopt this policy not only in outpatient but also in acutecare settings. [41][42][43] However, although ASB has been studied in multiple settings, including nursing homes and the community, 39 this approach has not been validated in the ED, where patients present for an acute event or change in status. In our data and prior studies, ED and inpatient physicians often diagnose UTIs in older adults in the absence of urinary symptoms.…”

Section: Discussionmentioning

confidence: 99%

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

Caterino

Kline

Leininger³

et al. 2018

J American Geriatrics Society

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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.

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“…Additionally, dietary requirements, enough hydration, hygiene care practices, as well as proper exercises such as Kegel's exercise, bladder training, and walking are recommended. Furthermore, medical follow-up and referral services are available (Crnich, 2017;Nicolle, 2018;Rarrick et al, 2020). The proposed education nursing program was designed to provide community-dowelling older adults with the essential information and skills related to appropriate preventive practices (Center for Disease Control and Prevention (CDC), 2021).…”

Section: Healthmentioning

confidence: 99%

“…The prevalence of UTI among older adults varies widely between nations; in the United States (USA), women over 65 years are diagnosed with UTI at a rate of 45% to 55%, while men of the same age are diagnosed at a rate of 33% to 46% (Crnich et al, 2017). Furthermore, in Alexandria, Egypt, 75% to 85% of geriatric patients hospitalized at the Main University Hospital and Health Insurance Hospital had UTI respectively, while in El Behera, Egypt, the percent of older adults admitted to Damanhur National Medical Institute outpatient clinics and suffering from UTI was 65% to 75% (Hospital Statistical Records, 2015.…”

Section: Introductionmentioning

confidence: 99%

“…They may exhibit atypical manifestations, such as low grade fever, confusion, lethargy, dyspnea, cough, and anorexia, as well as a sudden episode of urinary incontinence, foul-smelling urine, and a general sense of being ill (Elbeddini, 2018). Because of the lack of typical symptoms of UTI and the decreased host defense mechanism, diagnosis, prevention, and treatment are often difficult in older adults (Crnich, 2017).…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Effect of Education Nursing Program on Preventive Practices of Urinary Tract Infection among Community-Dwelling Older Adults

Abd-Elwahab

Ibrahim

Gouda

et al. 2021

Alexandria Scientific Nursing Journal

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Improving Management of Urinary Tract Infections in Older Adults: A Paradigm Shift or Therapeutic Nihilism?

Cited by 8 publications

References 25 publications

Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study

Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study

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

Effect of Education Nursing Program on Preventive Practices of Urinary Tract Infection among Community-Dwelling Older Adults

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