Evaluation and Management of Geriatric Infections in the Emergency Department: Focus on UTI

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Evaluation and Management of Geriatric Infections
in the Emergency Department Focus on UTI

• Jeffrey M. Caterino, MD,MPH, FACEP
• Associate Professor
• Departments of Emergency Medicine and Internal
  Medicine
• The Ohio State University, Columbus, Ohio

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Outline

• 1. Altered presentation of UTI in older adults
• 2. Diagnosis of UTI
• 3. Antibiotic choices in elders
• Why worry about UTI in the ED?
• 5 of all ED visits in those 65 years old
• 750,000 ED visits per year

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Why do elders get UTIs?

• 1. Physiologic changes of aging
• E.g., decreased barrier protection, impaired
  cough, increased aspiration, poor circulation,
  poor oral hygiene, malnutrition
• 2. Co-morbidities
• E.g., diabetes, CVA, cirrhosis, renal failure,
  immunosuppresive medications
• 3. Medical devices and procedures
• Indwelling lines, catheters, devices
• Recent instrumentation, prosthetic joints,
  orthopedic hardware
• 4. Waning immunity

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Atypical Presentation

• General alterations in presentation
• Fever
• Delirium
• Functional decline
• Lack of common symptoms

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Atypical Presentation Fever

• In ED elders with a fever
• 90 have an infection
• 90 of infections are bacterial
• 1/3 of elders with bacterial infection do not
  have a fever as traditionally defined

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Atypical PresentationWhats a fever in elders?

• Lower baseline body temperature, decreased immune
  response
• Elder ED nursing home patients
• Temp gt38.3C (101F) 40 sensitive for bacterial
  infection
• Temp 37.2C (99F) 83 sensitive and 89
  specific
• Increase from baseline is a better measure than
  an absolute cutoff
• An increase of 1.3C (2F) above baseline
  indicates elevated temperature

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Atypical presentation Whats a fever in elders?

• Proposed criteria for fever in elders
• Consider infection if temperature is
• 37.2C (99F) or
• Increased 1.3 (2F) above baseline
• The problem of diagnosis
• Surveillance definitions vs. acute clinical care

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Atypical Presentation - Delirium

• Altered mental status is common in infected
  elders
• 5-10 overall and 30-40 of nursing home patients
• Delirium is under recognized by ED MDs
• Missed in ¾ of cases
• Unrecognized delirium is a risk factor for ED
  revisit and mortality

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Atypical Presentation - Delirium

• Scales to recognize delirium
• CAM-ICU, short blessed test, six-item screener
• Establish baseline cognitive status
• Evaluate for
• Acute change
• Inattention
• Altered level of consciousness
• Disorganized thinking
• Delirium is both
• A clue that infection is present
• The sequela of that infection

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Delirium

• Scales to recognize delirium
• CAM-ICU, short blessed test, six-item screener
• Confusion Assessment Method (CAM)-ICU

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Atypical Presentation Functional Status

• Infection is often accompanied by acute declines
  in functional status
• Increased falls, near-falls
• Inability to perform common tasks
• Generalized weakness
• Among infected ED elders
• 1/2 have decreased functional status
• 1/3 have decreased functional status from
  baseline
• Decreased functional status is both
• A clue that infection is present
• The sequela of that infection

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Nonspecific signs of infection functional status
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Urinary tract infection Classic symptoms

• Presence of common symptoms
• Urinary symptoms 26
• Mental status changes 26
• Fever 17
• WBC gt11,000 43
• In the ED, those over 65
• 2x as likely to have altered mental status
• ½ as likely to have classic GU symptoms

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Urinary tract infection - Diagnosis

• Urine dipstick in elder ED patients
• Sensitivity 74
• (sensitivity for positive nitrites, leukocyte
  esterase, or both)
• Specificity 70
• Microscopy is preferred
• Culture should be obtained
• To identify true infection and resistance
• Replace indwelling catheters prior to obtaining
  samples

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UTI Asymptomatic Bacteriuria

• Positive culture does not always acute
  infection
• Asymptomatic bacteriuria
• Positive culture in the absence of symptoms
• Present in up to 20 of ED elders
• Cautions
• No benefit to treating asymptomatic bacteriuria
• But, remember symptoms may be atypical
• In the ED, err on side of treating
• Do not forgo the search for other sources of
  infection

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Urinary tract infection - Treatment

• Increased rates of antibiotic resistance
• One 2001 study of elder ED patients with UTI
• 50 with multi-drug resistant organism
• 50 with TMP-SMX resistance
• 11 with fluoroquinolone resistance
• Nursing home patients
• 70 TMP-SMX resistance
• 40 fluoroquinolone resistance

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Urinary tract infection

• Organisms cultured from OSU ED elders

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Urinary tract infection

• E coli fluoroquinolone resistance rates at OSU
• (95 CI) p-value
• Hospital antibiogram (n1483) 36 (33-38)
• Overall ED elders (n67) 45 (33-57) 0.145
• ECF ED elders (n21) 57 (34-78) 0.046

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Urinary tract infection

• Antibiotic resistance in elder UTIs at OSU
•  
• Overall ECF non-ECF p-value (n66) (n3
  1) (n35)
• Any MDRO 71 84 60 0.033
• Fluoroquinolone 50 58 43 0.218
• TMP-SMX 47 48 46 0.828

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Urinary tract infection - Treatment

• Risk factors for antibiotic resistance
• Nursing home resident
• Chronic indwelling catheter
• Structural or functional GU abnormalities
• Recent UTIs
• Recent GU instrumentation
• Immunosuppression

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Urinary tract infection

• Antibiotic selection Based on patient
  characteristics and local resistance patterns in
  this patient population
• Caution over use of TMP-SMX or fluoroquinolone
  monotherapy if risk factors for resistance are
  present
• Additional antibiotics to consider
• Nitrofurantoin
• Beta-lactams 2nd or 3rd generation
  cephalosporins, extended-spectrum penicillins
• Dual therapy
• ICU patients or complicated UTI
• Consider extended-spectrum beta-lactams to cover
  pseudomonas and other resistant gram negatives

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UTI Take Home Points

• Symptoms are often nonspecific
• Positive urinalysis may not represent true acute
  infection
• Continue to search for other sources of infection
• Obtain cultures
• Replace indwelling catheters before obtaining
  cultures
• Be aware of the possibility of antibiotic
  resistance

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Famous last words for infections in older adults

• The patients temperature was only 99.5 so I
  wasnt worried about infection.
• Yeah she had a fever just due to a viral URI
• Urine had some LE in it, so I just gave him some
  cipro. I figured thats what caused his altered
  mental status and falls.
• I didnt suspect pneumonia there was no cough
  or white count.
• I dont know why she fell but we got ortho to
  see her about the broken hip.