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- Title
Diagnostic uncertainty and empiric treatment of suspected urinary tract infection in older adults in the emergency department: a retrospective single-centre descriptive study.
- Authors
Samarasekara, Keshinie
- Abstract
Introduction Urinary tract infections (UTIs) are common in older adults1 and over-treatment or undertreatment has significant consequences (antibiotic resistance and increased morbidity/mortality respectively). Making a diagnosis of UTI in older adults poses a challenge due to high prevalence (7-10% of men and 17-20% of women over 75 years) of asymptomatic bacteriuria. On presentation to the emergency department, the decision to treat suspected UTI is based on the information available at the front door; history, examination, full blood count, C-reative protien and urine dipstick test. Older adults often present with non-specific symptoms and are unable to give a clear history due to cognitive impairment. The aims of this study were to retrospectively assess the diagnostic accuracy of UTI at the front door, with availability of further information (urine microscopy, urine culture, blood culture and chest X-ray etc) subsequently, and to describe the prescribing pattern of empirical antibiotics for suspected UTI at the front door. Materials and methods Electronic records of all patients over 75 years of age attending UCH emergency department within a 3-month period were retrospectively scrutinised to identify those treated at the front door with an antibiotic to cover UTI. Anonymised demographic data, signs and symptoms at presentation, investigation results and antibiotic prescription details were collected and analysed. Patients were categorised as having definite, possible or no evidence of UTI, as per Table 1. Results and discussion The ages of the study population ranged from 75-101 years (median 82). The majority were female (59.3%). Only 15.1% of the study population had evidence of definite UTI. The majority (53.5%) had 'possible UTI', indicating that currently available investigations are insufficient to accurately determine the true presence of UTI (as opposed to colonisation). Approximately one third (31.4%) had no evidence of UTI when all test results were available, indicating that clinical features and point-of-care tests at the front-door lack diagnostic accuracy for UTI. There is no significant difference between the number of patients with or without long-term catheter being diagnosed with definite UTI (P <0.05). Approximately half the study population received oral antibiotics and the others received IV antibiotics. The duration of antibiotics ranged from 3-7 days. The most commonly used IV antibiotics were cefuroxime (27.9%), co-amoxiclav (5.6%) and ciprofloxacin (5.6%). Nitrofurantoin (16.3%) and ciprofloxacin (10.5%) were the commonest oral antibiotics used. Conclusions Better diagnostic tests need to be developed for differentiating UTI from urinary colonisation in older adults, and for point-of-care diagnosis of UTI in the emergency department. Response to antibiotic treatment cannot be utilised for retrospective confirmation of diagnosis of UTI in older adults, as the vast majority of empiric antibiotics used also cover lower respiratory tract infections.
- Subjects
SCOTLAND; URINARY tract infection diagnosis; HOSPITAL emergency services; URINARY tract infections; UNCERTAINTY; CONFERENCES &; conventions; SENSITIVITY &; specificity (Statistics); OLD age
- Publication
Clinical Medicine, 2023, Vol 23, ps51
- ISSN
1470-2118
- Publication type
Article
- DOI
10.7861/clinmed.23-6-s51