Theresa Rowe

Diagnosis and Management of Urinary Tract Infection in Older Adults

Urinary tract infection (UTI) is a commonly diagnosed infection in older adults. Despite consensus guidelines developed to assist providers in diagnosing UTI, distinguishing symptomatic UTI from asymptomatic bacteriuria (ASB) in older adults is problematic, as many older adults do not present with localized genitourinary symptoms. This article summarizes the recent literature and guidelines on the diagnosis and management of UTI and ASB in older adults.

Urinary tract infection in older adults.

Urinary tract infection and asymptomatic bacteriuria are common in older adults. Unlike in younger adults, distinguishing symptomatic urinary tract infection from asymptomatic bacteriuria is problematic, as older adults, particularly those living in long-term care facilities, are less likely to present with localized genitourinary symptoms. Consensus guidelines have been published to assist clinicians with diagnosis and treatment of urinary tract infection; however, a single evidence-based approach to diagnosis of urinary tract infection does not exist. In the absence of a gold standard definition of urinary tract infection that clinicians agree upon, overtreatment with antibiotics for suspected urinary tract infection remains a significant problem, and leads to a variety of negative consequences including the development of multidrug-resistant organisms. Future studies improving the diagnostic accuracy of urinary tract infections are needed. This review will cover the prevalence, diagnosis and diagnostic challenges, management, and prevention of urinary tract infection and asymptomatic bacteriuria in older adults.

Entry into primary care-based buprenorphine treatment is associated with identification and treatment of other chronic medical problems

BackgroundBuprenorphine is an effective treatment for opioid dependence that can be provided in a primary care setting. Offering this treatment may also facilitate the identification and treatment of other chronic medical conditions.MethodsWe retrospectively reviewed the medical records of 168 patients who presented to a primary care clinic for treatment of opioid dependence and who received a prescription for sublingual buprenorphine within a month of their initial visit.ResultsOf the 168 new patients, 122 (73%) did not report having an established primary care provider at the time of the initial visit. One hundred and twenty-five patients (74%) reported at least one established chronic condition at the initial visit. Of the 215 established diagnoses documented on the initial visit, 146 (68%) were not being actively treated; treatment was initiated for 70 (48%) of these within one year. At least one new chronic medical condition was identified in 47 patients (28%) during the first four months of their care. Treatment was initiated for 39 of the 54 new diagnoses (72%) within the first year.ConclusionsOffering treatment for opioid dependence with buprenorphine in a primary care practice is associated with the identification and treatment of other chronic medical conditions.

Screening for Fall Risks in the Emergency Department: A Novel Nursing-Driven Program

Introduction Seniors represent the fasting growing population in the U.S., accounting for 20.3 million visits to emergency departments (EDs) annually. The ED visit can provide an opportunity for identifying seniors at high risk of falls. We sought to incorporate the Timed Up & Go Test (TUGT), a commonly used falls screening tool, into the ED encounter to identify seniors at high fall risk and prompt interventions through a geriatric nurse liaison (GNL) model. Methods Patients aged 65 and older presenting to an urban ED were evaluated by a team of ED nurses trained in care coordination and geriatric assessment skills. They performed fall risk screening with the TUGT. Patients with abnormal TUGT results could then be referred to physical therapy (PT), social work or home health as determined by the GNL. Results Gait assessment with the TUGT was performed on 443 elderly patients between 4/1/13 and 5/31/14. A prior fall was reported in 37% of patients in the previous six months. Of those screened with the TUGT, 368 patients experienced a positive result. Interventions for positive results included ED-based PT (n=63, 17.1%), outpatient PT referrals (n=56, 12.2%) and social work consultation (n=162, 44%). Conclusion The ED visit may provide an opportunity for older adults to be screened for fall risk. Our results show ED nurses can conduct the TUGT, a validated and time efficient screen, and place appropriate referrals based on assessment results. Identifying and intervening on high fall risk patients who visit the ED has the potential to improve the trajectory of functional decline in our elderly population.

Lack of Positive Association Between Falls and Bacteriuria Plus Pyuria in Older Nursing Home Residents

To the Editor: Falls are common in older nursing home residents. The 2004 National Nursing Home Survey estimated that 36% of residents had had at least one reported fall in the prior 6 months. Although multiple factors account for these falls, they often prompt empiric antibiotic treatment for urinary tract infection (UTI). Because antimicrobial prescriptions are frequent in nursing homes, and inappropriate use fosters the development of antibiotic resistance, it is important to examine the relationship between falls and UTI. Previous studies have reported a positive association between falls and UTI in older adults. The rate of UTI in older adults who fall has been reported to be as high as 18%, making it one of the most commonly associated diagnoses, but the diagnostic criteria for UTI have not been explicitly defined in these studies. The rate of falls in residents with suspected UTI and subsequently confirmed with bacteriuria (>100,000 colony forming units/ mL) plus pyuria (>10 white blood cells per high-power field on urinalysis) has not been systematically examined. The association between falls abd bacteriuria plus pyuria was investigated in a previously described cohort of noncatheterized nursing home residents with clinically suspected UTI. In this prospective cohort of 551 participants, there were 397 episodes of clinically suspected UTI in 228 residents. Nursing home staff caring for participants at the time of clinically suspected UTI identified falls. The longitudinal association between falls and bacteriuria plus pyuria was examined. Of 397 clinically suspected UTI episodes, 45 falls occurred in 39 participants (34 participants fell once, 4 fell twice, and 1 fell three times). Twelve participants had at least one urinary tract–specific signs or symptoms (costovertebral tenderness, suprapubic pain, hematuria, new or increased urinary incontinence, urgency, and frequency), 13 had changes in urinary characteristics (color or odor), eight had change in mental status, and four had dysuria. Table 1 shows a cross-classification of episodes of falls and bacteriuria plus pyuria. Of the 45 fall episodes, nine (20.0%) were cross-classified with bacteriuria plus pyuria. Of the 352 episodes without a fall, 137 (38.9%) were cross-classified with bacteriuria plus pyuria. A Rao-Scott chi-square statistic, adjusting for nesting of episodes within participants and participants within nursing homes, showed a statistically significant negative association between episodes of falls and bacteriuria plus pyuria (v = 6.69, degrees of freedom = 1, P = .01), but in a multivariable regression model, using a generalized estimating equation approach to account for serial correlation between recurrent episodes of bacteriuria plus pyuria and controlling for important covariates (dysuria, fever, and change in mental status), the negative association between falls and bacteriuria plus pyuria lost its statistical significance (results not shown). Of the 45 falls, 22 had urinary dipstick testing performed. Seven were negative to leukocyte esterase and nitrate; none had bacteriuria plus pyuria. In this study, contrary to previous reports, falls were not associated with bacteriuria plus pyuria. Eighty percent of the 45 fall episodes did not have bacteriuria plus pyuria, suggesting that UTI was unlikely to be associated with the fall. In addition, seven of the 22 participants who fell and were evaluated with a urine dipstick (32%) had a negative test for leukocyte esterase and nitrate, subsequently with no bacteriuria plus pyuria. Urinary dipstick testing for leukocyte esterase and nitrate has been shown to have a negative predictive value of 100%, consistent with the current findings. These results suggest that the majority of individuals in the cohort suspected of having UTI because of a fall would not have benefited from empiric antibiotics. Although participants in this study were from New Havenarea nursing homes only, they are representative of nursing home residents in the United States. Antibiotic resistance in nursing home residents is increasing and is often attributed to overuse of antibiotics. Nursing home residents are particularly susceptible to overuse of antibiotics because of nonspecific symptoms associated with infection such as altered mental status and falls. The results of the current study do not support claims of a positive association between falls and UTI, so empirical treatment with antibiotics for falls is not warranted and may contribute to the overuse of antimicrobials in nursing homes with negative consequences, including isolation of increasingly drug-resistant bacterial pathogens, adverse drug reactions, and secondary infections due to overgrowth of organisms such as Clostridium difficile.

SGIM-AMDA-AGS Consensus Best Practice Recommendations for Transitioning Patients’ Healthcare from Skilled Nursing Facilities to the Community

We assembled a cross-cutting team of experts representing primary care physicians (PCPs), home care physicians, physicians who see patients in skilled nursing facilities (SNF physicians), skilled nursing facility medical directors, human factors engineers, transitional care researchers, geriatricians, internists, family practitioners, and three major organizations: AMDA, SGIM, and AGS. This work was sponsored through a grant from the Association of Subspecialty Physicians (ASP). Members of the team mapped the process of discharging patients from a skilled nursing facility into the community and subsequent care of their outpatient PCP. Four areas of process improvement were identified, building on the prior work of the AMDA Transitions of Care Committee and the experiences of the team members. The team identified issues and developed best practices perceived as feasible for SNF physician and PCP practices to accomplish. The goal of these consensus-based recommended best practices is to provide a safe and high-quality transition for patients moving between the care of their SNF physician and PCP.

Outcomes of Older Adults With Sepsis at Admission to an Intensive Care Unit

Background. Sepsis is a major cause of morbidity and mortality among older adults. The main goals of this study were to assess the association of sepsis at intensive care unit (ICU) admission with mortality and to identify predictors associated with increased mortality in older adults. Methods. We conducted a prospective cohort study of 309 participants ≥60 years admitted to an ICU. Sepsis was defined as 2 of 4 systemic inflammatory response syndrome criteria plus a documented infection within 2 calendar days before or after admission. The main outcome measure was time to death within 1 year of ICU admission. Sepsis was evaluated as a predictor for mortality in a Cox proportional hazards model. Results. Of 309 participants, 196 (63%) met the definition of sepsis. Among those admitted with and without sepsis, 75 (38%) vs 20 (18%) died within 1 month of ICU admission (P < .001) and 117 (60%) vs 48 (42%) died within 1 year (P < .001). When adjusting for baseline characteristics, sepsis had a significant impact on mortality (hazard ratio [HR] = 1.80; 95% confidence interval [CI], 1.28–2.52; P < .001); however, after adjusting for baseline characteristics and process covariates (antimicrobials and vasopressor use within 48 hours of admission), the impact of sepsis on mortality became nonsignificant (HR = 1.26; 95% CI, .87–1.84; P = .22). Conclusions. The diagnosis of sepsis in older adults upon ICU admission was associated with an increase in mortality compared with those admitted without sepsis. After controlling for early use of antimicrobials and vasopressors for treatment, the association of sepsis with mortality was reduced.

The Evolution of Living Kidney Donation and Transplantation in Older Adults.

Kidney transplantation is a good option for adults aged 65 and older with end‐stage renal disease because it has been shown to reduce morbidity and mortality, improve quality of life, and is more cost‐effective than other renal replacement options. However, older age has been a deterrent to access to the deceased donor waiting list, and individuals aged 65 and older have a lower probability of being referred to and listed for transplantation compared to younger adults. Because the deceased organ supply is limited, living donor kidney transplantation offers an effective alternative for older adults facing long waiting times for cadaveric organs. This article describes the evolution of living kidney donation and transplantation in older adults over 15 years using the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients database. Between 1997 and 2011, 28,034 kidney transplantations were performed in adults aged 65 and older. Living‐donor and cadaveric kidney transplantation increased in older adults over the 15‐year period. Offspring are the most common living donors in this age group, followed by unrelated donors (e.g., friends), whereas the most common donors in younger transplant recipients are spouses, siblings, and parents. The number of living kidney donors aged 65 and older is slowly increasing, although the total number of transplants in this age group remains low. The expansion of living‐donor kidney transplantation in the aging population may offer a solution for organ shortage and thereby improve the quality of life of older adults. More research is needed to understand the older donor–recipient relationship and barriers to transplantation in this population.

Outbreak Response and Incident Management: SHEA Guidance and Resources for Healthcare Epidemiologists in United States Acute-Care Hospitals

David B. Banach, MD, MPH, MS; B. Lynn Johnston, MD, MS, FRCPC; Duha Al-Zubeidi, MD; Allison H. Bartlett, MD, MS; Susan Casey Bleasdale, MD; Valerie M. Deloney, MBA; Kyle B. Enfield, MD, MS; Judith A. Guzman-Cottrill, DO; Christopher Lowe, MD, MSc; Luis Ostrosky-Zeichner, MD; Kyle J. Popovich, MD, MS; Payal K. Patel, MD; Karen Ravin, MD, MS; Theresa Rowe, DO, MS; Erica S. Shenoy, MD, PhD; Roger Stienecker, MD; Pritish K. Tosh, MD; Kavita K. Trivedi, MD; and the Outbreak Response Training Program (ORTP) Advisory Panel

Fault Tree Analysis: Assessing the Adequacy of Reporting Efforts to Reduce Postoperative Bloodstream Infection

The purpose of this study was to use fault tree analysis to evaluate the adequacy of quality reporting programs in identifying root causes of postoperative bloodstream infection (BSI). A systematic review of the literature was used to construct a fault tree to evaluate 3 postoperative BSI reporting programs: National Surgical Quality Improvement Program (NSQIP), Centers for Medicare and Medicaid Services (CMS), and The Joint Commission (JC). The literature review revealed 699 eligible publications, 90 of which were used to create the fault tree containing 105 faults. A total of 14 identified faults are currently mandated for reporting to NSQIP, 5 to CMS, and 3 to JC; 2 or more programs require 4 identified faults. The fault tree identifies numerous contributing faults to postoperative BSI and reveals substantial variation in the requirements and ability of national quality data reporting programs to capture these potential faults. Efforts to prevent postoperative BSI require more comprehensive data collection to identify the root causes and develop high-reliability improvement strategies.