By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: In elderly patients with bacteremic urinary tract infection (UTI), symptoms of UTI were present in only one-third of patients, only four-fifths had fever, and just three-fifths had an early diagnosis of UTI.
SOURCE: Laborde C, Bador J, Hacquin A, et al. Atypical presentation of bacteremic urinary tract infection in older patients: Frequency and prognostic impact. Diagnostics (Basel) 2021;11:523.
Laborde and colleagues retrospectively evaluated the symptoms present in inpatients at the Dijon University hospital in patients 75 years of age or older who proved to have bacteremia and bacteriuria caused by the same gram-negative bacillus over a one-year period. They identified 105 such patients who had a mean age of 85.3 years and 61.9% of whom were women. Approximately one-fifth of them had a chronic urinary catheter. Infection was community-acquired in 49.5% of patients, hospital-acquired in 24.8%, and was acquired while residing in a long-term care facility in 25.7%. Patient falls were reported in 21 patients (20%), and reduction in an activity of daily living score was identified in 17 (16.2%).
Symptoms or signs of urinary tract infection (UTI) were present in 38 patients (36.2%), fever (> 38.3° C) was present in 61 patients (59.8%), and signs of sepsis were present at the time of blood culture phlebotomy in 85 patients (81.6%). Women were significantly less likely than men to have symptoms of UTI (44.7% vs. 71.6%; P = 0.01). A clinical diagnosis of UTI was made in only 58% of the entire cohort. The 90-day mortality was 23.6%. Independent predictors of lesser mortality were fever at presentation and early diagnosis of UTI — but the presence or absence of UTI symptoms was not associated with prognosis.
Dealing with suspected or proven UTI in the elderly, particularly residents of long-term care facilities, is a persistently perplexing problem. The frequent lack of urinary symptoms in bacteremic UTI has been identified previously. On the one hand, we are faced with the problem of overuse of urinalyses and urine cultures together with an inability to unequivocally distinguish UTI from urinary bacterial colonization in many instances. On the other hand, we have to deal with the fact that potentially life-threatening UTI may be present in the absence of localizing symptoms in the elderly. Thus, in this retrospective analysis of elderly patients with bacteremic UTI, symptoms of UTI were present in only one-third, and only four-fifths had fever and just three-fifths had an early diagnosis of UTI — with early diagnosis associated with better outcomes.
Does altered mental status warrant evaluation and, if so, how do you distinguish such changes that commonly occur as a result of “sundowning” or of medications? The routine examination of urine in such cases will lead to overprescribing and contribute to the problem of antibiotic resistance that is so prevalent in many long-term care facilities.
As clinicians recommending care for these patients, we, thus, are caught on the horns of a dilemma — one with which we do not seem to be making much progress in its resolution.