Profile and prognosis of febrile elderly patients with bacteremic urinary tract infection

https://doi.org/10.1016/j.jinf.2004.04.004Get rights and content

Abstract

Objective. To describe the profile of elderly patients with bacteremic urinary tract infections (UTI) and correlate clinical and laboratory findings with the outcome in order to identify independent predictors of mortality.

Methods. This retrospective study took place in a large community-based, geriatric hospital and included 191 patients aged 75–105 years with urine and blood cultures simultaneously positive for bacterial organisms. Records were analysed for demographic information, clinical and laboratory data over a 29 month period. Mortality was assessed and was correlated with these findings.

Results. Most of the patients (80.1%) had community-acquired infection. Gram-negative organisms accounted for 87.6% of bacterial isolates, with Escherichia coli accounting for 46.1% of cases. Non-Escherichia coli Gram-negative organisms were highly resistant to two common urinary tract antibiotics (gentamicin and ceftriaxone). Patients with chronic urinary catheter had Gram-negative bacteria significantly less sensitive to ciprofloxacin, gentamycin, ampicillin and ceftriaxon than patients without catheter (p<0.05). In-hospital mortality was 33%. Multiple logistic regression analysis revealed that mortality was significantly related to the number of underlying diagnoses (p<0.0203), cognitive status (p<0.0003), length of hospitalization (p<0.0397), low level of serum albumin (p<0.0021), high neutrophil count (p<0.0001) and high level of lactate dehydrogenase (p<0.0351). Fatality was not associated with advanced age in the very old.

Conclusion. Bacteremic UTI in the elderly has a high mortality rate. In frail elderly patients with age-associated multiple severe underlying disorders and cognitive impairment, early recognition of bacteremic UTI and prompt, appropriate treatment are critical in reducing the mortality.

Introduction

In older people, the most common bacterial infection is urinary tract infection (UTI), which appears as the most common cause of sepsis in this population. It is also the most common cause of fever in patients hospitalized because of acute febrile disease.1., 2., 3.

The clinical presentation of UTI in the elderly patients is variable, ranging from asymptomatic to septicaemia. Although most infections are asymptomatic or mild and are managed in outpatient, these infections can also be devastating resulting in sepsis and death.

Bacteremic UTI carries with it a mortality rate of 25–60%.1., 4., 5. When possible urosepsis is suspected in older patients, immediate decisions regarding appropriate antibiotic choice must be made. Instituting broad-spectrum coverage with one or more antibiotic is usually recommended.6., 7. Another problem in the choice of empiric antibiotic treatment is the increasing resistance of uropathogens to common antibiotic drugs.

In this retrospective study, we reviewed the records of 191 consecutive febrile patients over 75 years old with simultaneously positive urine and blood cultures for the same organism, who were seen in our hospital over a 29-month period, from January 1998 to May 2000. Clinical and laboratory findings were correlated with the outcome in order to identify independent predictors of mortality.

Section snippets

Material and methods

The study took place at the Subacute Department of Geriatric Hospital (a 300-bed community hospital) affiliated to a General Hospital. The majority of the patients in this department are admitted from the emergency room of the General Hospital. We reviewed the hospital records of all the patients, 75 years and older with fever over 38 °C, who were diagnosed as bacteremic UTI, which was diagnosed when the same organism was isolated from both urine and blood of the same patient within 48 h of

Results

We identified a total of 191 patients with positive blood and urine cultures for the same organism.

Discussion

UTI remains a significant cause of morbidity in all age groups and is the most frequent cause of sepsis in older adults.8 Several earlier studies have investigated bacteraemias in older patients. In these studies, UTI is the most commonly identified single source of bacteraemia responsible for 32% of the community-acquired bacteraemias and for 40% of the nosocomial bacteraemias with a single identifiable source.9., 10., 11. Bacteremic UTI have been described in relation to the specific places

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