Urine culture doubtful in determining etiology of diffuse symptoms among elderly individuals [Urinodling har tveksamt värde vid beslut om antibiotikabehandling av patienter på äldreboenden]

Background: As many as half of elderly residents at nursing homes have asymptomatic bacteriuria. Thus it’s hard to know if a new symptom is related to findings of bacteria in urine or not. There are different opinions on the possible connection between different non-specific symptoms and urinary tract infections (UTI). Non-specific symptoms in combination with diagnostic uncertainty often lead to antibiotic treatments of uncertain value. Antibiotic overuse increases the prevalence of antibiotic resistant bacteria. Research question: What is the relationship between bacteria in the urine and new or increased fatigue, confusion, restlessness, aggressiveness, not being herself/himself, dysuria, urgency and fever. Methods: In this cross-sectional study symptoms were registered and voided urine specimens collected for urine cultures from 651 elderly residents in 32 nursing homes located in south-western Sweden. Correlation between bacteriuria and presence of a symptom at group level were determined using logistic regression. To estimate the clinical relevance of correlations at group level positive and negative etiological predictive values (EPV) were calculated. EPV takes into account the presence of asymptomatic bacteriuria. Results: In this study 207/651 (32%) of urine cultures were positive. Fatigue, restlessness and confusion were the most common symptoms. Logistic regression indicated some correlations at group level. Aside from Escherichia coli in the urine and not being herself/himself present for at least one month, but less than three months, EPV indicated no clinically useful correlation between any symptoms in this study and findings of bacteriuria. Conclusion: Urine cultures are insufficiently specific when evaluating elderly patients at nursing homes presenting with new or increased restlessness, fatigue, confusion, aggressiveness, dysuria or urgency

Urine culture doubtful in determining etiology of diffuse symptoms among elderly individuals [Urinodling har tveksamt värde vid beslut om antibiotikabehandling av patienter på äldreboenden]

Background: As many as half of elderly residents at nursing homes have asymptomatic bacteriuria. Thus it’s hard to know if a new symptom is related to findings of bacteria in urine or not. There are different opinions on the possible connection between different non-specific symptoms and urinary tract infections (UTI). Non-specific symptoms in combination with diagnostic uncertainty often lead to antibiotic treatments of uncertain value. Antibiotic overuse increases the prevalence of antibiotic resistant bacteria. Research question: What is the relationship between bacteria in the urine and new or increased fatigue, confusion, restlessness, aggressiveness, not being herself/himself, dysuria, urgency and fever. Methods: In this cross-sectional study symptoms were registered and voided urine specimens collected for urine cultures from 651 elderly residents in 32 nursing homes located in south-western Sweden. Correlation between bacteriuria and presence of a symptom at group level were determined using logistic regression. To estimate the clinical relevance of correlations at group level positive and negative etiological predictive values (EPV) were calculated. EPV takes into account the presence of asymptomatic bacteriuria. Results: In this study 207/651 (32%) of urine cultures were positive. Fatigue, restlessness and confusion were the most common symptoms. Logistic regression indicated some correlations at group level. Aside from Escherichia coli in the urine and not being herself/himself present for at least one month, but less than three months, EPV indicated no clinically useful correlation between any symptoms in this study and findings of bacteriuria. Conclusion: Urine cultures are insufficiently specific when evaluating elderly patients at nursing homes presenting with new or increased restlessness, fatigue, confusion, aggressiveness, dysuria or urgency

Experiences and management strategies of Norwegian GPs during the COVID-19 pandemic: a longitudinal interview study

Objective: When the COVID-19 pandemic reached Norway, primary health care had to reorganize to ensure safe patient treatment and maintain infection control. General practitioners (GPs) are key health care providers in the municipalities. Our aim was to explore the experiences and management strategies of Norwegian GPs during the COVID-19 pandemic - over time, and in the context of a sudden organizational change. Design: Longitudinal qualitative interview study with two interview rounds. The first round of interviews was conducted from September–December 2020, the second round from January–April 2021. In the first interview round, we performed eight semi-structured interviews with GPs from eight municipalities in Norway. In the second round, five of the GPs were re-interviewed. Consecutive interviews were performed 2–4 months apart. To analyze the data, we used thematic analysis. Results: The COVID-19 pandemic required GPs to balance several concerns, such as continuity of care and their own professional efforts. Several GPs experienced challenges in the collaboration with the municipality and in relation to defining their own professional position. Guided by The Norwegian Association of General practitioners, The Norwegian College of General Practice and collegial support, they found viable solutions and ended up with a feeling of having adapted to a new normal. Conclusions: Although our study demonstrates that the GPs adapted to the changing conditions, the current municipal health care models are not ideal. There is a need for clarification of responsibilities between GPs and the municipality to facilitate a more coordinated future pandemic response

Urine culture doubtful in determining etiology of diffuse symptoms among elderly individuals: a cross-sectional study of 32 nursing homes

Background: The high prevalence of bacteriuria in elderly individuals makes it difficult to know if a new symptom is related to bacteria in the urine. There are different views concerning this relationship and bacteriuria often leads to antibiotic treatments. The aim of this study was to investigate the relationship between bacteria in the urine and new or increased restlessness, fatigue, confusion, aggressiveness, not being herself/himself, dysuria, urgency and fever in individuals at nursing homes for elderly when statistically considering the high prevalence of asymptomatic bacteriuria in this population.\ud \ud Methods: In this cross-sectional study symptoms were registered and voided urine specimens were collected for urinary cultures from 651 elderly individuals. Logistic regressions were performed to evaluate the statistical correlation between bacteriuria and presence of a symptom at group level. To estimate the clinical relevance of statistical correlations at group level positive and negative etiological predictive values (EPV) were calculated.\ud \ud Results: Logistic regression indicated some correlations at group level. Aside from Escherichia coli in the urine and not being herself/himself existing at least one month, but less than three months, EPV indicated no clinically useful correlation between any symptoms in this study and findings of bacteriuria.\ud \ud Conclusions: Urinary cultures provide little or no useful information when evaluating diffuse symptoms among elderly residents of nursing homes. Either common urinary tract pathogens are irrelevant, or urine culture is an inappropriate test

Evaluation of dipstick analysis among elderly residents to detect bacteriuria: a cross-sectional study in 32 nursing homes

Background: Up to half the residents of nursing homes for the elderly have asymptomatic bacteriuria (ABU), which should not be treated with antibiotics. Thus, it is difficult to know if new symptoms in residents with bacteriuria are caused by urinary tract infection (UTI), or if bacteriuria only represents an ABU. This is especially difficult in the presence of non-urinary tract specific symptoms. The diagnostic uncertainty is likely to generate significant overtreatment with UTI antibiotics. Aim: The general aim was to clarify the association between symptoms, bacteriuria, dipstick urinalysis and urine Interleukin-6 (IL-6) among nursing home residents to improve the diagnostic procedure of a suspected lower UTI. Methods: In 2003 a study protocol including newly onset symptoms was completed, and single voided urine specimens collected for dipstick urinalysis and cultures from 651 residents of 32 participating Swedish nursing homes for the elderly. This data was used for a study of dipstick urinalysis (Paper I) and for a study of nonspecific symptoms and bacteriuria (Paper II). In 2012, similar data was collected for 421 elderly residents of 22 nursing homes, which also included an analysis of IL-6 in urine and urine specimens from another 59 residents with urinary catheters. The association between bacteriuria, IL-6 in urine, dipstick urinalysis and newly onset symptoms was analysed (Paper III). Antimicrobial resistance rates were described among residents of nursing homes in 2012 and compared with those from 2003 (Paper IV). Results: Paper I: The negative predictive value for predicting absence of bacteriuria was 88 (84-92)% when dipstick urinalysis for nitrite and leukocyte esterase were simultaneously negative. A positive dipstick or any combination thereof could not sufficiently predict bacteriuria. Papers II-III: New or increased nonspecific symptoms were common among elderly residents of nursing homes. Residents without nonspecific symptoms had positive urine cultures as often as those with nonspecific symptoms with a duration of up to one month. Paper III: Residents with positive urine cultures had higher concentrations of IL-6 in the urine. However, among residents with positive urine cultures there were no differences in IL-6 concentrations or dipstick findings between those with or without nonspecific symptoms. Paper IV: The average rates of antimicrobial resistance were low and did not increase between 2003 and 2012 in Escherichia coli (E. coli) urinary isolates among Swedish nursing home residents. Any antibiotic treatment during the last month and hospitalization during the last six months predicted higher resistance rates among E. coli. Conclusions: Nonspecific symptoms among elderly residents of nursing homes are unlikely to be caused by bacteria in the urine. Therefore, dipstick urinalysis, IL-6 in the urine and urine cultures are of little or no value in clarifying the aetiology of nonspecific symptoms. If there is a reason for testing for bacteriuria, dipstick urinalysis for nitrite and leukocyte esterase can rule out but cannot reliably rule in bacteriuria. Antimicrobial resistance in urinary pathogens among Swedish nursing home residents remained low. It is important to use antibiotics rationally to preserve the effectiveness of antibiotics

Antivirals for influenza-Like Illness? A randomised Controlled trial of Clinical and Cost effectiveness in primary CarE (ALIC4 E): the ALIC4 E protocol

INTRODUCTION: Effective management of seasonal and pandemic influenza is a high priority internationally. Guidelines in many countries recommend antiviral treatment for older people and individuals with comorbidity at increased risk of complications. However, antivirals are not often prescribed in primary care in Europe, partly because its clinical and cost effectiveness has been insufficiently demonstrated by non-industry funded and pragmatic studies. METHODS AND ANALYSIS: Antivirals for influenza-Like Illness? An rCt of Clinical and Cost effectiveness in primary CarE is a European multinational, multicentre, open-labelled, non-industry funded, pragmatic, adaptive-platform, randomised controlled trial. Initial trial arms will be best usual primary care and best usual primary care plus treatment with oseltamivir for 5 days. We aim to recruit at least 2500 participants ≥1 year presenting with influenza-like illness (ILI), with symptom duration ≤72 hours in primary care over three consecutive periods of confirmed high influenza incidence. Participant outcomes will be followed up to 28 days by diary and telephone. The primary objective is to determine whether adding antiviral treatment to best usual primary care is effective in reducing time to return to usual daily activity with fever, headache and muscle ache reduced to minor severity or less. Secondary objectives include estimating cost-effectiveness, benefits in subgroups according to age (64 years), severity of symptoms at presentation (low, medium and high), comorbidity (yes/no), duration of symptoms (≤48 hours/>48-72 hours), complications (hospital admission and pneumonia), use of additional prescribed medication including antibiotics, use of over-the-counter medicines and self-management of ILI symptoms. ETHICS AND DISSEMINATION: Research ethics committee (REC) approval was granted by the NRES Committee South Central (Oxford B) and Clinical Trial Authority (CTA) approval by The Medicines and Healthcare products Regulatory Agency. All participating countries gained national REC and CTA approval as required. Dissemination of results will be through peer-reviewed scientific journals and conference presentations

The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing - a systematic literature review

Abstract Background Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI despite many other potential causes. This leads to significant overdiagnosis of UTI, inappropriate antibiotic use and potential harmful outcomes. This problem is particularly prevalent in nursing home settings. Methods A systematic review of the literature was conducted assessing the association between confusion and UTI in the elderly. PubMed, Scopus and PsychInfo were searched with the following terms: confusion, delirium, altered mental status, acute confusional state, urinary tract infection, urine infection, urinary infection and bacteriuria. Inclusion criteria and methods were specified in advance and documented in the protocol, which was published with PROSPERO (registration ID: CRD42015025804). Quality assessment was conducted independently by two authors. Data were extracted using a standardised extraction tool and a qualitative synthesis of evidence was made. Results One thousand seven hunderd two original records were identified, of which 22 were included in the final analysis. The quality of these included studies varied, with frequent poor case definitions for UTI or confusion contributing to large variation in results and limiting their validity. Eight studies defined confusion using valid criteria; however, no studies defined UTI in accordance with established criteria. As no study used an acceptable definition of confusion and UTI, an association could not be reliably established. Only one study had acceptable definitions of confusion and bacteriuria, reporting an association with the relative risk being 1.4 (95% CI 1.0–1.7, p = 0.034). Conclusions Current evidence appears insufficient to accurately determine if UTI and confusion are associated, with estimates varying widely. This was often attributable to poor case definitions for UTI or confusion, or inadequate control of confounding factors. Future well-designed studies, using validated criteria for UTI and confusion are required to examine the relationship between UTI and acute confusion in the elderly. The optimal solution to clarify this clinical issue would be a randomized controlled trial comparing the effect of antibiotics versus placebo in patients with new onset or worsening confusion and presence of bacteriuria while lacking specific urinary tract symptoms