Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department
Objectives To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED). Design Preplanned, secondary analysis of a prospective observational study. Setting Tertiary care, academic ED. Participants A to...
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| Veröffentlicht in: | Journal of the American Geriatrics Society (JAGS) 2019-03, Vol.67 (3), p.484-492 |
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| container_title | Journal of the American Geriatrics Society (JAGS) |
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| creator | Caterino, Jeffrey M. Kline, David M. Leininger, Robert Southerland, Lauren T. Carpenter, Christopher R. Baugh, Christopher W. Pallin, Daniel J. Hunold, Katherine M. Stevenson, Kurt B. |
| description | Objectives
To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED).
Design
Preplanned, secondary analysis of a prospective observational study.
Setting
Tertiary care, academic ED.
Participants
A total of 424 patients in the ED, 65 years or older, including all chief complaints.
Measurements
We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection.
Results
Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40‐2.53) or malaise/lethargy (PLR range, 1.25‐1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15‐18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79‐0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms.
Conclusions
The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484–492, 2019. |
| doi_str_mv | 10.1111/jgs.15679 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_2137460915</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2188132498</sourcerecordid><originalsourceid>FETCH-LOGICAL-c3889-52846dea6bc795e8d042cbbb1f7c366e2f23956ef8e4d6ed361660e806c21c7c3</originalsourceid><addsrcrecordid>eNp1kE1LxDAQhoMouq4e_AMS8KKHapK2aXqUXT9WFhVWzyVNp2vWNqlJi-y_N7rqQXAuAzPPvAwPQkeUnNNQF6ulP6cpz_ItNKJpzKI0oek2GhFCWCQ4TfbQvvcrQigjQuyivZgkPBMsHSF9b43vQOlaK7xYt11vW4_nUr3iqZZLY30fFpdKDU6qNa6twzNTg-q1NVgb_NBU4PCj7DWY3n9O-hfAVy24JZhwMIVOur4NywO0U8vGw-F3H6Pn66unyW00f7iZTS7nkYqFyKOUiYRXIHmpsjwFUZGEqbIsaZ2pmHNgNYvzlEMtIKk4VDGnnBMQhCtGVWDG6HST2zn7NoDvi1Z7BU0jDdjBF4zGWcJJHkSN0ckfdGUHZ8J3gRKCxizJRaDONpRy1nsHddE53Uq3LigpPv0XwX_x5T-wx9-JQ9lC9Uv-CA_AxQZ41w2s_08q7m4Wm8gPbtePEQ</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2188132498</pqid></control><display><type>article</type><title>Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department</title><source>MEDLINE</source><source>Wiley Online Library Journals Frontfile Complete</source><creator>Caterino, Jeffrey M. ; Kline, David M. ; Leininger, Robert ; Southerland, Lauren T. ; Carpenter, Christopher R. ; Baugh, Christopher W. ; Pallin, Daniel J. ; Hunold, Katherine M. ; Stevenson, Kurt B.</creator><creatorcontrib>Caterino, Jeffrey M. ; Kline, David M. ; Leininger, Robert ; Southerland, Lauren T. ; Carpenter, Christopher R. ; Baugh, Christopher W. ; Pallin, Daniel J. ; Hunold, Katherine M. ; Stevenson, Kurt B.</creatorcontrib><description>Objectives
To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED).
Design
Preplanned, secondary analysis of a prospective observational study.
Setting
Tertiary care, academic ED.
Participants
A total of 424 patients in the ED, 65 years or older, including all chief complaints.
Measurements
We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection.
Results
Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40‐2.53) or malaise/lethargy (PLR range, 1.25‐1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15‐18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79‐0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms.
Conclusions
The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484–492, 2019.</description><identifier>ISSN: 0002-8614</identifier><identifier>EISSN: 1532-5415</identifier><identifier>DOI: 10.1111/jgs.15679</identifier><identifier>PMID: 30467825</identifier><language>eng</language><publisher>United States: Wiley Subscription Services, Inc</publisher><subject>Acute Disease ; Aged ; Bacteria ; Bacterial infections ; Bacterial Infections - complications ; Bacterial Infections - diagnosis ; Bacterial Infections - epidemiology ; Consciousness Disorders - diagnosis ; Consciousness Disorders - etiology ; delirium ; diagnosis ; Diagnosis, Differential ; emergency department ; Emergency Service, Hospital - statistics & numerical data ; Female ; Fever ; Fever - diagnosis ; Fever - etiology ; Gastroenteritis - epidemiology ; Geriatric Assessment - methods ; Humans ; infection ; Lethargy - diagnosis ; Lethargy - etiology ; Male ; Medical diagnosis ; Older people ; Prospective Studies ; Respiratory Tract Infections - epidemiology ; Symptom Assessment - methods ; United States - epidemiology ; Urinary tract ; Urinary tract infections ; Urinary Tract Infections - epidemiology</subject><ispartof>Journal of the American Geriatrics Society (JAGS), 2019-03, Vol.67 (3), p.484-492</ispartof><rights>2018 The American Geriatrics Society</rights><rights>2018 The American Geriatrics Society.</rights><rights>2019 American Geriatrics Society and Wiley Periodicals, Inc.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c3889-52846dea6bc795e8d042cbbb1f7c366e2f23956ef8e4d6ed361660e806c21c7c3</citedby><cites>FETCH-LOGICAL-c3889-52846dea6bc795e8d042cbbb1f7c366e2f23956ef8e4d6ed361660e806c21c7c3</cites><orcidid>0000-0002-3561-8332 ; 0000-0002-2603-7157</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://onlinelibrary.wiley.com/doi/pdf/10.1111%2Fjgs.15679$$EPDF$$P50$$Gwiley$$H</linktopdf><linktohtml>$$Uhttps://onlinelibrary.wiley.com/doi/full/10.1111%2Fjgs.15679$$EHTML$$P50$$Gwiley$$H</linktohtml><link.rule.ids>314,778,782,1414,27907,27908,45557,45558</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/30467825$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Caterino, Jeffrey M.</creatorcontrib><creatorcontrib>Kline, David M.</creatorcontrib><creatorcontrib>Leininger, Robert</creatorcontrib><creatorcontrib>Southerland, Lauren T.</creatorcontrib><creatorcontrib>Carpenter, Christopher R.</creatorcontrib><creatorcontrib>Baugh, Christopher W.</creatorcontrib><creatorcontrib>Pallin, Daniel J.</creatorcontrib><creatorcontrib>Hunold, Katherine M.</creatorcontrib><creatorcontrib>Stevenson, Kurt B.</creatorcontrib><title>Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department</title><title>Journal of the American Geriatrics Society (JAGS)</title><addtitle>J Am Geriatr Soc</addtitle><description>Objectives
To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED).
Design
Preplanned, secondary analysis of a prospective observational study.
Setting
Tertiary care, academic ED.
Participants
A total of 424 patients in the ED, 65 years or older, including all chief complaints.
Measurements
We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection.
Results
Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40‐2.53) or malaise/lethargy (PLR range, 1.25‐1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15‐18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79‐0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms.
Conclusions
The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484–492, 2019.</description><subject>Acute Disease</subject><subject>Aged</subject><subject>Bacteria</subject><subject>Bacterial infections</subject><subject>Bacterial Infections - complications</subject><subject>Bacterial Infections - diagnosis</subject><subject>Bacterial Infections - epidemiology</subject><subject>Consciousness Disorders - diagnosis</subject><subject>Consciousness Disorders - etiology</subject><subject>delirium</subject><subject>diagnosis</subject><subject>Diagnosis, Differential</subject><subject>emergency department</subject><subject>Emergency Service, Hospital - statistics & numerical data</subject><subject>Female</subject><subject>Fever</subject><subject>Fever - diagnosis</subject><subject>Fever - etiology</subject><subject>Gastroenteritis - epidemiology</subject><subject>Geriatric Assessment - methods</subject><subject>Humans</subject><subject>infection</subject><subject>Lethargy - diagnosis</subject><subject>Lethargy - etiology</subject><subject>Male</subject><subject>Medical diagnosis</subject><subject>Older people</subject><subject>Prospective Studies</subject><subject>Respiratory Tract Infections - epidemiology</subject><subject>Symptom Assessment - methods</subject><subject>United States - epidemiology</subject><subject>Urinary tract</subject><subject>Urinary tract infections</subject><subject>Urinary Tract Infections - epidemiology</subject><issn>0002-8614</issn><issn>1532-5415</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2019</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp1kE1LxDAQhoMouq4e_AMS8KKHapK2aXqUXT9WFhVWzyVNp2vWNqlJi-y_N7rqQXAuAzPPvAwPQkeUnNNQF6ulP6cpz_ItNKJpzKI0oek2GhFCWCQ4TfbQvvcrQigjQuyivZgkPBMsHSF9b43vQOlaK7xYt11vW4_nUr3iqZZLY30fFpdKDU6qNa6twzNTg-q1NVgb_NBU4PCj7DWY3n9O-hfAVy24JZhwMIVOur4NywO0U8vGw-F3H6Pn66unyW00f7iZTS7nkYqFyKOUiYRXIHmpsjwFUZGEqbIsaZ2pmHNgNYvzlEMtIKk4VDGnnBMQhCtGVWDG6HST2zn7NoDvi1Z7BU0jDdjBF4zGWcJJHkSN0ckfdGUHZ8J3gRKCxizJRaDONpRy1nsHddE53Uq3LigpPv0XwX_x5T-wx9-JQ9lC9Uv-CA_AxQZ41w2s_08q7m4Wm8gPbtePEQ</recordid><startdate>201903</startdate><enddate>201903</enddate><creator>Caterino, Jeffrey M.</creator><creator>Kline, David M.</creator><creator>Leininger, Robert</creator><creator>Southerland, Lauren T.</creator><creator>Carpenter, Christopher R.</creator><creator>Baugh, Christopher W.</creator><creator>Pallin, Daniel J.</creator><creator>Hunold, Katherine M.</creator><creator>Stevenson, Kurt B.</creator><general>Wiley Subscription Services, Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7QP</scope><scope>7TK</scope><scope>K9.</scope><scope>NAPCQ</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0002-3561-8332</orcidid><orcidid>https://orcid.org/0000-0002-2603-7157</orcidid></search><sort><creationdate>201903</creationdate><title>Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department</title><author>Caterino, Jeffrey M. ; Kline, David M. ; Leininger, Robert ; Southerland, Lauren T. ; Carpenter, Christopher R. ; Baugh, Christopher W. ; Pallin, Daniel J. ; Hunold, Katherine M. ; Stevenson, Kurt B.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c3889-52846dea6bc795e8d042cbbb1f7c366e2f23956ef8e4d6ed361660e806c21c7c3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2019</creationdate><topic>Acute Disease</topic><topic>Aged</topic><topic>Bacteria</topic><topic>Bacterial infections</topic><topic>Bacterial Infections - complications</topic><topic>Bacterial Infections - diagnosis</topic><topic>Bacterial Infections - epidemiology</topic><topic>Consciousness Disorders - diagnosis</topic><topic>Consciousness Disorders - etiology</topic><topic>delirium</topic><topic>diagnosis</topic><topic>Diagnosis, Differential</topic><topic>emergency department</topic><topic>Emergency Service, Hospital - statistics & numerical data</topic><topic>Female</topic><topic>Fever</topic><topic>Fever - diagnosis</topic><topic>Fever - etiology</topic><topic>Gastroenteritis - epidemiology</topic><topic>Geriatric Assessment - methods</topic><topic>Humans</topic><topic>infection</topic><topic>Lethargy - diagnosis</topic><topic>Lethargy - etiology</topic><topic>Male</topic><topic>Medical diagnosis</topic><topic>Older people</topic><topic>Prospective Studies</topic><topic>Respiratory Tract Infections - epidemiology</topic><topic>Symptom Assessment - methods</topic><topic>United States - epidemiology</topic><topic>Urinary tract</topic><topic>Urinary tract infections</topic><topic>Urinary Tract Infections - epidemiology</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Caterino, Jeffrey M.</creatorcontrib><creatorcontrib>Kline, David M.</creatorcontrib><creatorcontrib>Leininger, Robert</creatorcontrib><creatorcontrib>Southerland, Lauren T.</creatorcontrib><creatorcontrib>Carpenter, Christopher R.</creatorcontrib><creatorcontrib>Baugh, Christopher W.</creatorcontrib><creatorcontrib>Pallin, Daniel J.</creatorcontrib><creatorcontrib>Hunold, Katherine M.</creatorcontrib><creatorcontrib>Stevenson, Kurt B.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Calcium & Calcified Tissue Abstracts</collection><collection>Neurosciences Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Premium</collection><collection>MEDLINE - Academic</collection><jtitle>Journal of the American Geriatrics Society (JAGS)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Caterino, Jeffrey M.</au><au>Kline, David M.</au><au>Leininger, Robert</au><au>Southerland, Lauren T.</au><au>Carpenter, Christopher R.</au><au>Baugh, Christopher W.</au><au>Pallin, Daniel J.</au><au>Hunold, Katherine M.</au><au>Stevenson, Kurt B.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department</atitle><jtitle>Journal of the American Geriatrics Society (JAGS)</jtitle><addtitle>J Am Geriatr Soc</addtitle><date>2019-03</date><risdate>2019</risdate><volume>67</volume><issue>3</issue><spage>484</spage><epage>492</epage><pages>484-492</pages><issn>0002-8614</issn><eissn>1532-5415</eissn><abstract>Objectives
To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED).
Design
Preplanned, secondary analysis of a prospective observational study.
Setting
Tertiary care, academic ED.
Participants
A total of 424 patients in the ED, 65 years or older, including all chief complaints.
Measurements
We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection.
Results
Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40‐2.53) or malaise/lethargy (PLR range, 1.25‐1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15‐18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79‐0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms.
Conclusions
The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484–492, 2019.</abstract><cop>United States</cop><pub>Wiley Subscription Services, Inc</pub><pmid>30467825</pmid><doi>10.1111/jgs.15679</doi><tpages>9</tpages><orcidid>https://orcid.org/0000-0002-3561-8332</orcidid><orcidid>https://orcid.org/0000-0002-2603-7157</orcidid><oa>free_for_read</oa></addata></record> |
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| source | MEDLINE; Wiley Online Library Journals Frontfile Complete |
| subjects | Acute Disease Aged Bacteria Bacterial infections Bacterial Infections - complications Bacterial Infections - diagnosis Bacterial Infections - epidemiology Consciousness Disorders - diagnosis Consciousness Disorders - etiology delirium diagnosis Diagnosis, Differential emergency department Emergency Service, Hospital - statistics & numerical data Female Fever Fever - diagnosis Fever - etiology Gastroenteritis - epidemiology Geriatric Assessment - methods Humans infection Lethargy - diagnosis Lethargy - etiology Male Medical diagnosis Older people Prospective Studies Respiratory Tract Infections - epidemiology Symptom Assessment - methods United States - epidemiology Urinary tract Urinary tract infections Urinary Tract Infections - epidemiology |
| title | Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department |
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