Asymptomatic bacteriuria, Antibiotics and Delirium: - PowerPoint Presentation

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Asymptomatic bacteriuria, Antibiotics and Delirium:Project Presentation

Kate McCollough

Jennifer

Dulin

FuNdAmentals

of Epidemiology I

October 31, 2019

Background

Exposure: Antibiotic treatment of asymptomatic bacteriuria (ASB)ASB: positive urine culture with ≥105 colony-forming units (CFU)/mL of organism without signs/symptoms attributable to UTI ASB occurs in up to 20% of elderlyDelirium: acutely altered mental status characterized by inattentions, disturbed cognition, altered LOC, fluctuating courseDelirium: up to 50% of hospitalized elderlybCAM (brief Cognitive Assessment Method), validated screening tool with 85% sn, 95% spUp to 82.7% of elderly with ASB receive inappropriate antibioticsIDSA recommends NOT treating ASB in elderly with confusion for 24-48h while work-up for delirium is underway

Outcome:

Increased discharge to a facility

Discharge to a facility is a marker of decreased functional status, increased morbidity

Institutionalization signals a cascade of loss of independence, increased morbidity and mortality and health care costs

Increases likelihood of rehospitalization

30-40% of delirium may be preventable, work-up often stops with identification of bacteriuria, allowing underlying cause to perpetuate and outcomes to worsen

Gap:

disposition impact of antibiotic treatment of ASB in delirious elderly

Elderly patients with delirium disproportionately receive antibiotics for ASB

ASB does not cause delirium but is due to underlying patient factors

Inappropriate antibiotic therapy leads to increased morbidity, mortality, LOS, institutionalization and loss of independence

Population

Target PopulationElderly (age > 70) hospitalized patientsUp to 50% experience deliriumUp to 20% have ASBInappropriate antibiotics carry riskDischarge to facility marks increased morbidity, mortality and health care cost

Source Population

age

>

70

Admitted to large, urban academic medical center between 1/1/2016 and 7/31/2019

Positive delirium (

bCAM

) screen

Documentation of ASB (urine culture > 10

5

CFUs, no symptoms)

Absence of treatment with antibiotics for any other reason

Admitted from ambulatory setting

Excluding: patients with urinary stent, nephrostomy, urinary surgery, ICU stay, transplant recipient, AIDS (CD4 <200)

Question & Hypothesis

Question:

Does antibiotic treatment of ASB decrease the incidence of discharge to a facility for hospitalized patients aged 70 or older admitted from home with a positive delirium screen (

bCAM

)?

Exposure: antibiotic treatment for ASB

Outcome: discharge to facility (marker of decreased functional status

)

Hypothesis:

Antibiotic treatment increases incidence of discharge to a facility in the study population

May lead to increased hospital LOS, complications (

C.Diff

, antibiotic resistance), increased institutionalization

GAP:

No studies looking at impact of antibiotic treatment of ASB in hospitalized patients with delirium

We address impact of antibiotics for ASB on discharge disposition in those patients with delirium diagnosed by a validated tool and ASB

Design

Retrospective, non-randomized, cohort study of delirious elderly medical inpatients with asymptomatic bacteriuria

Large, urban, academic medical center

Patients aged 70 or older

Delirium defined by positive

bCAM

(delirium screen employed on admission and every shift thereafter on all units) at any point during hospitalization

ASB: positive urine culture with ≥10

5

colony-forming units (CFU)/mL of organism without signs or symptoms attributable to UTI

Exposure: antibiotic treatment for ASB

Exclude antibiotics prescribed for other indication

Outcome: discharge to facility other than home

Marker of decreased functional independence, increased health care costs

Facilities include: SNF, hospice, LTAC, rehab