ACUTE CONFUSIONAL STATES IN OLDER ADULTS WITH MAJOR NEUROCOGNITIVE DISORDER AND BACTERIURIA: IS ANTIBIOTIC TREATMENT WARRANTED?

Abstract

Introduction Uncomplicated urinary tract infection (UTI)/acute simple cystitis (ASC) is defined as an infection confined to the bladder/lower urinary tract with the absence of signs and symptoms that would suggest an upper tract or systemic infection (such as fever, chills, rigors, significant fatigue or malaise beyond baseline, flank pain, costovertebral angle tenderness, pelvic or perineal pain in men). Presence of systemic symptoms suggests a complicated UTI. Symptoms of ASC include dysuria, urinary frequency or urgency, and/or suprapubic pain. The term asymptomatic bacteriuria refers to isolation of bacteria in an appropriately collected urine specimen from an individual without symptoms of UTI. Asymptomatic bacteriuria generally is not treated unless the patient is pregnant, undergoing urological procedure or has a history of recent renal transplant. However, it is recommended that ASC be treated empirically with antibiotics. Minimum criteria for the initiation of antibiotics for urinary tract infection in long-term care residents without indwelling catheter include acute dysuria or fever and at least one of the following: new or worsening urgency, frequency, suprapubic pain, gross hematuria, CVA tenderness, urinary incontinence. Acute change in mental status is not considered as a criterion to diagnose and treat UTI. However, it is known that infection in older patients may be associated with nonspecific symptoms such as increased confusion, falling, and anorexia besides other classic symptoms of infection. Diagnosis of ASC is based solely on the subjective complaints of patients. Cognitive impairment with reduced capacity to specifically communicate symptoms makes it challenging to rule out the diagnosis of ASC in older patients with major neurocognitive disorder (MNCD). Such patients may communicate the pain and discomfort from ASC by having increased confusion and behavioral disturbances. Under these circumstances, is bacteriuria a clinically significant condition that warrants antibiotic therapy? Guidelines to relate urinalysis findings to the diagnosis of ASC in older adults with MNCD with behavioral disturbance are not currently available. Establishing the diagnosis in older patients is further complicated due to the higher prevalence in this group, of asymptomatic bacteriuria and chronic urinary symptoms (such as chronic urinary nocturia, incontinence, and general sense of lack of well-being). The Infectious Diseases Society of American (IDSA) Guidelines of 2019 recommend against antibiotic “trials” as these may cause drug toxicity, drug-drug interactions, and antimicrobial resistance. Recommendation is not to routinely test urine in elderly or debilitated patients with nonspecific changes in mental or functional status in the absence of focal urinary tract symptoms, and instead hydrate, carefully observe, and assess other potential contributing factors.However, as a part of work-up for delirium/acute change in mental status ruling out UTI with UA is still standard practice despite the recommendation not to do so in the absence of specific genitourinary symptoms. This is possibly due to the failure of current guidelines to convince clinicians of its adequacy to rule out possibility of UTI in cognitively impaired patients. This diagnostic challenge often leads to dilemma in the treatment approach of these patients. Methods Case series, systematic literature review Results Case identification: Six cases of elderly patients with MNCD who presented to the emergency department with acute change in mental status and behavioral disturbance were identified. Initial work-up included abnormal urinanalysis results. In the absence of patients reporting genitourinary symptoms, a diagnosis of UTI was not considered and they were admitted to a geriatric psychiatric unit for evaluation and behavioral management.. Variation in the treatment approach for each case was evaluated which included either considering the mental status change to be a result of UTI and treating with antibiotics or managing them with psychotherapeutic interventions and psychotropic medications for behavioral stabilization if safety and well-being were concerns. Discrepancies were noted in the recommendations made by the consulting internist and geriatric psychiatrist regarding whether or not antibiotic therapy vs. psychotropic medication treatment was most appropriate for older adults with MNCD and acute confusional states who had bacteriuria >100,000?CFU/?ml. While internists were concerned about adding load of antibiotic resistance to the community, psychiatrists were worried about the adverse effects of antipsychotics including thromboembolic events and sudden deaths in elderly patients. Conclusions The cases described here illustrate the need for concrete specialized diagnostic criteria for early and accurate identification of uncomplicated UTI/ ACS in elderly population with MNCD along with an appropriate management protocol. This research was funded by: Not applicable