Abstract
In older patients, urinary tract infection (UTI) often has an atypical clinical presentation, making its diagnosis difficult. We aimed to describe the clinical presentation in older inpatients with UTI-related bacteremia and to determine the prognostic impact of atypical presentation. This cohort study included all consecutive patients older than 75 years hospitalized in a university hospital in 2019 with a UTI-related gram-negative bacillus (GNB) bacteremia, defined by blood and urine cultures positive for the same GNB, and followed up for 90 days. Patients with typical symptoms of UTI were compared to patients with atypical forms. Among 3865 inpatients over 75 with GNB-positive urine culture over the inclusion period, 105 patients (2.7%) with bacteremic UTI were included (mean age 85.3 ± 5.9, 61.9% female). Among them, UTI symptoms were reported in only 38 patients (36.2%) and 44 patients (41.9%) had no fever on initial management. Initial diagnosis of UTI was made in only 58% of patient. Mortality at 90 days was 23.6%. After adjustment for confounders, hyperthermia (HR = 0.37; IC95 (0.14–0.97)) and early UTI diagnosis (HR = 0.35; IC95 (0.13–0.94)) were associated with lower mortality, while UTI symptoms were not associated with prognosis. In conclusion, only one third of older patients with UTI developing bacteremia had UTI symptoms. However, early UTI diagnosis was associated with better survival.
Highlights
Urinary tract infections (UTI) are the most common source of bacteremia in older patients [1], with a prevalence twenty times higher than in younger patients [2]
The diagnosis of urinary tract infection (UTI)-related sepsis was more frequent in the presence of UTI symptoms (81.6% vs. 44.8%, p < 0.01) and antibiotic therapy targeting gram-negative bacillus (GNB) was more frequently introduced within 24 h (81.6% vs. 62.7%, p = 0.04)
More observational data from older patients are needed to better characterize the age-related clinical specificities of such a frequent condition and to establish the prognostic relevance of these potential signs. In this unselected cohort of older inpatients with UTI-related bacteremia, UTI symptoms were found in only one-third of patients and an initial diagnosis of UTI was made in only 58%
Summary
Urinary tract infections (UTI) are the most common source of bacteremia in older patients [1], with a prevalence twenty times higher than in younger patients [2]. These frequent infections have to be distinguished from even more common urinary tract colonization in order to avoid abusive and potentially deleterious antibiotic treatment [3]. The diagnosis of sepsis and its origin are, more difficult to determine [2,7,8,9,10] These atypical presentations have been associated with an increased mortality in bloodstream infections [9]
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