To the Editor: As anyone who practices in a long-term care facility knows, infections are a common cause of acute or subacute deterioration in function. This was appropriately highlighted in “Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents of Long-Term Care Facilities: 2008 Update by the Infectious Diseases Society of America,”1 recently published in the Journal of the American Geriatrics Society, although I would like to take issue with one of the recommendations of the Guidelines and present a case that supports my objection. I would also like to add to the Guideline's list of atypical symptoms of infections and note a possibly misleading statement regarding symptoms of urinary tract infection. Recommendation 17 of the Guideline states that “if pyuria (>10 [white blood cells] WBCs/high-power field) or a positive leukocyte esterase or nitrite test is present on dipstick, only then should a urine culture (with antimicrobial susceptibility testing) be ordered.” If this recommendation is followed in a patient in whom infection is suspected, there will be a small but real chance that a urinary tract infection that is causing significant problems will be overlooked. An 89-year-old white woman with baseline mild-to-moderate dementia was admitted to the hospital after a fall that caused a head laceration. Because of her son's wishes, which he stated were consistent with the patient's previously expressed desires, no laboratory or radiological testing was done. It was determined that, because of her recent falls, weakness, and increasing confusion, she was no longer capable of living in the assisted living unit where she had been and needed permanent nursing home care. When she arrived at the nursing home, she was observed to be more confused than she had been a few weeks earlier and to have difficulty with attention, consistent with delirium. Urinalysis was obtained with the son's permission, which was negative according to dipstick testing. Urine culture was also ordered, which grew more than 100,000 colony-forming units (CFU)/mL of Enterococcus faecalis and mixed flora with no organism greater that 1,000 CFU/mL. After a few days of taking antibiotics, she was noted to be back to her baseline cognition and level of consciousness. After a short course of physical therapy, she regained her former functional status and was able to return to her assisted living room. If the recommendations of the Clinical Guideline had been used, this patient's delirium and decrease in function would have gone undiagnosed and untreated, and she would have remained in the nursing home. The incidence of patients with normal urinalysis but positive culture, proven significant by resolution of symptoms with appropriate treatment, is unknown but almost certainly uncommon, although I have had several other patients similar to the one described above. If only urinalysis, or “urinalysis with reflex culture,” had been ordered, these infections would have been missed. Because the incidence of urinary infection with normal urinalysis is unknown, the cost-effectiveness of ordering a urine culture in every case in which urine infection is part of the differential diagnosis is also unknown. At a minimum, if the cause of acute or subacute decline in function is unclear after standard evaluation, urine culture should be performed despite a normal urinalysis. Second, two other common symptoms of infection in elderly patients that are not seen in younger patients should be added to the list in recommendation 2 of the Guideline. The first is a decrease in level of consciousness or an increase in sleepiness. The second is the “lateral slump sign,” in which the patient has a new tendency to lean to one side in the wheelchair.2 These symptoms are often the only manifestation of any type of infection in elderly people, but recommendation 12 could be interpreted as indicating that more classic symptoms are needed before a urinary tract infection should be considered. The authors state that “urinalysis and urine culture should not be performed for asymptomatic residents” and in the following recommendation list the traditional symptoms of urinary tract infection (fever, dysuria, hematuria, urinary incontinence, and suspected bacteremia). It may not have been their intention to exclude the common, less-specific, manifestations of infection in elderly patients listed in recommendation 2 (confusion, incontinence, falls, decreased oral intake, decreased cooperation), but a reader may take this statement as recommending against testing for urinary infection without the presence of classic symptoms, which are often absent in the patients being considered in this guideline. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this letter. Author Contributions: The author is the sole contributor to this letter. Sponsor's Role: None.
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Apr 9, 2024
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