Age is Not an Indication: Antibiotics for Urinary Tract Infections in Geriatric Trauma Patients

Authors:
Jessica Weaver, John Austin, Michelle Lippincott

Body of Abstract:
Background
Falls are the most common mechanism of traumatic injury in geriatric patients. There are studies suggesting that urinary tract infections (UTIs) may be a cause for fall. Thus, a screening urinalysis (UA) is frequently obtained in geriatric patients. However, this does not discern between UTI and asymptomatic bacteriuria. Geriatric patients may present with either baseline or acquired cognitive impairment that prevent them from describing genitourinary symptoms. According to the Infectious Diseases Society of America (IDSA), patients without systemic signs of infection such as fever or hemodynamic instability should be assessed for other causes and closely monitored, even with bacteriuria. We conducted a study in our trauma system to assess UTI screening and treatment. We hypothesize that geriatric falls are likely to receive unnecessary urinalyses (UAs) and receive antibiotic treatment that is not otherwise indicated.
Methods
Our trauma registry was queried for all patients admitted to the trauma service aged 65 years and older between 2020-23 for a ground-level fall with an initial Glasgow Coma Score less than 15. Demographics such as age, sex, race, ethnicity, and insurance were obtained from the registry. Individual charts were reviewed for vital signs, lab values, UA, urine culture (UCx), antibiotic treatment and indication data. A UA was recorded as positive if it was positive for nitrites, leukocyte esterase, had greater than 10 white blood cells per high power field, or had at least “few” bacteria. Our institution automatically reflexes to UCx based on pre-set criteria for UAs. Estimated charge of a UA with microscopy was obtained from the chargemaster.
Results
489 geriatric trauma patients met inclusion criteria. Of these, 268 (54.8%) had a UA done within 24 hours of admission and were included for further analysis. 115 of these 268 (42.9%) patients had positive UAs, of which 103 automatically reflexed to a UCx. Women were more likely to have a positive UA, with 69.6% of positive UAs belonging to women versus 43.8% of negative UAs (p < 0.005). Of those with positive UAs, 69/115 (60%) patients were initially given antibiotic therapy for UTI treatment, with 50/69 (72.5%) of these patients eventually growing a positive UCx. There was no difference in rates of sepsis on presentation (p = 0.65) or mortality (p = 0.16) between the treated and untreated groups. Of all UAs done, 263/268 (98.1%) were given to patients without a systemic sign of infection or other reason for UA testing, leading to excess medical costs of $38,398. Only 4 of the 69 patients who received antibiotics for a UTI (5.8%) had urosepsis or other IDSA criteria for treatment. Conclusion Cognitively impaired geriatric fall patients in our trauma system were consistently over-tested and over-treated for UTIs. Application of IDSA guidelines to current screening practices for geriatric fall patients can potentially reduce unnecessary antibiotic use in these patients.