1/14
Hey #MedTwitter!
Ever question the utility of asymptomatic urine testing in delirious, older patients?
Passionate about avoiding low-value tests that may harm vulnerable patients?
If so, please join us on this Tweetorial journey based on our @JHospMedicine @TWDFNR piece!
Hey #MedTwitter!
Ever question the utility of asymptomatic urine testing in delirious, older patients?
Passionate about avoiding low-value tests that may harm vulnerable patients?
If so, please join us on this Tweetorial journey based on our @JHospMedicine @TWDFNR piece!
2/14
Let's start off by getting a sense of how everyone approaches this clinical situation.
In the work-up of delirium in an older adult, which of the following groups would benefit from urine testing?
Let's start off by getting a sense of how everyone approaches this clinical situation.
In the work-up of delirium in an older adult, which of the following groups would benefit from urine testing?
3/14
Some background on delirium's impact:
This @jama study (Oh et al, pubmed.ncbi.nlm.nih.gov/28973626/) states that in US alone, more than 2.6 million adults 65 years and older each year develop delirium, accounting for an estimated $38-$152 billion in annual healthcare expenditures!
Some background on delirium's impact:
This @jama study (Oh et al, pubmed.ncbi.nlm.nih.gov/28973626/) states that in US alone, more than 2.6 million adults 65 years and older each year develop delirium, accounting for an estimated $38-$152 billion in annual healthcare expenditures!
4/14
Altered mental status is a common indication for urine tests in older adults.
But many older patients, including ~50% of 🚺 and ~40% of 🚹 in long term care, have asymptomatic bacteriuria (ASB)!
In addition, this systematic review suggests the 🔗 btwn UTI & AMS is murky...
Altered mental status is a common indication for urine tests in older adults.
But many older patients, including ~50% of 🚺 and ~40% of 🚹 in long term care, have asymptomatic bacteriuria (ASB)!
In addition, this systematic review suggests the 🔗 btwn UTI & AMS is murky...
5/15
What do the guidelines say?
From the 2019 @IDSAInfo Clinical Practice Guidelines: "Do not screen for ASB in older, functionally/cognitively impaired patients without local genitourinary symptoms or other signs of infection (strong recommendation, very low-quality evidence)"
What do the guidelines say?
From the 2019 @IDSAInfo Clinical Practice Guidelines: "Do not screen for ASB in older, functionally/cognitively impaired patients without local genitourinary symptoms or other signs of infection (strong recommendation, very low-quality evidence)"
6/16
Now let's examine the harms of treating ASB...
A @JAMAInternalMed retrospective cohort study (Petty et al) of 2733 hospitalized patients found that treatment of ASB was associated with ⬆️ duration of hospitalization (4 vs 3 days; relative risk, 1.37; 95% CI, 1.28-1.47).
Now let's examine the harms of treating ASB...
A @JAMAInternalMed retrospective cohort study (Petty et al) of 2733 hospitalized patients found that treatment of ASB was associated with ⬆️ duration of hospitalization (4 vs 3 days; relative risk, 1.37; 95% CI, 1.28-1.47).
7/14
What about the public health angle, inspired by our #IDtwitter colleagues?
A study by Pop-Vicas et al (pubmed.ncbi.nlm.nih.gov/18557965/) suggests that ASB treatment may ⬆️ the prevalence of multi-drug resistant bacteria in care facilities - making it harder to treat true infections!
What about the public health angle, inspired by our #IDtwitter colleagues?
A study by Pop-Vicas et al (pubmed.ncbi.nlm.nih.gov/18557965/) suggests that ASB treatment may ⬆️ the prevalence of multi-drug resistant bacteria in care facilities - making it harder to treat true infections!
8/14
In diagnostic terms, the link between delirium and bacteriuria may be an example of the availability heuristic at play, not to mention the risk of anchoring and premature closure.
What if we are missing the true underlying cause of delirium when we attribute it to ASB?
In diagnostic terms, the link between delirium and bacteriuria may be an example of the availability heuristic at play, not to mention the risk of anchoring and premature closure.
What if we are missing the true underlying cause of delirium when we attribute it to ASB?
9/14
Here's another poll for you, #MedTwitter, based on the information we have given you...
What do you consider the most significant harm described in studies on treating patients with asymptomatic bacteriuria?
Here's another poll for you, #MedTwitter, based on the information we have given you...
What do you consider the most significant harm described in studies on treating patients with asymptomatic bacteriuria?
10/14
What should we do instead?
Oh et al offer this helpful and thorough algorithm for diagnosis & mgmt of delirium in @JAMA_current:
Key points:
➡️Use validated screening instrument
➡️Perform thorough clinical eval
➡️Review meds
➡️Manage w/ suggested pharm & non-pharm options
What should we do instead?
Oh et al offer this helpful and thorough algorithm for diagnosis & mgmt of delirium in @JAMA_current:
Key points:
➡️Use validated screening instrument
➡️Perform thorough clinical eval
➡️Review meds
➡️Manage w/ suggested pharm & non-pharm options
11/14
Caveat: There may be circumstances when urine testing in delirious older adults is indicated even w/o symptoms, including:
➡️Concerning exam/labs - suprapubic/CVA tenderness,⬆️WBCs
➡️Signs of sepsis - fevers/⏬BP/⬆️HR
➡️Catheterized pts
➡️Patients w/ urologic complications
Caveat: There may be circumstances when urine testing in delirious older adults is indicated even w/o symptoms, including:
➡️Concerning exam/labs - suprapubic/CVA tenderness,⬆️WBCs
➡️Signs of sepsis - fevers/⏬BP/⬆️HR
➡️Catheterized pts
➡️Patients w/ urologic complications
12/14
In summary, for older patients presenting with delirium w/o localized urinary symptoms or systemic signs of infection, forgo routinely ordering urine studies to:
⬇️Antibiotic overuse
➡️Avoid adverse outcomes in vulnerable older adults
➡️Not overlook true cause of delirium
In summary, for older patients presenting with delirium w/o localized urinary symptoms or systemic signs of infection, forgo routinely ordering urine studies to:
⬇️Antibiotic overuse
➡️Avoid adverse outcomes in vulnerable older adults
➡️Not overlook true cause of delirium
13/14
#Medtwitter, tell us how we did! Do you agree that we should avoid this common, low value and potentially harmful practice?
#Medtwitter, tell us how we did! Do you agree that we should avoid this common, low value and potentially harmful practice?
14/14
On behalf of my incredible co-authors (@ORourkeJr, @DoctorBhav + @MariAleMendozaD), thank you for joining us on this #Medtweetorial journey!
And a special thanks to @tony_breu for your support and guidance!
You can read the full @TWDFNR piece here: journalofhospitalmedicine.com/jhospmed/artic…
On behalf of my incredible co-authors (@ORourkeJr, @DoctorBhav + @MariAleMendozaD), thank you for joining us on this #Medtweetorial journey!
And a special thanks to @tony_breu for your support and guidance!
You can read the full @TWDFNR piece here: journalofhospitalmedicine.com/jhospmed/artic…
Link to full piece by Oh et al: pubmed.ncbi.nlm.nih.gov/28973626/
Re-post of algorithm from slide 10/14, from Oh et al in @JAMA_current (available at ncbi.nlm.nih.gov/pmc/articles/P…) on diagnosis and management of delirium:
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