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Antibiotics for Delirium in Older Adults With Pyuria or Bacteriuria
TAKE-HOME MESSAGE
- This large systematic review evaluated the effects of antibiotic therapy in elderly adults with acute delirium and bacteriuria or pyuria (positive bacterial urine culture or positive leukocytes in urine sample) but the absence of systemic symptoms such as fever or hemodynamic instability and the absence of new urinary symptoms. Overall, none of the studies included in the review showed a clear benefit or improved delirium outcomes with antibiotic therapy, and some studies showed evidence of harm. The authors did note that the available data are limited and carry a moderate to high risk of bias.
- Antibiotic therapy for delirium with bacteriuria or pyuria in the absence of urinary tract infections or systemic symptoms in the elderly is likely not helpful and may be harmful; however, the subtleties of evaluating delirium and infection in elderly patients remain a challenge.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
It is unclear whether antibiotics impact delirium outcomes in older adults with pyuria or bacteriuria in the absence of systemic signs of infection or genitourinary symptoms.
METHODS
We registered our systematic review protocol with PROSPERO (CRD42023418091). We searched the Medline and Embase databases from inception until April 2023 for studies investigating the impact of antimicrobial treatment on the duration and severity of delirium in older adults (≥60 years) with pyuria (white blood cells detected on urinalysis or dipstick) or bacteriuria (bacteria growing on urine culture) and without systemic signs of infection (temperature > 37.9C [>100.2F] or 1.5C [2.4F] increase above baseline temperature, and/or hemodynamic instability) or genitourinary symptoms (acute dysuria or new/worsening urinary symptoms). Two reviewers independently screened search results, abstracted data, and appraised the risk of bias. Full-text randomized controlled trials (RCTs) and observational study designs were included without restriction on study language, duration, or year of publication.
RESULTS
We screened 984 citations and included 4 studies comprising 652 older adults (mean age was 84.6 years and 63.5% were women). The four studies were published between 1996 and 2022, and included one RCT, two prospective observational cohort studies, and one retrospective chart review. None of the four studies demonstrated a significant effect of antibiotics on delirium outcomes, with two studies reported a worsening of outcomes among adults who received antibiotics. The three observational studies included had a moderate or serious overall risk of bias, while the one RCT had a high overall risk of bias.
CONCLUSIONS
Our systematic review found no evidence that treatment with antibiotics is associated with improved delirium outcomes in older adults with pyuria or bacteriuria and without systemic signs of infection or genitourinary symptoms. Overall, the evidence was limited, largely observational, and had substantial risk of bias.
Additional Info
Disclosure statements are available on the authors' profiles:
Antibiotics for delirium in older adults with pyuria or bacteriuria: A systematic review
J Am Geriatr Soc 2024 Jun 19;[EPub Ahead of Print], NM Stall, C Kandel, C Reppas-Rindlisbacher, KL Quinn, L Wiesenfeld, DR MacFadden, J Johnstone, M FralickFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
A systematic review of four studies showed no benefit of antimicrobial treatment on the duration and severity of delirium in the short term on the Brief Confusion Assessment Method or in the medium to long term in activities of daily living and on the Behavioral Rating Scale. A total of 652 older adults (age, ≥60 years; average age, 84.6 years) had pyuria (white blood cells detected on urinalysis or dipstick) or bacteriuria (bacteria growing on a urine culture) but no systemic signs of infection (a temperature of >37.9 °C [>100.2 °F] or a 1.5 °C [2.4° F] increase above the baseline temperature and/or hemodynamic instability) or genitourinary symptoms (acute dysuria or new/worsening urinary symptoms) based on Loeb criteria.1 Another screening tool is based on McGeer criteria, which also requires three of the five criteria to justify urinalysis and culture:2
The Infectious Diseases Society of America's clinical practice guideline recommends assessing for other causes of delirium along with close observation rather than the initiation of antibiotics. Furthermore, up to half of the patients residing in a nursing home have bacteriuria at any given time. The American Geriatrics Society and the Society for Post-Acute and Long-Term Care Medicine recommend against treating asymptomatic bacteriuria.
So, what can we do when families and staff report mental status changes? Start by increasing hydration. Dehydration is prevalent in older adults, with 37% in community living3 and up to 75% in patients residing in a nursing home.4 Older adults are notorious for not drinking enough owing to the fear of incontinence, difficulty toileting, and not wanting to go to the bathroom so frequently. Added to that are several aging changes that put older adults at risk of dehydration: as our hypothalamus atrophies, we feel less thirsty, and this is more pronounced in dementia. As we get older, we need more fluids because our anterior pituitary produces a less amount of antidiuretic hormone, and, owing to the atrophy of the long nephrons in the kidney, we are less able to concentrate the urine than younger adults, leading to greater fluid losses.5 Furthermore, our reserve is decreased, with 70% of body water at birth; but, at the age of 80 years, men have 50% and women only 40% of body water because of reduced muscle mass.6 Tasking families to encourage fluid intake by their loved ones also gives them a purpose and a feeling that they are doing something about mental status changes.
Other reasons for delirium could be medications. Anticholinergic medications can cause delirium by depleting the already low cholinesterase levels in the brain. Some medications, such as tramadol or gabapentin, may accumulate over time owing to decreased renal function and cause delirium immediately or later. The Beers Criteria are a good guide for the medications to avoid.
References