Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department.

OBJECTIVES: To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED). DESIGN: Preplanned, secondary analysis of a prospective observational study. SETTING: Tertiary care, academic ED. PARTICIPANTS: A total of 424 patients in the ED, 65 years or older, including all chief complaints. MEASUREMENTS: We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection. RESULTS: Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40-2.53) or malaise/lethargy (PLR range, 1.25-1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15-18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79-0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms. CONCLUSIONS: The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484-492, 2019.

Accuracy of Current Diagnostic Criteria for Acute Bacterial Infection in Older Adults in the Emergency Department.

OBJECTIVES: To compare the accuracy of the Loeb criteria, emergency department (ED) physicians' diagnoses, and Centers for Disease Control and Prevention (CDC) guidelines for acute bacterial infection in older adults with a criterion standard expert review. DESIGN: Prospective, observational study. SETTING: Urban, tertiary-care ED. PARTICIPANTS: Individuals aged 65 and older in the ED, excluding those who were incarcerated, underwent a trauma, did not speak English, or were unable to consent. MEASUREMENTS: Two physician experts identified bacterial infections using clinical judgement, participant surveys, and medical records; a third adjudicated in cases of disagreement. Agreement and test characteristics were measured for ED physician diagnosis, Loeb criteria, and CDC surveillance guidelines. RESULTS: Criterion-standard review identified bacterial infection in 77 of 424 participants (18%) (18 (4.2%) lower respiratory, 19 (4.5%) urinary tract (UTI), 22 (5.2%) gastrointestinal, 15 (3.5%) skin and soft tissue). ED physicians diagnosed infection in 71 (17%), but there were 33 with under- and 27 with overdiagnosis. Physician agreement with the criterion standard was moderate for infection overall and each infection type (κ = 0.48-0.59), but sensitivity was low (<67%), and the negative likelihood ratio (LR(-)) was greater than 0.30 for all infections. The Loeb criteria had poor sensitivity, agreement, and LR(-) for lower respiratory (50%, κ = 0.55; 0.51) and urinary tract infection (26%, κ = 0.34; 0.74), but 87% sensitivity (κ = 0.78; LR(-) 0.14) for skin and soft tissue infections. CDC guidelines had moderate agreement but poor sensitivity and LR(-). CONCLUSION: Emergency physicians often under- and overdiagnose infections in older adults. The Loeb criteria are useful only for diagnosing skin and soft tissue infections. CDC guidelines are inadequate in the ED. New criteria are needed to aid ED physicians in accurately diagnosing infection in older adults.

Epidemiology of 1.6 million pediatric soccer-related injuries presenting to US emergency departments from 1990 to 2003.

BACKGROUND: As soccer participation in the United States increases, so does the number of children at risk for injury. PURPOSE: To examine pediatric soccer-related injuries presenting to US emergency departments from 1990 to 2003. STUDY DESIGN: Descriptive epidemiology study. METHODS: A descriptive analysis of nationally representative, pediatric, soccer-related injury data from the US Consumer Product Safety Commission's National Electronic Injury Surveillance System. RESULTS: Among those 2 to 18 years of age, a nationally estimated 1597528 soccer-related injuries presented to US emergency departments from 1990 to 2003. Mean age was 13.2 years (range, 2-18 years); 58.6% were male. From 1990 to 2003, there was an increase in the absolute number of injuries among girls (P < .0001). The wrist/finger/hand (20.3%), ankle (18.2%), and knee (11.4%) were the most commonly injured body parts. The most common diagnoses were sprain/strain (35.9%), contusion/abrasion (24.1%), and fracture (23.2%). Boys were more likely to have face and head/neck injuries (17.7%; relative risk, 1.40; 95% confidence interval, 1.32-1.49; P < .01) and lacerations/punctures (7.5%; relative risk, 3.31; 95% confidence interval, 2.93-3.74; P < .01) than were girls (12.7% and 2.3%, respectively). Girls were more likely to have ankle injuries (21.8%; relative risk, 1.38; 95% confidence interval, 1.33-1.45; P < .01) and knee injuries (12.9%; relative risk, 1.25; 95% confidence interval, 1.15-1.35; P < .01) than were boys (15.7% and 10.4%, respectively). Girls were more likely to have sprains or strains (42.4%) than were boys (31.3%; relative risk, 1.36; 95% confidence interval, 1.31-1.40; P < .01). Children 2 to 4 years old sustained a higher proportion of face and head/neck injuries (41.0%) than did older children (15.5%; relative risk, 2.65; 95% confidence interval, 2.09-3.36; P < .01). CONCLUSION: When comparing these data to available national statistics that estimate participation in youth soccer, true injury rates may actually be decreasing for boys and girls. Young children should be closely supervised because of risk of head injuries and rate of hospitalization. The establishment of a national database of soccer participation and injury data is needed to better identify injury risks.