Table 4 Summary of Studies with Invalid/Biased Criteria for Confusion
Study | Design of Study | Patient Sample Number, Age, Female %, Catheter % | Care Setting | Association between Confusion and UTI Primary Aim of Study | Confusion Diagnostic Criteria | UTI/Bacteriuria Diagnostic Criteria | Results |
|---|---|---|---|---|---|---|---|
Assantachai et al. 1997 [56] | Cross Sectional; Prospective | 100 patients with UTI, Age: ≥ 60 years, mean 72 +/− 8.6, range 60–100 Female: 78% Catheter: 46% | Hospital (General and Intensive care wards 95:5) | No | Confusion Not stated | Bacteriuria ≥105 bacteria/ml UTI Not described | 60 out of 100 (60%) patients with UTI had Confusion |
Caterino et al. 2012 [59] | Cross Sectional; Retrospective | 25.4 million presentations of UTI Age: ≥ 18 years, 18,200,000 aged 18–64, Female 87% 5,015,000 aged 65–84, Female 68% 2,203,000 aged ≥85, Female 76% Catheter: Unclear | Hospital (Emergency Department) | Yes | Altered Mental Status ICD - 9 code 780.97; or documentation of disorientation; or presence of reason for visit ICD - 9 codes 5840.0, 5841.0, or 5842.0 | Bacteriuria Not Stated UTI ICD-9 CM codes for UTI; or cystitis; or pyelonephritis; (590, 595.0, 595.89, 595.9, or 599.0) | Altered mental status was present in 7% of those aged 65–84, and 13% of those aged ≥85, with UTI. Compared to adults aged 18 to 64 years, those aged ≥85 with UTI were more likely to present with altered mental status. (Adjusted OR = 2.5, 95% CI = 1.3–5.0; p = 0.009) Nursing home residents more likely to present with altered mental status (Adjusted OR 4.8 95% CI 2.9–7.8 < 0.001) |
Gau et al. 2009 [67] | Cross-Sectional, case control retrospective | 154 bacteriuric patients Age: ≥65 years, mean 83, SD 8 Female: 84% Catheter: 51% Control group 142 non-bacteriuric patients Age: ≥65 years, mean 82, SD 8 Female: 75% Catheter: 37% | Hospital | Partial | Delirium Defined by delirium, acute confusion, or mental status change as documented on admission | Bacteriuria ≥5 × 104 cfu/ml of a single uropathogen, pyuria, or nitrate positive test results UTI Positive urine culture and atleast local symptoms, fever, delirium (mental status change) or other symptoms (lower abdominal pain, falls, emesis) | 46 out of 154 (30%) patients with bacteriuria had delirium Patients with bacteriuria were more likely to have Delirium OR 5.1 (95% CI 2.5–10, P < 0.05) 40 out of 104 (39%) patients with UTI had delirium Patients with UTI were more likely to have delirium in comparison to patients with asymptomatic bacteriuria. OR 4.6 (95% CI 1.8–12, p < 0.05) |
Levkoff et al. 1988 [61] | Retrospective Case Controlled | 117 Patients with Delirium Age: ≥60, 54 > 80+ Female: 65% Catheter: Unclear | Hospital | No | Delirium ICD-9 Codes for Delirium | Bacteriuria Not Stated UTI Discharge ICD-9 Codes for UTI | 37 out of 117 (32%) with delirium had UTI UTI was associated with delirium OR 3.05 (95% CI 2.01–4.50) |
Lin et al. 2010 [62] | Cross-sectional; Retrospective | Total 1,968,527 hospitalizations with CHF, UTI, pneumonia or lower limb orthopaedics Age: ≥ 18 years 1,952,301 without delirium Age: ≥ 18 years median age 75 female 60% Catheter: Unclear 16,226 with delirium Age: median age 83, Female 63% Catheter: Unclear | Hospital | Partial | Delirium 6 ICD-9 Codes (drug-induced delirium, presenile dementia with delirium, senile dementia with delirium, vascular dementia with delirium, subacute delirium or delirium not otherwise specified) | Bacteriuria Not Stated UTI CMS-DRG classifications kidney/urinary tract infections (DRGs 320–321) | 2700 out of 254,000 (1.1%) patients with UTI presented with delirium on admission 3750 out of 254,000 (1.5%) patients with UTI had delirium at any time during hospitalisation Multivariate models for predicting delirium produced, however UTI used as reference group. |
Lin et al. 2010 [63] | Cross- Sectional; Retrospective | 26,057,988 hospitalizations with CHF, UTI, pneumonia or lower limb orthopaedics Age: ≥ 18 years 25,806,657 without delirium Age: ≥ 18 years median age 74 female 60% Catheter: Unclear 251,331 with any delirium Age: ≥ 18 years median age 83, Female 63% Catheter: Unclear | Hospital | Partial | Delirium 6 ICD-9 Codes (drug-induced delirium, presenile dementia with delirium, senile dementia with delirium, vascular dementia with delirium, subacute delirium or delirium not otherwise specified) Non-dementia, Non-drug Delirium 2 ICD-9 Codes (subacute delirium or delirium not otherwise specified) | Bacteriuria Not Stated UTI CMS-DRG classifications kidney/urinary tract infections (DRGs 320–321) | 58,000 out of 3,158,000 (1.8%) patients with UTI had any delirium 38,000 out of 3,158,000 (1%) patients with UTI had non-dementia, non-drug delirium Yearly prevalence of any delirium in patients with UTI 16.6–20.9/1000 Multivariate models for predicting delirium produced, however UTI used as reference group |
Lixouriotis et al. 2011 [53] | Cross-sectional; Retrospective | 9 patients with Delirium Age: mean 76, range 58–83 Female: 44% Catheter: Unclear | General Practice | No | Delirium ICD-10 | Bacteriuria Not Stated UTI Not Stated | 2 out of 9 (22%) patients with delirium had UTI |
Manepalli et al 1990 [64] | Cross-Sectional; Retrospective | 407 patients Age: Not Stated Female: Not Stated Catheter: Unclear Of the 14 patients with UTI and delirium Age: 81.9 years, range 70–93 | Hospital (Psychogeriatric Unit) | Partial | Delirium ICD-9 | Bacteriuria Not Stated UTI ICD - 9 | 14 out of 83 (17%) patients with UTI had delirium 14 out of 54 (26%) patients with delirium had UTI |
Rothberg et al. 2013 [65] | Cohort; Retrospective | 225,028 Age: ≥ 65 years, median 82; Female: 58% Catheter: Unclear | Hospital (Admissions) | No | Delirium Defined as on Day 3 or later prescribed an antipsychotic or placed into restraints | Bacteriuria Not Stated UTI ICD-9-CM | 944 out of 20,986 (4.5%) patients with UTI had delirium |
Sabzwari et al. 2014 [73] | Cross-Sectional; Retrospective | 464 patients Age: ≥ 65 years, mean 72.7 SD 6.4; Female: 42% Catheter: Unclear | Hospital (Admission) | Partial | Delirium Key words in clinical notes: acute confusion, acute mental status changes, fluctuating consciousness, acute agitation and organic brain syndrome | Bacteriuria Not Stated UTI Not Stated | 17 out of 43 (40%) patients with UTI had delirium 17 out of 101 (17%) patients with delirium had UTI 17% of patients with delirium had UTI compared to 7% of patients without delirium. Adjusted OR 3.1 (95% CI 1.5–6.8, p < 0.005) |
Schultz et al 1991 [57] | Cohort; Prospective | 65 residents Age: Not reported Female: Unclear Catheter: Unclear | Nursing Home | Yes | Delirium Not Stated Altered Mental Status Not Stated | Bacteriuria Not Stated UTI significant change in condition + new +ve urine culture (≥104 cfu/ml for gram positive or ≥ 5 × 104 cfu/ml for gram negative organisms) + ≥10 WBCs per high power field. | 3.4% of residents with UTI had delirium 12% of residents with UTI had altered mental status |
Silver et al. 2009 [58] | Cohort; Prospective | 335 Patients Age: ≥ 18 years, mean 68, Female: 36% Catheter: 51% | Hospital | No | Confusion or Altered Mental Status Clinical Notes | Bacteriuria > 104 cfu/ml on urine culture Catheter: 102 cfu/mL on urine culture UTI Bacteriuria and either fever without another explanation or ≥ 1 urinary symptom | 77 out of 137 (56%) patients with positive urine cultures had confusion or Altered mental status compared to 114 out of 198 (58%) patients with negative urine cultures (p = 0.82) 19 out of 34 (56%) UTI patients presented with confusion or altered mental status compared to 44 out of 67 (66%) patients with asymptomatic bacteriura (p = 0.17) |
Sundvall 2014 [11] | Cross-sectional; Prospective | 421 residents Age (Female): mean 87 years, SD 6.4, range 63–100 Age (Male): mean 85 years, SD 7.1, range 65–100 Female: 70% Catheter: 0% | Nursing Home | Partial | Confusion Nursing Clinical Notes | Bacteriuria ≥105 cfu/ml on urine culture or if signs of possible UTI present: ≥103 for E. coli or males with Klebsiella and E.Faecalis; or ≥ 104 women with Klebsiella and E.Faecalis. UTI Not Stated | 3 out of 22 (14%) residents with confusion had bacteriuria 3 out of 135 (2.2%) residents with bacteriuria had confusion Residents with bacteriuria were less likely to have confusion OR 0.15 (95% CI 0.033–0.68, p = 0.014) |
Sundvall 2011 [69] | Cross-sectional; Prospective | 651 residents Age (Female): mean 86 years, SD 7.4, range 46–102 Age (Male): mean 82 years, SD 7.8, range 54–99 Female: 74% Catheter: 0% | Nursing Home | Yes | Confusion Nursing Assessment | Bacteriuria ≥105 cfu/ml on urine culture or if signs of possible UTI present: ≥103 for E. coli or males with Klebsiella and E.Faecalis; or ≥ 104 women with Klebsiella and E.Faecalis. UTI Not Stated | Correlation between bacteriuria with E. Coli and confusion OR 1.8 (95% CI 0.96–3.6, p = 0.067) Correlation between bacteriuria and confusion OR 1.9 (95% CI 1.0–3.5, p = 0.044) |