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Risk Factors for Urosepsis in Older Adults: A Systematic Review

Brian C. Peach, MSN1, Gerard J. Garvan, BS1,
Cynthia S. Garvan, PhD1, and Jeannie P. Cimiotti, PhD1

Gerontology & Geriatric Medicine Volume 2: 1–7
© The Author(s) 2016
Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2333721416638980 ggm.sagepub.com

Abstract
Objective: To identify factors that predispose older adults to urosepsis and urosepsis-related mortality. Method: A systematic search using PubMed and CINAHL databases. Articles that met inclusion criteria were assessed using the Strengthening the Reporting of OBservational studies in Epidemiology (STROBE) criteria and were scored on a 4-point Likert-type scale. Results: A total of 180 articles were identified, and six met inclusion criteria. The presence of an internal urinary catheter was associated with the development of urosepsis and septic shock. Although a number of factors were examined, functional dependency, number of comorbidities, and low serum albumin were associated with mortality across multiple studies included in this review. Discussion: Little scientific evidence is available on urosepsis, its associated risk factors, and those factors associated with urosepsis-related mortality in older adults. More research is warranted to better understand urosepsis in this vulnerable population in an effort to improve the quality of patient care.

Keywords

mortality, older adults, systematic review, urosepsis
Manuscript received: December 30, 2015; final revision received: February 17, 2016; accepted: February 19, 2016.

Urosepsis is defined as sepsis in which the urinary tract is the known or the strongly suspected source of infec- tion. Approximately 25% of all adult sepsis cases are urosepsis, and urinary tract infection has been identified as the source in approximately 10% to 30% of all severe sepsis or septic shock cases (Wagenlehner, Weidner, & Naber, 2007). Mortality rates for patients with urosepsis range from 25% to 60% (Ackermann & Monroe, 1996; Meyers et al., 1989; Rosser, Bare, & Meredith, 1999). Complicated urinary tract infections (UTIs) are the most frequent cause of sepsis in older adults above 65 years of age (Kalra & Raizada, 2009). These complex infections occur in patients with anatomical or functional abnor- malities, which impede urine flow, or in immunosup- pressed individuals, and usually precede urosepsis.

The Centers for Disease Control and Prevention (CDC) National Center for Healthcare Statistics reported that the number of admissions for sepsis almost doubled between 2000 and 2008 (Hall, Williams, DeFrances, & Golosinskiy, 2011). This is evidence to suggest that sep- sis increases on average by 9% annually (Martin, Mannino, Eaton, & Moss, 2003) as a result of an aging population, a rise in chronic disease, increased use of invasive procedures, immunosuppressant medications, chemotherapy, organ transplantation, and antibiotic resistance (CDC, 2014). Sepsis is now the 10th leading cause of overall death in the United States (Heron et al.,

2009) claiming 220,000 lives annually (Joint Commission Center for Transforming Healthcare, 2014). An estimated 28% to 50% of patients who develop severe sepsis in the United States die, which is more than prostate cancer, breast cancer, and acquired immune deficiency syndrome (AIDS)-related deaths combined (Wood & Angus, 2004), and it is the leading cause of death in intensive care units in high-income countries (Russell, 2006). The Agency for Healthcare Research & Quality (AHRQ) has reported sepsis as the most expensive condition treated in U.S. hospitals, at a cost of more than US$20 billion in 2011 (Torio & Andrews, 2013).

More than 60% of the patients who develop severe sepsis are older adults above 65 years of age (Angus et al., 2001). Although older adults represent only 12% of the U.S. population, they account for 65% of all sep- sis cases in hospitals (Martinet al., 2003). Older adults are 13 times more likely to develop sepsis and have a twofold higher risk of death from sepsis than other

1University of Florida, Gainesville, FL, USA

Corresponding Author:

Jeannie P. Cimiotti, Florida Blue Center for Health Care Quality, College of Nursing, University of Florida, P.O. Box 100187, Gainesville, FL 32610-0187, USA.
Email: [email protected].edu

Creative Commons CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-

NonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

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Gerontology & Geriatric Medicine

adults even when controlling for race, sex, comorbid conditions, and the severity of illness (Martin et al., 2003). Older adults are particularly predisposed to sep- sis due to their many comorbidities, repeated and lengthy hospitalizations, reduced ability to fight infections, and their functional limitations related to aging (Nasa, Juneja, & Singh, 2012). A sudden deterioration in condi- tion to severe sepsis or septic shock is common in older adults (Nasa et al., 2012). In this review, we attempt to determine which factors predispose older adults to uro- sepsis and urosepsis-related mortality.

Method

Table 1. Raw and Adjusted STROBE Mean Scores for Studies on Urosepsis.

Authors

Bahagon, Raveh, Schlesinger, Rudensky, and Yinnon (2007)

Chin et al. (2010) Kizilbash, Petersen, Chen,

Naik, and Trautner (2013) Shigemura et al. (2013)
Tal et al. (2005)
van Nieuwkoop et al. (2010)

Raw M score

49.5

51.5 66.5

50.5 49.5 56.5

Adjusted M score

2.48

2.86 3.50

2.66 2.61 3.14

A systematic search of the PubMed and CINAHL data- bases included the following combinations of search terms: “bacteremic urinary tract infection,” “nosoco- mial” and “urosepsis,” “sepsis” and “elderly,” “urosep- sis” and “catheter,” “urosepsis” and “diarrhea,” “urosepsis” and “E-coli,” “urosepsis” and “elderly,” “urosepsis” and “Foley,” “urosepsis” and “gastrointesti- nal,” “urosepsis” and “geriatric,” “sepsis” and “older adults,” and “urosepsis” and “older adults.” Two study investigators (BP and GG) screened the abstracts identi- fied in this search for appropriate topical content and identified additional articles through a review of the ref- erence lists from the articles found during the original search. Criteria for inclusion were as follows: (a) studies that focused on urosepsis in older adults, and (b) studies published within the last 10 years. Exclusion criteria included (a) studies not published in English, and (b) studies on sepsis that did not identify the urosepsis patients within the larger sepsis sample.

Our search of the scientific literature was conducted in November 2015 and resulted in 180 articles. After application of inclusion and exclusion criteria, six arti- cles remained for analysis. The research team enlisted the assistance of the university’s health science center librarian, but the articles she found did not meet inclu- sion and exclusion criteria even when the team expanded the search to include articles in print for 15 years or more.

All members of the study team screened the six remaining articles for content. Two investigators (BP and GG) independently evaluated the quality of the arti- cles using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) cri- teria as reported elsewhere (Vandenbroucke etal., 2007). The investigators independently applied a 4-point Likert-type scale to the criteria, with 1 = poor, 2 = fair, 3 = good, and 4 = excellent. If a particular criterion did not apply, it assigned a value of “not applicable.” Investigators then met to compare scoring and adjusted discrepancies in scores based on mutual agreement of quality and content. Scores were totaled for each article to create a raw score and then divided it by the number of items used from the STROBE Scale to generate an adjusted score. Raw scores were adjusted to account for

Note. STROBE = STrengthening the Reporting of OBservational studies in Epidemiology.

items that were not applicable to individual articles, so as not to negatively affect the scores based on these exclusions. The adjusted score is a more accurate repre- sentation of the quality of the articles.

Results

The six studies that met inclusion criteria were con- ducted in five different countries (Israel, Japan, the Republic of Korea, the Netherlands, and the United States) and across care settings, reflecting the global nature of this problem. All of the studies selected pro- vided data on known risk factors for urinary tract infec- tion (UTI) and sepsis that have been identified by the CDC (see Table 2; CDC, 2014, 2015). The raw STROBE scores of the articles ranged from 49.5 to 66.5 and the adjusted scores ranged from 2.48 to 3.5 with a mean of 2.88. A summary of raw and adjusted mean STROBE scores for each study can be found in Table 1.

Demographic Factors

The studies included in this review reported important information on a total of 1,586 patients, of which 801 were male and 785 were female (see Table 2). Four of the studies reported on the mean age of patients, which ranged from 67.2 to 83.6 years, and one study (van Nieuwkoop et al., 2010) reported that the median patient age was 66 years (range, 46-78 years). Three studies (Bahagon, Raveh, Schlesinger, Rudensky, & Yinnon, 2007; Tal et al., 2005; van Nieuwkoop et al., 2010) reported a significant association between older age and female gender and the development of bacteremic UTI; one study (Shigemura et al., 2013) did not find an asso- ciation between age and bacteremic UTI. In a multicenter trial of medical units (n = 35) and emergency depart- ments (n = 8), it was reported that patients older than 65 years of age admitted with febrile UTIs were nearly 2.5 times (p < .001) more likely to develop bacteremia than patients under the age of 65 (van Nieuwkoop et al., 2010). Similarly, patients admitted with a history of Peach et al. 3