A snapshot of geriatric infections in Turkey: ratio of geriatric inpatients in hospitals and evaluation of their infectious diseases: A multicenter point prevalence study

A

snapshot

of

geriatric

infections

in

Turkey:

ratio

of

geriatric

inpatients

in

hospitals

and

evaluation

of

their

infectious

diseases:

A

multicenter

point

prevalence

study

Behice

Kurtaran

*

,

Ferit

Kuscu

,

Pinar

Korkmaz

,

Burcu

Ozdemir

,

Dilara

Inan

,

Ne

fise

Oztoprak

,

Duru

Mistanoglu

Ozatag

,

Ozgur

Dagl

ı

,

Serhat

Birengel

,

Kevser

Ozdemir

,

Turkey

EKMUD

Geriatric

Infections

Study

Group

a

CukurovaUniversity,FacultyofMedicine,InfectiousDiseasesandClinicalMicrobiology,Turkey

b_Dumlupınar

University,KutahyaEvliyaCelebiTrainingandResearchHospital,InfectiousDiseasesandClinicalMicrobiology,Turkey

c_{AnkaraNumuneTrainingandResearchHospital,InfectiousDiseasesandClinicalMicrobiology,Turkey} d

AkdenizUniversity,FacultyofMedicine,InfectiousDiseasesandClinicalMicrobiology,Turkey

e

AntalyaTrainingandResearchHospital,InfectiousDiseasesandClinicalMicrobiology,Turkey

f

BursaYüksek _IhtisasTrainingandResearchHospital,InfectiousDiseasesandClinicalMicrobiology,Turkey

g

AnkaraUniversity,FacultyofMedicine, _Ibn-iSinaHospital,InfectiousDiseasesandClinicalMicrobiology,Turkey

h

PamukkaleUniversity,FacultyofMedicine,InfectiousDiseasesandClinicalMicrobiology,Turkey

ARTICLE INFO Articlehistory:

Received17January2020

Receivedinrevisedform12August2020 Accepted16August2020 Keywords: Geriatrics Hospitalization Infection Antibiotic ABSTRACT

Introduction:Thehumanpopulationisagingatanastonishingrate.Theaimofthisstudyistocapturea situationsnapshotrevealingtheproportionofindividualsaged65yearsandoveramonginpatientsin healthcareinstitutionsinTurkeyandtheprevalenceandtypeofinfectionsinthispatientgroupinorder todrawaroadmap.

MaterialsandMethods:Hospitalizedpatientsover65yearsatanyofthe62hospitalsin29citiesacross TurkeyonFebruary9,2017wereincludedinthestudy.Web-basedSurveyMonkeywasusedfordata recordingandevaluationsystem.

Results:Of17,351patients5871(33.8%)were65yearsold.Themeanagewas75.17.2years;3075 (52.4%)patientsweremale.Infectionwasreasonforadmissionfor1556(26.5%)patients.Pneumoniawas themostcommoninfection.Themedianlengthof hospitalstaywas5 days(IQR: 2–11 days).The Antibiotictherapywasinitiatedfor2917(49.7%) patientsatthetimeofadmission,and23%ofthe antibioticsprescribedwereinappropriate.Healthcare-associatedinfectionsdevelopedin1059(18%) patients.Urinarycatheterswereplacedin2388(40.7%)patientswith7.5%invalidindication. Conclusion:Thisstudyusedrealdatatorevealtheproportionofelderlypatientsinhospitaladmissions. The interventions done, infections developed during hospitalization, length of hospital stay, and excessivedrugloademphasizethesignificantimpactonhealthcostsandillustratetheimportanceof preventivemedicineinthisgroupofpatients.

©2020TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases. ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(

http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

TurkeyisadevelopingcountrybridgingtheEuropeanandAsian continents, and the Turkish population features a broad

socioculturalstructure,includingcitizensofawiderangeofraces, languages, and religions. Worldwide, the human population is agingatanastonishingrate.Whileonly1%oftheworldpopulation wasover65yearsoldinthe1900s,itispredictedthatthisratewill

* Correspondingauthorat:CukurovaUniversityFacultyofMedicine,InfectiousDiseasesandClinicalMicrobiology,Saricam,01330,Adana,Turkey.

E-mailaddresses:behicekurtaran@gmail.com(B.Kurtaran),feritkuscu@gmail.com(F.Kuscu),drpinarkor@gmail.com(P.Korkmaz),burcubagci17@hotmail.com

(B.Ozdemir),inan@akdeniz.edu.tr(D.Inan),nefiseoztoprak@yahoo.com(N.Oztoprak),durumistan@gmail.com(D.M.Ozatag),drozgurdagli@yahoo.com(O.Daglı),

serhat.birengel@medicine.ankara.edu.tr(S.Birengel),drkevser@gmail.com(K.Ozdemir).

1

EKMUDGeriatricInfectionsStudyGroupislistedinthebelowtext.

https://doi.org/10.1016/j.ijid.2020.08.046

1201-9712/©2020TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

ContentslistsavailableatScienceDirect

International

Journal

of

Infectious

Diseases

reach approximately 20% by 2050. The elderly population constituted8.7%oftheglobalpopulationin 2016(Sharifi-Mood

andMetanat,2007).

AccordingtodatafromtheTurkishStatisticalInstitute,Turkeyis 66thamong167countriesrankedaccordingtohighestproportionof elderlyintheirpopulation.Theelderly(aged65yearsandover) populationinTurkeywas5,682,003in2012andincreasedby17.1% over a period of five years, reaching 6,651,503 in 2016. The proportionofelderlywithinthetotalpopulationwas7.5%in2012 androseto8.3%in2016.Withintheelderlypopulation,43.9%were male and 56.1% were female (Türkiye _Istatistik Kurumu Haber

Bülteni,2016).Inthiscasethereisagrowingpopulationofolder

adultsandincreasinghealthcareneeds.

Along with these changes in population distribution, age-related health problems have become more common and will undoubtedlycontinuetobecomeincreasinglyprevalent.Impaired hostdefenseandchangesinlifestyleaspotentialchangesinhabits, likeincreasedalcoholortobaccousing,limitedabilitytoexercise, decreased income, combined with community and hospital-acquiredinfectionscontributetomorbidityandmortalityamong olderadults(Castle,2000).Thehealthcareneedsofolderadultsin Turkey,specificallywithregardtoinfectionisnotproperlyknown. Todate,therehavebeennocomprehensivestudiesinTurkeyon theprevalenceofinfectionsamonghospitalizedolderadultsand thefeatures of infection,and webelieve this preventsus from seeingtheextentoftheproblemandunderstandingwhatstepsare necessary.

Whenplanningthisstudy,ourgoalwastocapturethecurrent situationinordertodrawaroadmapforgeriatricpatientcare.We conducteda survey-based point-prevalencestudy todetermine thenumberandreasonsforadmissionofolderadultshospitalized inTurkeyandalso,theprevalenceanddistributionofinfections, the antimicrobial drug usage and, interventions performed (catheterization,mechanicalventilation,etc.)ofthesepatients.

Materialsandmethods

Patientsaged65yearsandolderwhowereunderinpatientcare inoneof62secondaryandtertiaryhealthcareinstitutionsin29 citiesacrossTurkeyonFebruary9,2017wereincludedinthestudy. Thenumberofbedsinallhospitalsparticipatinginthestudywas over100.

TheGeriatricInfectionsStudyGroupoftheInfectiousDiseases and Clinical MicrobiologySpecialty Society of Turkey (EKMUD) sentinvitationstoallmembersviae-mail.Aseparatemailgroup consistingof infectious diseasesspecialist (IDS) who wished to participateinthestudywascreatedandinformationregardingthe studywassharedviathegroup.Necessarypermitsandapprovals wereobtainedfromthemanagersofallhospitalsand_filedforthe study.EthicscommitteeapprovalwasalsoobtainedfromCukurova University,theplanningcenter.Participantswereaskedtorecord the number and age distribution of all inpatients onthe date –October9,2017,specifiedforthestudy.Aformconsistingof20 questions(showninappendix)waspreparedtobefilledinforall individualsaged65yearsandoverinthehospitals.Thisformwas placed on the web-based SurveyMonkey data recording and evaluationsystem.Thecentersparticipatinginthestudyentered thedatapertainingtopatientsintotheSurveyMonkeysystemusing aone-pagedataentryformaccessedviaalinksenttothem.All doctors who entered the data were IDS and answered the questionsbyassessingthepatients’infectiondiagnoses, catheteri-zationindications,andtheappropriatenessofantibiotics admin-isteredsimultaneously.Allwereinformedinordertomaketheir diagnosis of healthcare and nosocomial infection appropriate antibioticuseandalsoaskedifthereisavalidreasonforurinary

catheter insertion adhering tothe international guidelines that theyfollow.Expertsfilledoutaseparateformforeachpatient.In addition,theIDSwereaskedtoreportthetotalnumberofpatients hospitalizedintheinpatientclinicsandintensivecareunits.AnIDS fromeachhospitalattendedtothestudy.However,morethanone willingphysicianwerealsoallowedtoenterdatafromthesame hospital. However, in this case, they were asked to share the hospitalizedpatientswitheachother,sothattheydidnotoverlap. Surveyquestionsweresetsoasnottoswitchfromonetotheother, thereby preventing the missing form from being saved in the system.

Statistical analysis of the acquireddata was done after the completionoftheentryprocedureusingtheSPSS20.0(SPSSInc., Chicago, IL, USA) software package. Categorical measurements were summarized as numbers and percentages, and numerical measurementsasmeanandstandarddeviation(withmedianand minimum-maximumwherenecessary).TheKolmogorov–Smirnov test was used to determine whether the continuous variables showed normal distribution; Student's t-test was used for normally distributed variables and the Mann–Whitney U test wasusedfornon-normallydistributedvariables.Achi-squaretest was usedincomparisonsofcategoricalvariables.Thestatistical significancelevelwasacceptedas0.05inalltests.

Results

Thesurveywas recordedintheSurveyMonkeysystem forall patientsover65years’oldwhoweremonitoredintheintensive careand generalmedicaland surgicalunitsof theparticipating centersbetween9AMand5PMonFebruary9,2017.Thesystem wasclosedtodataentryattheendoftheworkinghouronthesame day. The participants were asked to report the number of all hospitalizedpatientswithin48hthatdayandwererecorded.

Of 17,351 patientsstaying in 62 hospitalsin 29 cities,5871 (33.8%)wereaged65yearsorolder.Themeanageofthesepatients was 75.17.2years;3075 (52.4%) weremale and 2796(47.6%) werefemale.Thetypesofhospitalsfromwhichdatawerecollected arelistedinTable1accordingtotheproportionofinpatientsaged 65 yearsand older. Table1 alsoshowsthepatients’residential status, comorbidities, and the inpatientunits where theywere beingtreated.Thepatients’diagnosesatadmissionarepresented

inTable2.Nocomorbiddiseasewasrecordedfor743(12.7%)ofthe

patients. The remaining patients had a history of at least one comorbiddisease.

It was observed that 1768 (35%) of the patientswerebeing treated in surgicalunits, 3127(65%) werein internal medicine units,4766(81.2%)wereinotherinpatientunits,and1105(18.8%) wereinintensivecareunits.

Infectionwasthecauseofhospitalizationfor1556(26.5%)of thepatients.Pneumoniawasthemostcommonoftheseinfections, withnearlyhalfofthepatientshavinga diagnosisoftypicalor atypicalpneumonia.Thiswasfollowedbyurinarytractinfections, acutecholecystitis,anddiabeticfootinfections(Table3).

Asofthedaythestudydatawerecollected,themedianlengthof hospitalstaywas5days(IQR:211days).Antimicrobialtherapywas initiated for 2917(49.7%) ofthepatientsatthetime ofadmission,and 23%oftheantimicrobialagentsgivenwereinappropriate.Themost commonlyadministeredantibioticclasseswere firstandsecond generation cephalosporins (69.4%), beta-lactam/beta-lactamase inhibitors (35.8%), fluoroquinolones (32.8%), and carbapenems (14.7%).Thelist ofantimicrobialsadministeredisinTable4.Antiviral and antifungal agents also initiated to 38 (%1.9) and 28 (%1.5) patients atadmission,respectively.

Healthcare-associatedinfectionsdevelopedin1059(18%)ofthe patients. Mean duration of hospitalization was 25 days among patientswhodevelopedinfectionand6.7daysamongthosewho

did not develop infections (p<0.0001). The prevalence of nosocomialinfectionamongpatientsinintensivecareunitswas 44.9%(n=475),whilethisratewas12.3%(n=584)forpatientsin otherinpatientunits(p<0.0001).

Urinary catheters were placed in 40.7% of the patients (n=2388), and181(7.5%)ofthesepatientsdidnothaveavalid indicationforcatheterization.Meandurationofurinarycatheter usewas13days(1730days).Indicationsforurinarycatheterization areshowninTable5.

Decubitus ulcers were present in 259 patients (4.4%) at admissionanddevelopedin259patients(4.4%)duringinpatient treatment.

Discussion

Ourpointprevalencestudyhasdemonstratedthatinfectionis the most common cause of hospitalization among geriatric patients in Turkey (26.5%) different from developed countries withhigherrate(RussoandElixhauser,2003).Thiswasfollowed by neurological diseases, cancers, heart diseases, and chronic

Table1

Demographicdataofthepatients.

DemographicData Patientnumber (n=5871) Percentage(%) Sex Female 2796 47.6 Male 3075 52.4 AgeGroups 65–80years 4440 75.6 81andover 1431 24.4 HospitalType UniversityHospital 2172 37 TrainingandResearchHospital 2645 45 StateHospital 767 13 PrivateHospital 172 3 PrivateUniversityHospital 115 2 ResidentialStatus Independent 3038 51.7 Withfamily 2761 47 Nursinghome 60 1 Other 12 0.2 Comorbidities* Hypertension 2948 50.2 Diabetesmellitus 1799 30.6 Congestiveheartfailure 1176 20.0 Chronicobstructivepulmonary

disease

1143 19.5

Solidtumor 548 9.3

Chronickidneydisease 536 9.1 Cerebrovascularaccident 527 9.0 Cerebrovascularaccident 363 6.2 Alzheimer’s/Dementia 308 5.2 Alzheimer’s/Dementia 104 1.8 Chronicischemicheartdisease 1143 19.5 Leukemia/Lymphoma

Other*

InpatientUnits

MedicalWards** 2529 41.7 SurgicalWards*** 1629 27.8 IntensiveCareUnits

Reanimation/AnesthesiaIntensive Care

329 5.6

InternalMedicineIntensiveCare 219 3.7 SurgicalIntensiveCare 139 2.4 MainIntensiveCare 136 2.3 EmergencyIntensiveCare 12 0.2

Other**** 878 15.0

*

Onepatientmayhavemorethanoneaccompanyingdisease.

**

Internal Medicine, Pulmonary Diseases, Cardiology, Neurology, Physical TherapyandRehabilitation,InfectiousDiseases,Dermatology.

*** _{General Surgery, Orthopedics and Traumatology, Urology, Cardiovascular}

Surgery, Neurosurgery, Ophthalmology, Plastic and Reconstructive Surgery, Otorhinolaryngology.

****

Generalservices,Mixedservices.

Table2

Diseasecausinghospitaladmission.

Diseases* Patientnumber(n=5871) Percentage(%)

Infection 1556 26.5

Cerebrovasculardisease 520 8.9 Cardiovasculardisease 493 8.4 Solidmalignancies 377 6.4 Orthopedicsurgery 321 5.4 Chronicpulmonarydiseases 293 5.0 Chronickidneydisease 245 4.2 Abdominalsurgery 192 3.3 Gastrointestinaldiseases 184 3.1 Urologicdiseases 178 3.0 Neurosurgery 134 2.3 Kidneyfailure 180 3.0 Ocularsurgery 108 1.8 Trauma 97 1.7 Diabetesmellitus 88 1.5 Rheumatologicdiseases 64 1.1 Other 841 14.4 *

Onepatientmayhavemorethanonediseaseforhospitaladmission.

Table3

Infectiondiseasescausinghospitaladmission.

InfectionDiagnosis Number(n=1556) Percentage(%)

Pneumonia* 820 52.6

Urinarytractinfection** 198 12.8 bdominalinfection*** 124 7.9 Skinandsofttissueinfection**** 120 7.6 Sepsiswithnoidentifiedsource 60 3.8 Bonejointinfection*****

52 3.3

Surgicalsiteinfection 33 2.1 Meningitis******

17 1.2

Ocularinfections 7 0.5

Endocarditis 6 0.4

Upperrespiratorytractinfection 5 0.4

Tuberculosis 2 0.1

Other 112 7.2

TOTAL 1556 100

*_{typicalpneumonia 651(%41.8),Atypicalpneumonia 141(%9,1),}

Ventilator-associatedpneumonia18(%1.1),Viralpneumonia10(%0,6).

**

Pyelonephritis166(%10.7),Cystitis32(%2.1).

***

Acutecholecystitis/cholangitis93(%5.9),Intra-abdominalabscess14(%0.9), Acutegastroenteritis11(%0.7)Bowelinfections6(%0.4).

****

Diabeticfootinfection65(%4),Cellulitis 48(%3.1),Necrotizing fasciitis/ Fournier’sgangrene7(%0.5).

*****_{Spondylodiscitis8(%0.6),Osteomyelitis7(%0.5)Prosthesisinfection37(%}

2.2).

******

Bacterialmeningitis12(%0.8)Viralmeningoencephalitis5(%0.4).

Table4

Antimicrobialdrugsinitiatedattimeofadmission*.

Antimicrobialdrug N % 1st/2ndgenerationcephalosporins 1371 69.4 Beta-lactam/beta-lactamaseinhibitors 709 35.8 Fluoroquinolones 648 32.8 Carbapenems 291 14.7 Macrolides 228 11.5 Nitroimidazoles 120 6.1 Glycopeptides 93 4.7 Aminoglycosides 37 1.9 Oxazolidinones 34 1.7 Sulfonamides 27 1.4

Expandedspectrumcephalosporins 24 1.3

Tigecycline 21 1.1 Daptomycin 20 1.0 Colistin 19 1.0 Clindamycin 7 0.4 Fusidicacid 6 0.3 Doxycycline 3 0.2 *

obstructive pulmonary disease (COPD). Epidemiological differ-ences between populations are expected, but an excess of infectious diseases may indicate that a society does not have good infection control and that socioeconomic and cultural conditions are poor. Despite the rapid growth of the older populationinourcountry,hospitalunitsprovidingspecialservices forgeriatricpatientsareveryfewinnumberandlimitedtocertain centers.AccordingtolistingsoftheMedicalSpecialist Examina-tion,13 universitiesin Turkey have a Department of Geriatrics (TıptaUzmanlıkKurulu,2020).

Age-associatedimmunedysregulation,comorbiddamage,and age-relatedfunctionallimitationsarealsoimportantfactorsinthe highrateof infectious diseases(Castle,2000, Loeb,2003; High et al., 2005). Pneumonia, urinary system infections, soft tissue infections,gastroenteritis,andprosthesisinfectionsareknownto be common among geriatric patients. Accompanying problems such as diabetes, COPD, bronchiectasis, urinary obstruction, dysphagia, poor oral hygiene, cutaneous and mucosal barrier disruption,degenerativechangesinboneandcartilage,andmore frequentimplantationofforeignbodiesleadtoahigherincidence of infectionnot only community-acquired infections, but also hospital-acquiredinfectionssuchaspneumonia,urinarysystem infections, and cellulitis (Castle, 2000; Heppner et al., 2013;

Rozzinietal.,2007; Juthani-MehtaandQuagliarello, 2010).The

snapshotwehavetakenofthesituationshowsthatpneumoniais themostcommoninfection.Itisreportedthatpneumoniais10 timesmorecommoninelderlyindividuals.Inaddition,antibiotic useis commonin this patient group, resultingin theissue of antibioticresistance. Althoughthis pointprevalence studydoes not include resistance data, antibiotic resistance in Turkey is knowntobehigh(Soyletiretal.,2016;CentralAsianandEastern EuropeanSurveillanceofAntimicrobialResistance(CentralAsian

and Eastern European Surveillance of AntimicrobialResistance

(CAESAR),2016).Theextensiveuseofantibioticsrevealedinthe

presentstudyisoneofthemajorriskfactorsforresistanceand antibiotic-relatedcomplications(Highetal.,2009).

Compared to cases seen in younger patients, cases of pneumoniaintheelderlylastlongerandresultinhighermortality (14).IthasbeenshownthatinTurkey,wheretraditionalfamilylife isstillpreserved,mostpatientsaged65yearsandoverlivewith theirfamilyorintheirownhome;veryfewpatientsliveinnursing homes(1%).Despitethislowproportionofnursinghomeresidents, thehighrates of infection indicatethat age-related factorsare moreinfluentialthansocialconditionsin determining suscepti-bilitytoinfection.

Lowerrespiratory tractinfectionsand pneumoniaaccounted fornearlyhalfofallinfection-relatedhospitalizationsinelderly individuals(Millettetal.,2013;Curnsetal.,2005,Kaplanetal., 2002).Our dataalso supporttheliterature. However,despitea similarrate,therewasalargenumberofpatientshospitalizedfor pneumoniaduetothehighprevalenceofinfectioninourstudy. Thisdemonstratestheimportanceofpreventivemeasures.

Appropriateandtimelymanagementofinfectionsintheelderly requires experience and knowledge of the different signs and symptoms of infection in this patient group (van Duin, 2012). However,swhocareforgeriatricpatientsholdtheopinionthatitis bettertomonitorthesepatientscarefullywithoutgivingantibiotics unlessaninfectionisconfirmed(Beckettetal.,2015).Unfortunately, oursnapshotshowsthatthisopinionwasnotpracticed,as49.7% (n=2917)of thepatients were startedonantibiotics at time of admission. This issue should be addressed by providing more educationalactivitiestoraisephysicianawareness.

Urinary catheterizationis performed frequently in theolder population;itsprevalencerangesbetween6%and40%depending onthestudypopulation(Wangetal.,2012).Inourpopulation,the rateofurinarycatheterizationwashigh,at40.7%.Furthermore,the meancatheterizationperiodwasalsohigh,at13days. Catheteri-zationis themostimportantrisk factorfor nosocomialurinary infections, and longer catheter use is associated with higher infectionrates.Urinaryinfectionisthemostcommonnosocomial infectionintheelderly.Studieshaveshownthat60%ofurinary tractinfectionsaretheresultofunindicatedurinarycatheteruse (Inelmenetal.,2007;Hazelettetal.,2006).Therateofunindicated useinourstudywas7.5%.

Ithasbeenreportedthatgeriatrichospitalshavehigherratesof nosocomialinfections(Saxetal.,2001).Inthepresentstudy,this ratewas18%overalland44.9%forintensivecareunits.Moreover, becausethisisapointprevalencestudy,itdoesnotincludedataon nosocomialinfectionsdevelopedbythesepatientsduring follow-up.

Themanagementofinfectiousdiseasesingeriatricpatientsis challengingduetofactorssuchasmultiplecomorbiddiseasesand polypharmacy,restrictivecircumstances,andfunctionaldisorders (Heppneretal.,2013).Earlyinitiationofappropriateantibioticsin patients with severe infections requiring monitoring in an intensivecareunithaskeyimportanceinsurvival(Gaieskietal., 2010).However,the rapidand indiscriminateadministration of broad-spectrumempiricalantibioticsisaninvitationforresistance (Carletetal.,2011).Inourpopulation,therateofantibioticusewas fairlyhigh.Nearlyhalfofthepatientswerestartedonantibioticsat thetimeofadmissionandtheantibioticsusedwereinappropriate foraquarterofthepatients.Inaddition,althoughtheproportionof patientsbeingtreatedinintensivecareunitswas14.2%,thehigh ratioofempiricalandearlytreatmentwasstriking.

Another issue requiring consideration is theuse of vascular accessdevicesandurinarycatheters.Theseforeignbodiescanact asfociofinfectionandmusteventuallyberemoved,andsurgeryis knowntohavearoleindeep-seatedinfections.Forthisreason,itis crucial that Geriatrics departments be monitored closely by infection controlspecialists(vanDuin,2012; Esmeet al.,2019; Letica-Kriegeletal.,2019)

Limitations

Inthismulti-centerstudy,itwasacceptedthattheinformation provided bythe participatingcentersin thestudy was correct. However,thereisapossibilitythattheremaybedatathatiseither duetolackofinformationoroverlooked.Again,errorsmayhave occurredduringthesurveyresponse.

Variousstudiesindicatethatageisanimportantriskfactorfor multidrug-resistantmicroorganisms,independentofotherfactors. Itisalsoestablishedthatinfectionshaveamoreseverecourseand cause more morbidity and mortality in elderly patients. As mentioned earlier, resistance rates are not compared in the presentstudybecausewedidnotobtainresistancedata.

Sincethestudywasapointofprevalencestudy,informationon prognosticfindingssuchasmortalitydataandhospitalstaywas notobtained.

Table5

Indicationsforurinarycatheterization.

Indication Number(n) Percentage(%) Tomonitorinput/output 1646 68.9 Tocorrectanatomicor

functionalobstruction

129 5.4 Forpreoperativeurinedrainage 65 2.7 Forpostoperativeurinedrainage 234 9.8 Forneurogenicdysfunctions 106 4.4 Forbladderirrigation 27 1.13 Notindicated 181 7.5

Infection diagnoses, appropriate antimicrobial therapy and interventionalapplicationsweredeterminedbytheevaluationof IDS. Qualification related to the field of expertise has been accepted.Inordertoavoidindividualerrors,thedefinitionsofthe diseaseandthecriteriafortreatmentandurinarycatheterization shouldhavebeendefined.

Conclusion

Priortoour research, a comprehensive multicenter geriatric infectionstudyhadnotbeenconductedinTurkey.Thislarge-scale, multicenterstudyhasrevealedtheproportionofelderlyinpatients usingactualdata.Thefiguresarequitedramatic,indicatingthat one-thirdofallhospitalinpatientsareovertheageof65years. Infectionsaccountforonequarterofhospitaladmissions.These infection rates are significantly higher compared to those in developed countries. Pneumoniais the mostcommon causeof hospitalization. The interventions performed, infections con-tracted during hospitalization, length of hospital stay, and excessivedrugloademphasize thesignificantimpactonhealth costsandillustratetheimportanceofpreventivemedicineinthis groupofpatients.

Authordisclosurestatement Noconflictofinterest. Financialdisclosure

Nospecificfunding.

EKMUDgeriatricinfectionsstudygroup

Hande Aslaner1_{, Aslıhan Ulu}2_{, Emine Sehmen}3_{, Serpil Erol}4_, YeşimUygunKızmaz5_,GülDurmuş6_{,MEmirhanIşık}5_{,AslıHaykır} Solay7_{, Suheyla Komur}2_{, Emel Azak}8_{, _Ilknur Yavuz}9_{, Ergenekon} Karagöz10_{, Merve Sefa Sayar}10_{, Hasan Naz}11_{, Zehra Demirbaş}7_, Nevin _Ince7_{, Fatime Korkmaz, Şule Özdemir Armagan}13_{, Ümit} Savaşçı14_{, Sabahat Aktaş}15_{,Elif TükenmezTigen}16_{,Buket Ertürk} Şengel16_{,NurCancanGürsul}17_,AliAcar7_,SemaSarı18_,SemaTuran18_, UgurKostakoglu19

,GülizEvik20,KaderArslan21,EsraKayaKılıç21 , Aynur Atilla22_{, Canan Agalar}23_{, Selma Ateş}24_{, Kenan Ugurlu}25_, Mustafa Dogan26_{, Funda Bilman}27_{, Nirgül Kılıçaslan}28_{, Gülay} Okay29,NilsunAltunal30,YaseminBalkan25,MevliyeYetik27,Serhat Uysal31_{, A _Irfan Baran}32_{,Nurettin Erben}33_{, Hande Aydemir}34_{, B} ErgütSezer26_{,AbdulkadirDaldal}25_{,AytenKadanalı}30_{,AyşeSagmak} Tartar35,AlperŞener36

,RezanHarman37,MReşatCeylan38,Hatice Ürgüdücü35_{, _Ilyas Dökmetaş}39_{, Ahmet Hamidi}39_{, A Altunçekiç} Yıldırım40_{, Sedat Kaygusuz}41_{, Esmeray Mutlu Yılmaz}42_{, Şaban} Esen42_{,Selçuk Nazik}43_,FilizKoç44_{,Hale TuranÖzden}45_{, Aslıhan} Demirel46_,Ye

şimKürekçi47_{,HalukErdogan}48_,EmineF

ıratGökta_ş44_, MehmetUlug49_{,HülyaKuşoglu}50_{,RamazanGözüküçük}51_,Habibe TülinElmaslarMert52_{, _IlknurErdem}53_{,Hüseyin Şahintürk}54_,Işıl DenizAliravc_ı55_,R

ıdvanKaraAli53_,FundaKoçak56_{, _IEY}

ıldız19_,Emel Aslan57_{,FatmaYılmazKaradag}58_,ASezaInal2_,YesimTasova2

1AnkaraNumune TrainingandResearchHospital,Infectious DiseasesandClinicalMicrobiology,2CukurovaUniversity,Faculty of Medicine, Infectious Diseases and Clinical Microbiology, 3 SamsunGaziStateHospital,4HaydarpaşaNumuneTrainingand ResearchHospital,5KartalKoşuyoluYüksek _IhtisasTrainingand Research Hospital, Bursa Yüksek _Ihtisas Training and Research Hospital,6InfectiousDiseasesandClinicalMicrobiology,7Ankara DışkapıYıldırımBeyazıtTrainingandResearchHospital,8Kocaeli University,Facultyof Medicine,9 GiresunUniversity,Facultyof Medicine, Prof. Dr. A. _Ilhan Özdemir Training and Research Hospital,10VanTrainingandResearchHospital,11KocaeliDerince

EAH Enfeksiyon Hastalıkları ve Klinik Mikrobiyoloji Klinigi, 12 Düzce University, Faculty of Medicine, 13 Konya Training and ResearchHospital,14GülhaneTrainingandResearchHospital,15 Kartal LütfiKırdarTraining and Research Hospital,16Marmara UniversityPendik Training andResearch Hospital,17Çanakkale StateHospital,18 Türkiye Yüksek _IhtisasTraining and Research Hospital,19RecepTayyipErdoganUniversity,FacultyofMedicine, 20MersinUniversity,FacultyofMedicine,21AnkaraTrainingand ResearchHospital,22SamsunTrainingandResearchHospital,23 Fatih Sultan Mehmet Training and Research Hospital, 24 KahramanmaraşSütçü _ImamUniversity,FacultyofMedicine,25 Aral_ıkStateHospital,26ÇorluStateHospital,27 _IzmirMenemen State Hospital, 28 Ankara Abdurrahman Yurtaslan Onkoloji Training and Research Hospital,29 Bezmialem VakıfUniversity FacultyofMedicine,30ÜmraniyeTrainingandResearchHospital, 31BucaSevgiDemirsoyStateHospital,32YüzüncüYılUniversity FacultyofMedicine,33OsmangaziUniversityFacultyofMedicine, 34 Bülent Ecevit University Faculty of Faculty of Medicine, 36 Onsekiz Mart UniversityFaculty of Medicine, 37 PrivateSanko Hospital, 38 Harran University Faculty of Medicine, 39 Şişli HamidiyeEtfalTrainingandResearchHospital,40OrduUniversity FacultyofMedicine,41KırıkkaleUniversityFacultyofMedicine,42 Ondokuz Mayıs UniversityFaculty of Medicine,43 BingölState Hospital,44KeçiörenTrainingandResearchHospital,45Başkent UniversityKonyaPracticeandResearchCenter,46 _IstanbulBilim Universtiy Florence Nightingale Hospital, 47 Arnavutköy State Hospital, 48 Başkent University Alanya Practice and Research Center,49PrivateÜmitHospital,50AcıbademUniversityFacultyof Medicine, 51 Hisar Intercontinental Hospital, 52 Ardahan State Hospital, 53 Namık Kemal University Faculty of Medicine, 54 Batman Medical Park Hospital, 55 Ordu University Faculty of Medicine,56BaşakşehirStateHospital,57DicleUniversityFaculty ofMedicine,58 _IstanbulMedeniyetUniversityGöztepeTraining andResearchHospital.

Acknowledgement

ThistrialwassupportedbySocietyforInfectiousDiseasesand ClinicalMicrobiologySpecialtyofTURKEY(EKMUD)

References

BeckettCL,HarbarthS,HuttnerB.Specialconsiderationsofantibioticprescription inthegeriatricpopulation.ClinMicrobiolInfect2015;21:3–9.

CarletJ,CollignonP,GoldmannD,etal.Society’sfailuretoprotectaprecious resource:antibiotics.Lancet2011;378:369–71.

Castle SC.Impactof age-relatedimmunedysfunction onriskofinfections. Z GerontolGeriatr2000;33:341–9.

Central Asian and Eastern EuropeanSurveillance of Antimicrobial Resistance (CAESAR).CentralAsianandEasternEuropeanSurveillanceofAntimicrobial Resistance(CAESAR)annualreport2016.[Internet].2016Availablefrom:http:// www.euro.who.int/en/health-topics/disease-prevention/antimicrobial-resis- tance/about-amr/central-asian-and-eastern-european-surveillance-of-antimi-crobial-resistance-caesar.Accessed:18.09.2017.

CurnsAT,HolmanRC,SejvarJJ,OwingsMF,SchonbergerLB.Infectiousdisease hospitalizationsamongolderadultsintheUnitedStatesfrom1990through 2002.ArchInternMed2005;165:2514–20.

EsmeM,TopeliA,BalamYavuzB,AkovaM.Infectionsintheelderlycritically-ill patients.FrontiersMed2019;(6):118.

Gaieski DF, Mikkelsen ME, Band RA, etal. Impactof time to antibiotics on survivalinpatientswithseveresepsisorsepticshockinwhomearly goal-directedtherapywasinitiatedintheemergencydepartment.CritCareMed 2010;38:1045–53.

HazelettSE,TsaiM,GareriM,AllenK.Theassociationbetweenindwellingurinary catheteruseintheelderlyandurinarytract infectioninacutecare.BMC Geriatrics2006;6(15),doi:http://dx.doi.org/10.1186/1471-2318-6-15.

HeppnerHJ,CornelS,PeterW,PhilippB,KatrinS.Infectionsintheelderly.CritCare Clin2013;29:757–74.

HighKP,BradleyS,LoebM,PalmerR,QuagliarelloV,YoshikawaT.Anewparadigm forclinicalinvestigationofinfectioussyndromesinolderadults:assessmentof functional status as a risk factor and outcome measure. Clin Infect Dis 2005;40:114–22.

High KP,BradleySF, Gravenstein S,et al. ClinicalPractice Guideline for the EvaluationofFeverandInfectioninOlderAdultResidentsofLong-TermCare Facilities:2008UpdatebytheInfectiousDiseasesSocietyofAmerica.ClinInfect Dis2009;48:149–71.

InelmenEM,SergiG,EnziG.Whenareindwellingurinarycathetersappropriatein elderlypatients?.Geriatrics2007;62(October(10)):18–22.

Juthani-MehtaM,QuagliarelloVJ.Infectiousdiseasesinthenursinghomesetting: challenges and opportunities for clinical investigation. Clin Infect Dis 2010;51:931–6.

KaplanV,AngusDC,GriffinMF,etal.HospitalizedCommunity-acquiredpneumonia intheelderly:ageandsex-relatedpatternsofcareandoutcomeintheUnited States.AmJRespirCritCareMed2002;165:766–72.

Letica-KriegelAS,SalmasianH,VawdreyDK,YoungermanBE,GreenRA,FuruyaEY, CalfeeDP,PerotteR.Identifyingtheriskfactorsforcatheter-associatedurinary tractinfections:alargecross-sectionalstudyofsixhospitals.BMJOpen2019;9: e022137,doi:http://dx.doi.org/10.1136/bmjopen-2018-022137.

LoebMB.Community-acquiredpneumoniainolderpeople:theneedforabroader perspective.JAmGeriatrSoc2003;51:539–43.

MillettER,QuintJK,SmeethL,DanielRM,ThomasSL.Incidenceof community-acquiredlowerrespiratorytractinfectionsandpneumoniaamongolderadults intheUnitedKingdom:Apopulation-basedstudy.PloSOne2013;8:e75131.

RozziniR,SabatiniT,TrabucchiM.Assessmentofpneumoniainelderlypatients.J AmGeriatrSoc2007;55:308–9.

RussoCA,ElixhauserA.HospitalizationsintheElderlyPopulation,2003.Statistical Brief#6.May2006.AgencyforHealthcareResearchandQuality,Rockville,Md; 2003 [Internet]. Available from: http://www.hcup-us.ahrq.gov/reports/stat-briefs/sb6.pdfAccessed:18.09.2017.

SaxH,HugonnetS,HarbarthS,HerraultP,PittetD.Variationinnosocomialinfection prevalenceaccordingtopatientcaresetting:ahospital-widesurvey.JHosp Infect2001;48:27–32.

Sharifi-MoodB,MetanatM.Spectrumofclinicalinfectiousdiseasesinhospitalized elderlypatientsinthesoutheastofIran.TurkJMedSci2007;37(4):213–7.

SoyletirG,AltinkanatG,GurD,etal.ResultsfromtheSurveyofAntibioticResistance (SOAR)2011-13inTurkey.JAntimicrobChemother.2016;71(Suppl1):i71–83, doi:http://dx.doi.org/10.1093/jac/dkw075.

TıptaUzmanlıkKurulu.UzmanlıkEgitimProgramları[Internet]. 2020 Available from:

http://www.tuk.saglik.gov.tr/programlar/index.html.Accessed:18.09.2017. Türkiye _IstatistikKurumuHaberBülteni. _IstatistiklerleYaşlılar.2016Publication

number:24644[Internet].Availablefrom: http://www.tuik.gov.tr/PreHaber-Bultenleri.do?id=24644.Accessed:18.09.2017.

vanDuinD.Diagnosticchallengesandopportunitiesinolderadultswithinfectious diseases.ClinInfectDis2012;54:973–8.

WangL,LansingB,SymonsK,etal.Infectionrateandcolonizationwith antibiotic-resistantorganismsinskillednursingfacilityresidentswithindwellingdevices. EurJClinMicrobiolInfectDis2012;31:1797–804.