Hospitalists are used to determining the etiology of a patient's fall, but they may be overlooking infection as a potential cause. A new study suggests that physicians should routinely consider coexisting systemic infections when evaluating patients who present with a fall.
Researchers reviewed the electronic health records of 161 adult patients admitted from 2000 to 2014 to Massachusetts General Hospital in Boston. All patients presented primarily because of a fall, were subsequently hospitalized, and were found to have a coexisting systemic infection.
Of these patients, 71 had urinary tract infections (UTIs), 64 had bacteremia, 37 had lower respiratory tract infections, and 34 had sepsis of unclear source. Less common infections were endocarditis, skin and soft-tissue infections, cholangitis, and prosthetic joint infection.
Coexisting systemic infection was not initially suspected as a contributing factor to the fall in 123 patients (76.4%). In 64 cases (39.8%), physicians did not suspect coexistence of an infection at all. Twenty-nine patients (18.0%) died in the hospital.
Study coauthor and infectious disease specialist Farrin A. Manian, MD, MPH, FACP, a clinician educator in the department of medicine at Mass General, recently spoke with ACP Hospitalist about the potential consequences of these yet-unpublished findings, which were presented last October at IDWeek 2015 in San Diego.
Q: What led to the study?
A: I was struck by the fact that, from time to time, I would consult on a patient who apparently [had] a fall as their main reason for coming to the emergency room and then was found to have a severe infection. Then, when I looked at their history, it seemed like a sudden thing, and it really appeared that, had it not been for the fall, they wouldn't be coming to the hospital. So I always wondered: Could the fall be an early manifestation of a severe infection?... Everything that was in the literature, which is a scant amount, had to do primarily with patients with dementia in nursing homes who had UTIs and fell. It was generally thought that the UTI actually led to the fall because of patients having confusion or getting up in the middle of the night and going to the bathroom, but to our knowledge, no systematic study of the problem outside of that group of patients had ever been done.
Q: Were you surprised by the results?
A: What I was really surprised about was that many of these patients had really serious infections: About 40% of them had bloodstream infections, and some had pneumonia. So these were not just minor infections and UTIs that had been reported before; it really looked like some of these patients were quite ill, and it wasn't just limited to the elderly. A lot of our patients [18%] were younger than 65, as opposed to the previous studies, and the majority of our patients came from home instead of having lived in an institution like long-term care facilities or nursing homes. I was surprised at the breadth of the scope of this problem, both in terms of the younger age group being involved and the type of infections that were found, which were often quite serious.
Q: How do you think the infections relate to the falls?
A: There are probably several potential mechanisms, although we're going to have to do further studies to try to figure out exactly why some of these patients fell. One is that, especially in the case of the elderly, any kind of infectious disease process can potentially cause more confusion and mental status changes that could certainly lead to a fall. We also know that people who have serious infections, especially ones that get into their blood, have problems with their muscles not working correctly, with weakness being a very common problem in severe infections. If you have an infection, especially if it's been going on for a couple of days, you may not be able to eat as well and may not be hydrated, so you may actually get more lightheaded and dizzy, and you may potentially fall because you're volume-depleted. We don't really have enough information about whether each specific bug has a different mechanism for causing a fall, except for the possibility that the urinary tract pathogens like E. coli may have also caused a fall because of [urinary] urgency and frequency.
Q: When were these infections discovered?
A: We suspect that the great majority, if not all of them, were present at the time patients came in, and they were all diagnosed based on the evaluation during the first 48 hours of admission. They weren't all suspected to be present [at admission]—in fact, in about 40% of our patients, the physician didn't even suspect there was an infection, so some patients actually had the evaluation later during that 48-hour period.
Q: What should hospitalists do differently in diagnosis and treatment of these patients?
A: I think it's important to look at a fall as not just purely a mechanical event but also potentially a manifestation of an acute medical illness, including a potentially serious infection. Once you label a fall as “mechanical”—which is often the case; about two-thirds of our patients' falls were considered mechanical—then you may not look further into the cause of it or other contributing factors....We need to be more proactive and actually ask specific questions about how the patient was doing before the fall occurred.
When weighing in on whether it's safe for patients to go through surgery or not because of a fracture, for example, I think it's important to make sure there's nothing new that contributed to the fall in the first place that could potentially complicate their perioperative course. Infections, especially the bloodstream infections, can cause a lot of hemodynamic instability, blood pressure problems, and heart rate problems, and these things can all be magnified with anesthesia, so we could potentially place them at high risk of complications if we're not diagnosing these infections in a timely manner and treating them.
I think it's also important to educate patients and families regarding the possibility that falls and near-falls may be a manifestation of an acute medical illness and that, when in doubt, they should get medical attention or at least seek medical advice before the actual fall occurs, so that injuries can be avoided.
Q: How should these findings affect fall prevention efforts?
A: Our next step is to study patients who have falls with coexisting infections versus those with falls without coexisting infections and then see if there are any potential markers, symptoms, signs, or anything that could potentially help the clinicians who see these patients as the result of a fall identify early who may have an infection and who may not have an infection. And then, if those signs really appear to be associated with the coexisting infections, then we could potentially use it to educate the public. If we can prevent the fall from occurring because of seeking medical attention early, then I think we could potentially have a huge impact on the morbidity of a lot of our patients.