Special Article| Volume 21, ISSUE 5, P578-582.e1, May 2020

International Consensus Definition of a Serious Infection in a Geriatric Patient Presenting to Ambulatory Care

Published:February 25, 2020DOI:


      Early recognition and prompt treatment of a serious infection is important to optimize prognosis in older patients. The current evidence base underpinning this early recognition in ambulatory care is scattered and haphazard, calling for new research to strengthen clinical practice. Before embarking on such studies, it is important to seek consensus on what constitutes a serious infection in older patients presenting to ambulatory care. We conducted a 4-round e-Delphi study seeking consensus among medical professionals who deliver clinical care to older patients using online questionnaires and feedback. Twenty-two specialists in emergency care, general practice, geriatrics, and infectious diseases from 10 different countries participated in our study. We constructed 18 statements from the answers to the open questions in round 1, which were then rated by the participants in 2 consecutive rounds. After assessing the level of agreement, consensus, and stability, the following definition was preferred by 94% of the participants: “A serious infection in a geriatric patient presenting to ambulatory care is an infection with a high risk of complications, functional decline, and/or mortality, requiring a prompt diagnostic and therapeutic approach in the appropriate care setting. The most important determinants of the choice of setting are the level of emergency, the geriatric profile of the patient (frailty status, functional status, and comorbidities), and the patients’ level of autonomy and personal preferences. Factors such as the feasibility of home care, the potential consequences of delayed or suboptimal treatment and infection specific treatment requirements should be weighed as well when choosing the appropriate care setting.” Based on consensus among 22 clinicians working in 10 different countries, we propose a definition for serious infections in geriatric patients presenting to ambulatory care. This will form the basis of future studies in this domain.


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        • Web PageUN
        World Population Prospects 2019.
        United Nations Population Division, Department of Economic and Social Affairs, 2019
        • Millett E.R.
        • Quint J.K.
        • Smeeth L.
        • et al.
        Incidence of community-acquired lower respiratory tract infections and pneumonia among older adults in the United Kingdom: A population-based study.
        PloS One. 2013; 8: e75131
        • ReportWHO
        Global Health Estimates 2016: Estimated Deaths by Age, Sex and Cause.
        WHO, Geneva2016
        • Gavazzi G.
        • Krause K.H.
        Ageing and infection.
        Lancet Infect Dis. 2002; 2: 659-666
        • Yoshikawa T.T.
        • Norman D.C.
        Geriatric infectious diseases: Current concepts on diagnosis and management.
        J Am Geriatr Soc. 2017; 65: 631-641
        • Kumar A.
        • Roberts D.
        • Wood K.E.
        • et al.
        Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
        Crit Care Med. 2006; 34: 1589-1596
        • Roghmann M.C.
        • Warner J.
        • Mackowiak P.A.
        The relationship between age and fever magnitude.
        Am J Med Sci. 2001; 322: 68-70
        • Geier F.
        • Popp S.
        • Greve Y.
        • et al.
        Severity illness scoring systems for early identification and prediction of in-hospital mortality in patients with suspected sepsis presenting to the emergency department.
        Wiener Klinische Wochenschrift. 2013; 125: 508-515
        • Caterino J.M.
        • Scheatzle M.D.
        • Forbes M.L.
        • D'Antonio J.A.
        Bacteremic elder emergency department patients: Procalcitonin and white count.
        Acad Emerg Med. 2004; 11: 393-396
        • de Guadiana Romualdo L.G.
        • Torrella P.E.
        • Acebes S.R.
        • et al.
        Diagnostic accuracy of presepsin (sCD14-ST) as a biomarker of infection and sepsis in the emergency department.
        Clinica Chimica Acta. 2017; 464: 6-11
        • de Guadiana Romualdo L.G.
        • Albaladejo Oton M.D.
        • Rebollo Acebes S.
        • et al.
        Diagnostic accuracy of lipopolysaccharide-binding protein for sepsis in patients with suspected infection in the emergency department.
        Ann Clin Biochem. 2018; 55: 143-148
        • Heining L.
        • Giesa C.
        • Ewig S.
        MR-proANP, MR-proADM, and PCT in patients presenting with acute dyspnea in a medical emergency unit.
        Lung. 2016; 194: 185-191
        • van Nieuwkoop C.
        • Bonten T.N.
        • van't Wout J.W.
        • et al.
        Procalcitonin reflects bacteremia and bacterial load in urosepsis syndrome: A prospective observational study.
        Crit Care (London, England). 2010; 14: R206
        • Gbinigie O.A.
        • Onakpoya I.J.
        • Richards G.C.
        • et al.
        Biomarkers for diagnosing serious bacterial infections in older outpatients: A systematic review.
        BMC Geriatr. 2019; 19: 190
        • Lee S.H.
        • Chan R.C.
        • Wu J.Y.
        • et al.
        Diagnostic value of procalcitonin for bacterial infection in elderly patients‒A systemic review and meta-analysis.
        Int J Clin Pract. 2013; 67: 1350-1357
        • Goodman C.M.
        The Delphi technique: A critique.
        J Adv Nurs. 1987; 12: 729-734
        • Trevelyan E.G.
        • Robinson P.N.
        Delphi methodology in health research: How to do it?.
        Eur J Integr Med. 2015; 7: 423-428
        • Schreier M.
        Qualitative Content Analysis in Practice.
        Sage Publishing, Los Angeles, London, new Delhi, Singapore, Washington DC2012
        • Lozano L.M.
        • García-Cueto E.
        • Muñiz J.
        Effect of the number of response categories on the reliability and validity of rating scales.
        Methodology Eur J Res Methods Behav Soc Sci. 2008; 4: 73-79
        • Holey E.A.
        • Feeley J.L.
        • Dixon J.
        • Whittaker V.J.
        An exploration of the use of simple statistics to measure consensus and stability in Delphi studies.
        BMC Med Res. 2007; 7: 52
        • von der Gracht H.A.
        Consensus measurement in Delphi studies: Review and implications for future quality assurance.
        Tech Forecast Soc Change. 2012; 79: 1525-1536
        • Argyrous G.
        Statistics for Research, 3rd Edition.
        3rd ed. Sage Publishing, London2011
        • Hasson F.
        • Keeney S.
        • McKenna H.
        Research guidelines for the Delphi survey technique.
        J Adv Nurs. 2000; 32: 1008-1015
        • Okoli C.
        • Pawlowski S.D.
        The Delphi method as a research tool: An example, design considerations and applications.
        Inform Manage. 2004; 42: 15-29
        • Hasson F.
        • Keeney S.
        Enhancing rigour in the Delphi technique research.
        Tech Forecasting Soc Change. 2011; 78: 1695-1704
        • Garcia-Garcia F.J.
        • Carcaillon L.
        • Fernandez-Tresguerres J.
        • et al.
        A new operational definition of frailty: The Frailty Trait Scale.
        J Am Med Dir Assoc. 2014; 15: 371.e7-371.e13
        • Kelaiditi E.
        • Cesari M.
        • Canevelli M.
        • et al.
        Cognitive frailty: Rational and definition from an (I.A.N.A./I.A.G.G.) international consensus group.
        J Nutr Health Aging. 2013; 17: 726-734
        • Rodriguez-Manas L.
        • Feart C.
        • Mann G.
        • et al.
        Searching for an operational definition of frailty: A Delphi method based consensus statement: The frailty operative definition-consensus conference project.
        J Gerontol A Biol Sci Med Sci. 2013; 68: 62-67
        • Gobbens R.J.
        • Luijkx K.G.
        • Wijnen-Sponselee M.T.
        • Schols J.M.
        In search of an integral conceptual definition of frailty: Opinions of experts.
        J Am Med Dir Assoc. 2010; 11: 338-343