# Association Between Clinical Frailty and Antibiotic Resistance Among Older Patients with Fever in the Emergency Department

## TL;DR

Older emergency department patients with fever who are frail are more likely to have antibiotic-resistant infections and worse outcomes.

## Contribution

This study is the first to show a strong link between frailty and antibiotic resistance in older ED patients with fever.

## Key findings

- Frail patients had a 30% rate of antibiotic-resistant isolates compared to 10.7% in robust patients.
- Frailty was independently associated with resistant infections (adjusted OR 2.84).
- Frail patients had higher ICU admission and mortality rates than robust patients.

## Abstract

Background: Frailty may predispose older adults to antibiotic-resistant infections; however, evidence in emergency department (ED) patients with fever remains limited. Methods: We conducted a retrospective multicenter cohort study of 544 ED patients aged ≥65 years with fever (tympanic temperature ≥ 37.5 °C) between August and October 2023. The cohort included 234 men and 310 women. Frailty was assessed using the Clinical Frailty Scale (CFS) and categorized as robust (CFS 1–3), pre-frail (CFS 4–5), or frail (CFS 6–9). ED-initiated microbiological cultures were obtained in 329/544 (60.5%) patients. The primary outcome was the detection of antibiotic-resistant isolates among culture-tested patients. Results: Among culture-tested patients (n = 329), antibiotic-resistant isolates were detected in 65/329 (19.8%), with a graded increase across frailty strata: robust 13/121 (10.7%), pre-frail 16/88 (18.2%), and frail 36/120 (30.0%). In multivariable logistic regression restricted to culture-tested patients, frailty was independently associated with resistant infection (adjusted OR 2.84, 95% CI 1.15–7.04, p = 0.024). Frail patients also experienced greater therapeutic complexity, including higher rates of antibiotic regimen modification (68.1% vs. 54.5%) and longer antibiotic duration (median, 11 vs. 8 days), as well as worse clinical outcomes, including higher ICU admission (37.7% vs. 17.8%) and in-hospital mortality (7.2% vs. 1.8%) compared with robust patients. Conclusions: Frailty is independently associated with antibiotic-resistant infections in older ED patients with fever. Integrating frailty assessment into ED protocols can enhance risk stratification, inform empirical antibiotic selection, and antimicrobial stewardship strategies.