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CMAJ • March 6, 2001; 164 (5)
© 2001 Canadian Medical Association or its licensors

Letters
Correspondance

To treat or not to treat: managing bacteriuria in elderly people

Mark Loeb and Allison McGeer

Microbiologist and infectious diseases physician Hamilton Health Sciences Corporation Hamilton, Ont.; Director of Infection Control Mount Sinai Hospital Toronto, Ont.

The definition of asymptomatic bacteriuria as the presence of bacteria in the absence of urinary symptoms1 is based on inclusion criteria from clinical trials assessing the effect of antibiotic therapy on subsequent urinary symptoms in institutionalized elderly people with bacteriuria.2,3,4 Residents with cognitive impairments similar to those described by John Miller were included in these studies. No relationship between bacteriuria and symptoms such as anorexia, fatigue, malaise or weakness was noted in a prospective study.5 Unfortunately, these types of symptoms often lead to antibiotic treatment in elderly people with bacteriuria.6

We agree with Miller that a resident with fever and an acute confusional state is not asymptomatic. The empiric use of antibiotics for a severely ill resident may be appropriate after the resident has been carefully assessed. It is important to note that the presence of bacteria or of white blood cells in the urine does not automatically mean that a urinary infection has caused the symptoms. In febrile residents who do not have a urinary catheter, the predictive value of bacteriuria for urinary infection is 10%.7 The cause of the fever, therefore, is most often not a urinary infection, and other explanations for the fever or delirium need to be considered, including the possibility of pneumonia or skin and soft tissue infections. Similarly, pyuria, which is present in up to 90% of residents with bacteriuria, is not a predictor of symptomatic urinary infection.8 For residents with mild to moderate illness with no localizing symptoms or signs of urinary infection, we agree with Lindsay Nicolle that nontreatment with close clinical monitoring is a reasonable clinical strategy, although more research is needed to validate this approach.9

References

  1. Walker S, McGeer A, Simor AE, Armstrong-Evans M, Loeb M. Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? CMAJ 2000;163 (3): 273-7. [Abstract/Free Full Text]
  2. Nicolle LE, Bjornson J, Harding GKM, MacDonell JA. Bacteriuria in elderly institutionalized men. N Engl J Med 1983;309:1420-5.[Abstract]
  3. Nicolle LE, Mayhew JW, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized women. Am J Med 1987;83:27-33.
  4. Boscia JA, Kobasa WD, Knight RA, Abrutyn E, Levison ME, Kaye D. Therapy vs. no therapy in elderly ambulatory nonhospitalized women. JAMA 1987;257:1067-71.[Abstract/Free Full Text]
  5. Boscia JA, Kobasa WD, Abrutyn E, Levison ME, Kaplan AM, Kaye D. Lack of association between bacteriuria and symptoms in the elderly. Am J Med 1986;81:979-82.[Medline]
  6. Warren JW, Palumbo FB, Fitterman L, Speedie SM. Incidence and characteristics of antibiotic use in aged nursing home patients. J Am Geriatr Soc 1991;39:963-72.[Medline]
  7. Orr PH, Nicolle LE, Duckworth H, Brunka J, Kennedy J, Murray D, et al. Febrile urinary infection in the institutionalized elderly. Am J Med 1996;100:71-7.[Medline]
  8. Boscia JA, Abrutyn E, Levison ME, Pitsakis PG, Kaye D. Pyuria and asymptomatic bacteriuria in elderly ambulatory women. Ann Intern Med 1989; 110:404-5.
  9. Nicolle LE. Asymptomatic bacteriuria in institutionalized elderly people: evidence and practice [commentary]. CMAJ 2000;163(3):285-6.[Free Full Text]




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