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Letters

Response to “When is pus not pus?”

Tokunbo O. Ajayi
CMAJ March 13, 2017 189 (10) E415; DOI: https://doi.org/10.1503/cmaj.732862
Tokunbo O. Ajayi
Hospitalist, Johns Hopkins Hospital, Baltimore, MD; Howard County General Hospital, Columbia, MD
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Thank you for your comment1 on our article.2

Based on the Infectious Diseases Society of America’s (IDSA’s) 2010 guideline3 on when to treat asymptomatic bacteriuria, I disagree with your statement and stand by our publication.

“Pyuria accompanying CA-ASB [asymptomatic bacteriuria] should not be interpreted as an indication for antimicrobial treatment (A-II).”3

If a patient’s urine culture grows a pathogenic organism, but the patient does not have symptoms suggestive of urinary tract infection (UTI), then you do not need to treat.

In long-term care facilities, patients develop changes in mental status due to dehydration from diuresis, poor oral intake, infection and a variety of other issues. However, UTI is sometimes blamed for changes in mental status when other factors have not been considered and treated. Also, when a patient does not have fever, dysuria, frequency and leukocytosis, UTI is a less likely cause.

This is a quote directly from the IDSA UTI 2005 guidelines: “Pyuria is present with asymptomatic bacteriuria … in 90% of elderly institutionalized patients, 90% of hemodialysis patients, 30%–75% of bacteriuric patients with short-term catheters in place …”4

Another direct quote from IDSA guidelines: “Screening for or treatment of asymptomatic bacteriuria is not recommended for the following persons.

  • Premenopausal, nonpregnant women (A-I).

  • Diabetic women (A-I).

  • Older persons living in the community (A-II).

  • Elderly, institutionalized subjects (A-I).

  • Persons with spinal cord injury (A-II).

  • Catheterized patients while the catheter remains in situ (A-I).”4

Footnotes

  • Competing interests: None declared.

References

  1. ↵
    1. Carr T
    . When is pus not pus? [letter]. CMAJ 2017; 189:E414.
    OpenUrlFREE Full Text
  2. ↵
    1. Ajayi T,
    2. Radhakrishnan R
    . Urinary tract infection in older adults in long-term care facilities. CMAJ 2016;188:899.
    OpenUrlFREE Full Text
  3. ↵
    1. Hooton TM,
    2. Bradley SF,
    3. Cardenas DD,
    4. et al
    .; Infectious Diseases Society of America. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50:625–33.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Nicolle LE,
    2. Bradley S,
    3. Colgan R
    . Infectious Diseases Society of America; American Society of Nephrology; American Geriatric Society. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643–54.
    OpenUrlCrossRefPubMed
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Canadian Medical Association Journal: 189 (10)
CMAJ
Vol. 189, Issue 10
13 Mar 2017
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Response to “When is pus not pus?”
Tokunbo O. Ajayi
CMAJ Mar 2017, 189 (10) E415; DOI: 10.1503/cmaj.732862

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Tokunbo O. Ajayi
CMAJ Mar 2017, 189 (10) E415; DOI: 10.1503/cmaj.732862
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