Response to “When is pus not pus?”
======================================

* Tokunbo O. Ajayi

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.  Carr T. When is pus not pus? [letter]. CMAJ 2017; 189:E414.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTg5LzEwL0U0MTQiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTg5LzEwL0U0MTUuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  Ajayi T, Radhakrishnan R. Urinary tract infection in older adults in long-term care facilities. CMAJ 2016;188:899.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTg4LzEyLzg5OSI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xODkvMTAvRTQxNS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

3.  Hooton TM, Bradley SF, Cardenas DD, 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.
    
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4.  Nicolle LE, Bradley S, 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.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1086/427507&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=15714408&link_type=MED&atom=%2Fcmaj%2F189%2F10%2FE415.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000227492700001&link_type=ISI)