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 Canadian
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To treat or not to treat: managing bacteriuria in elderly people
The definition of asymptomatic bacteriuria as the presence of bacteria in the absence of urinary symptoms [Research]1 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 [Commentary].9
Mark Loeb References
Copyright 2001 Canadian Medical Association or its licensors |
