Treatment for UTIs in the Oldest Old

TO THE EDITOR:

The review by Kamel1 dutifully reviews the literature on managing urinary tract infections (UTIs) in the elderly. Unfortunately, he misses the key point, which is that the medical management of UTIs, particularly in extremely vulnerable subgroups of patients such as the elderly with Foley catheters, is a delicate balancing act. Kamel is right, periodic urine culturing will confuse colonization with infection and may lead to overtreatment and emergence of resistant strains. On the other hand, waiting for alterations in mental status or delirium before treatment—as the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA) recommend—places the patient at extreme risk of complications and death from sepsis. For example, by the time mental status changes are observed in an octogenarian, it is more likely than not too late for successful treatment of a UTI with oral antibiotics. I suggest that those caring for the oldest of the old consider the risks and benefits of treatment and err on the side of “overtreatment” at the earliest signs of a UTI. It may be possible to wait for changes in mental status in selected patients who have some reserve, but delaying treatment too often will lead to death from urosepsis in patients with multiple comorbid conditions.

E. Schwartz MD, MPH
South Hadley, MA

Reference

1. Kamel HK. Managing urinary tract infections: Guide for nursing home practitioners. Annals of Long-Term Care: Clinical Care and Aging 2005;13(9): 25-30.

----------

DR. KAMEL RESPONDS:

I agree with Dr. Schwartz that the management of urinary tract infections in residents with urethral catheters constitutes a challenge to nursing home practitioners. Bacteriuria is a frequent complication of urinary catheter placement. Urinary tract infections are common among nursing home residents with catheters and are associated with increased morbidity. Evidence from the literature indicates that randomly screening urine from asymptomatic individuals with urethral catheters and the use of prophylactic antibiotics to prevent urinary tract infections in catheterized individuals should be avoided.¹ The newly published Clinical Practice Guideline on common infections by the American Medical Directors Association that I have chaired stresses that treatment of asymptomatic bacteriuria in patients with or without catheters should be avoided, as it was not shown to be beneficial or cost-effective, and it may lead to the development of antibiotic-resistant strains of uropathogens, as well as antibiotic-related colitis.² On the other hand, the presence of any symptom or sign that suggests urinary tract infection (eg, fever, rigors, suprapubic pain, flank pain, change in urine character, or change in mental status) in nursing home patients with urethral catheters should prompt catheter change, sending urine for analysis and culture and sensitivity, as well as initiating antibiotic therapy without delay.

Hosam K. Kamel, MD, MPH, CMD, AGSF
Director, Geriatrics and Extended Care
St. Joseph’s Mercy Health Center Hot Springs, AR

References

1. Kamel HK. Managing urinary tract infections: Guide for nursing home practitioners. Annals of Long-Term Care: Clinical Care and Aging 2005: 13(9):25-30.

2. American Medical Directors Association. Clinical Practice Guideline on Common Infections in the Long Term Care Setting. Baltimore, MD: American Medical Directors Association; 2004.