Urinary Tract Infections in LTC

To the Editor:

When I received the February 2010 issue and saw on the cover that it was the “Infectious Diseases Issue,” I was excited. I take care of 80 long-term care (LTC) patients, and previously had 160. I consider my specialty the treatment and prevention of urinary tract infection (UTI) and the prevention of antibiotic resistance. There is a quote in the article by Mouton¹ on page 37 that reads as follows: “Duration of antibiotic therapy is generally 10-14 days in the elderly; shorter treatment regimens of 3-5 days are not satisfactory in the elderly patient.” I really don’t think this represents a true statement. I have twice gone into nursing homes and changed the antibiotic prescribing from long duration to short duration and have been amazed at how the drug resistances just go away. We use some alternative things to help these patients get healthier to fight their infections. We have them either take acidophilus or eat yogurt. Many of them are placed on cranberry capsules, and many are placed on high-dose vitamin C. I marvel at how, over time, the patients start to have bugs that are pan-sensitive. When we have a physician who comes in and uses the “old” prescribing habits, then the resistances start to revisit us. Lastly, we use methenamine and high-dose ascorbic acid in all of our catheters and don’t use any antibiotics on them at all. We have had excellent results, and the beautiful thing is that all of our bacteria, more or less, are sensitive to quinolones now.

Name Withheld

Reference

1. Mouton C, Adenuga B, Vijayan J. Urinary tract infections in long-term care. Annals of Long-Term Care: Clinical Care and Aging 2010;18(2):35-39.

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Response from Charles A. Cefalu MD, MS, Editorial Advisory Board Member, Annals of Long-Term Care:

Thank you for your letter regarding the above referenced article. Your comments certainly deserve a response. Regarding the quote in the article that “Duration of antibiotic therapy is generally 10-14 days in the elderly; shorter regimens of 3-5 days are not satisfactory in the elderly,” this is based on consensus in the field of Geriatrics and not on evidence-based research. The reason for the consensus is that older, frail LTC patients have blunted immune systems and impaired response to infection. Therefore, it would make sense to treat them for longer than 3 days. The geriatric literature indeed references this statement consistently in review articles on this subject. Could 3 days of antibiotic treatment be sufficient in the LTC setting? As is typically the case in the LTC and frail elderly, there is a dearth of literature regarding clinical trials that back up this consensus. Therefore, research in LTC is indeed needed, and therein lies the problem. Regarding your comment that the regimen of 3 days of treatment reduces drug resistance, I do not agree. In addition, the use of yogurt and acidophilus is intended to restore the bowel flora when using antibiotics to prevent overgrowth of bacteria and antibiotic-induced diarrhea rather than to fight the infection. Regarding the use of methenamine and high-dose ascorbic acid (vitamin C), this is an old remedy used in the past by physicians for suppressive therapy. There are no evidence-based studies to back up the claim that this regimen sufficiently suppresses the risk of UTI. Cranberry capsules have been shown to have medicinal benefit in reducing the risk of UTI.¹ One last point: There is no evidence-based medicine I am aware of that recommends more than the amount of vitamin C unequivocally in a multivitamin for any specific ailment except for true vitamin C deficiency first discovered at sea in the 1600s!

Reference

1. Cefalu CA. Urinary incontinence. In: Ham RJ, Sloan PD, Warshaw GA, et al. Primary Care Geriatrics. 5th ed. New York: Mosby/Elsevier; 2007:306-323.