#335 Asymptomatic bacteriuria in the elderly: Don’t drug the bugs?
CLINICAL QUESTION
In elderly, does asymptomatic bacteriuria (ASB) cause altered mental state and will treating ASB improve clinical outcomes?
BOTTOM LINE
Due to important evidence limitations, it is not confirmed that ASB, or even Urinary Tract Infection (UTI), is clearly associated with altered mental state. Treating ASB does not improve clinical outcomes (including altered mental state) but may increase adverse events from 1% to 7%. In elderly patients with ASB and altered mental state, antibiotics should be avoided without clear signs/symptoms of infection.
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EVIDENCE
- Results statistically significant unless stated.
- 3 systematic reviews (5-29 observational studies; 2630-16,618 patients).1-3
- UTI and altered mental state:
- Two conclude association is unclear.1,2
- One3 reports an association odds ratio=2.67 (2.12–3.36).
- Unreliable as UTI case-definition often includes altered mental state/delirium (without infection symptoms).1-3 Example, in one study ≥57% UTI diagnoses had no UTI symptoms.3
- ASB and altered mental state:
- No association in one observational study.3
- UTI and altered mental state:
- 5 systematic reviews (3-9 randomized controlled trials [RCTs]; 328-1087 patients)4-8 of antibiotic treatment versus placebo/no-treatment. Most recent (9 RCTs; 1087 patients) x3-108 months:4
- Symptomatic UTI, mortality: No difference.
- Adverse effects (examples diarrhea, rash, candidiasis): 6.5% versus 0.7% no antibiotics.
- Others found similar.5-8
- RCT 58 ASB long-term care patients, norfloxacin versus placebo (7 days), followed 3-months (not included above).9
- Mental state/function: No difference.
- Two observational studies, 150-343 newly diagnosed delirious elderly found no difference in functional10 or delirium11 recovery when given antibiotics versus none.
- Three RCTs (2 cluster-RCTs12,13 with 22 long-term care centers 1-year each, and 214 newly admitted patients 7-days14).
- Reducing antibiotic prescribing does not increase hospitalizations, mortality, or adverse events.12-14
- Ordering urine culture is associated with antibiotic use.15
- ASB is common in elderly: 5-20% in community age>80 (females>males) and institutionalization (25-50% women/15-40% men).16,17
- ASB guidelines16 recommend:
- Avoiding ASB treatment in elderly without clear infection signs/symptoms.
- Assessment for other causes; careful observation; attention to contributing factors like dehydration.
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Excellent recap and reminder
Good review
Informative
It confirmed what I have been doing
But in the hospital the work up for delirium seems to include ruling out UTI. With this study I may reserve it to symptomatic patients other than delirium.
Important information for everyone caring for elders.
This is very interesting and something I will be using alot
Great article!
Good to know
Reaffirms indication to treat
I will not order Urine c/s unless needed and will not traatASB
Very useful in the elderly with fever, not to treat for UTI if no symptoms
great evidence review+summary