Diagnosis of UTI amongst elderly patients in hospital (Age and Ageing 2006; 35(Supp 1): i24)
SIR—While the authors of this survey of practice [1] are correct in their conclusion that the elderly are probably over-treated with antibiotics for urinary tract ‘infection’, we feel that they reach this for the wrong reasons. It is well established that, in the presence of symptoms, a monoculture of as few as 102 colony-forming units per cubic centimetre of urine (cfu/mm3) can be clinically significant [2]. Most laboratory cell counters are set to detect 104 cfu/mm3, below the conventional definition of 105, but are sufficiently insensitive to miss up to 50% of positive samples. This probably accounts for much of the perceived discrepancy in their result. Dipstick testing for leucocyte esterase and urinary nitrites only has an acceptable rate of detection/exclusion when the tests are used in combination and in conjunction with other tests [3]. Thus, a positive test in a single category would not be expected to be of great diagnostic utility.The cardinal features of urinary tract infection; dysuria, haematuria, an increased urinary frequency and urinary urgency may sometimes be absent in older people; occasionally, a worsening of established urinary incontinence may be the only feature. However, symptoms should guide treatment. The prevalence of asymptomatic bacteriuria in older women may reach 25% [4] and there is no evidence that treating this is of benefit 5]. Whilst examination of a mid-stream specimen of urine is essential for a hospital-acquired infection, community-acquired infection can be treated with appropriate antimicrobial agents in the absence of such a sample, as waiting for the results only delays treatment.
Many older people admitted to hospital are treated in the absence of symptoms or have non-specific diagnoses attributed to their ‘UTI’ and receive antibiotics. This probably accounts for much of the over-treatment observed in this study.
1 Specialist Registrar Care of the Elderly, Department of Geriatric Medicine, University College London Hospitals, 2nd Floor Maple House, Rosenheim Wing, Grafton Way, London WC1E 5DB, UK
2 Consultant Physician, Department of Geriatric Medicine, University College London Hospitals, 2nd Floor Maple House, Rosenheim Wing, Grafton Way, London WC1E 5DB, UK
* To whom correspondence should be addressed Email: catherinemcadam{at}hotmail.com
References
- Chambers S, Williams L, Gosney MA. Diagnosis of urinary tract infection (UTI) amongst elderly patients in hospital. Age Ageing (2006) 35(Suppl. 1):24.[Web of Science]
- Stamm WE. Protocol for diagnosis of urinary tract infection: reconsidering the criterion for significant bacteriuria. Urology (1988) 32(Suppl. 2):6–12.[CrossRef][Web of Science][Medline]
- Ouslander JG, Schapira M, Fingold S, Schnelle J. Accuracy of rapid urine screening tests among incontinent nursing home residents with asymptomatic bacteriuria. J Am Geriatr Soc (1995) 43:772–75.[Web of Science][Medline]
- Abrutyn E, Mossey J, Levinson M, Boscia J, Pitakis P, Kaye D. Epidemiology of asymptomatic bacteriuria in elderly women. J Am Geriatr Soc (1991) 39:388–93.[Web of Science][Medline]
- Abrutyn E, Mossey J, Berlin JA, et al. Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly ambulatory women? Ann Intern Med (1994) 120:827–33.
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