I admitted an elderly woman to the hospital recently. The previous week, she had presented to the emergency department (ED) with chest pain and shortness of breath. For some unknown reason, a urinalysis was obtained and was found to be abnormal. The patient left the hospital with a prescription for cephalexin, in addition to unexplained chest pain and shortness of breath. The patient presented to the hospital this time with, you guessed it, profuse watery diarrhea (oh, and chest pain and shortness of breath). When I inquired if she was experiencing any genitourinary tract symptoms at the time of the initial ED presentation, she emphatically replied, “No!” But the doctor told her she had a “UTI,” and she accepted the diagnosis and prescription.
Why is it that we love to diagnose urinary tract infections (UTIs) so much? Is it the incorrect notion many of us have that they can cause pretty much any symptom? Is it the beautiful simplicity of discovering urinalysis abnormalities and exclaiming, “Gotcha!” Or is it the inherent desire we have to offer patients the possibility of a cure?
Over-diagnosis of UTIs is both similar and dissimilar to issues we are experiencing in healthcare with high utilization of antibiotics for viral respiratory tract infections. Both, I think, are driven by our desire to offer patients curative treatment. Trying to explain that your nasal congestion is from a virus and not a bacterium is difficult and time-consuming; it is often easier just to prescribe the azithromycin, with the patient satisfied that you have saved them from certain death at the expense of some terrible bacterial infection. However, I believe that over-diagnosis of urinary tract infections is different in that oftentimes, patients come to us with symptoms that should not prompt us to obtain a urinalysis and urine culture. Then, we find abnormalities and prescribe an antibiotic. As above, patients are satisfied because we have prevented them from perceived horrible complications.
Here’s the problem: Almost all clinicians and patients think that urine is always supposed to be “sterile” – and this is just simply not true. Let me repeat that in another way: not everyone is walking around with a bladder that is free from bacteria. Enter the diagnosis of something called asymptomatic bacteriuria. Luckily, the Infectious Disease Society of America (IDSA) just updated its guidelines on this topic in 2019. Essentially, this entity is exactly what it sounds like: there are bacteria in the bladder, but the patient doesn’t have any symptoms. You might be tempted to assume this is a rare phenomenon – maybe 1 to 2 percent? Nope. Per the IDSA guidelines, up to 16 percent and 19 percent of elderly women and men, respectively, have asymptomatic bacteriuria. And up to 50 percent of men and women living in long-term care communities have it. And 100 percent of patients with chronic foley catheters have bacteriuria.
Now, I know what you are thinking: “But if we identify these patients and give them antibiotics, we will prevent them from getting symptomatic UTIs, so it is in their best interest to treat them anyway.” Here the literature says: wrong. Studies demonstrate that treating asymptomatic bacteriuria doesn’t necessarily clear the bacteria permanently, nor does it reduce the risk of future symptomatic UTIs (interestingly, some studies reveal an increased risk for subsequent UTIs). Additionally, there is no increased risk of mortality from not treating.
So what are the harms of treating asymptomatic patients? Hopefully, you can rattle off a few of these pretty easily: C. diff colitis, potential adverse effects of the antibiotic chosen, anaphylaxis, increased cost, and increased risk of resistant organisms in the individual patient and community. How many times have you seen a patient repeatedly receive, for example, ciprofloxacin for a UTI, and then all of a sudden, the next urine culture sensitivity data reveals the dreaded “R” after ciprofloxacin.
Here are some general tips for how to proceed with making the diagnosis of a UTI:
- Before you order a urinalysis and urine culture, think about why you are ordering it. Does the patient have UTI symptoms (dysuria, hematuria, urinary frequency or urgency), have unexplained fever, or is septic? If not, maybe just don’t order the urinalysis. Or, if you are ordering the urinalysis for another reason, be able to accurately interpret it.
- Don’t attribute symptoms clearly not genitourinary in origin to a UTI. I can’t tell you how many times I’ve seen a UTI diagnosed with a presenting symptom of epigastric abdominal pain, shortness of breath, or malaise.
- Don’t assume that every elderly patient presenting to you with confusion has a UTI. The IDSA guideline discusses this diagnostic dilemma and offer diagnostic and therapeutic strategies for this challenging clinical scenario.
- Educate patients, family members, and other clinicians that just because there is bacteria on the urinalysis, this doesn’t necessarily warrant antibiotic treatment.
- Or just don’t listen to me and go and read the IDSA guidelines on asymptomatic bacteriuria.
Let’s all educate ourselves on this topic and spread the word. Over-diagnosis of UTIs is rampant and is associated with real risks of harm. Let’s do what is best for patients and not what is easiest for us.
Scott Keeney is an internal medicine physician.
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