Our hosts and Dr Finucane cannot claim first hand knowledge of acute cystitis, a common and painful condition. In retrospect, our conversation failed to acknowledge the true suffering that acute cystitis causes for most women at some point in their lives. We did not mean to minimize it’s significance. This episode is meant to question the overuse of antibiotics for treating “UTIs”, especially asymptomatic bacteruria. Our focus was mainly on older adults presenting with delirium. Too often, they have “UTI” blamed for their delirium. We advocate for a thoughtful risk-benefit analysis before quickly prescribing antibiotics for non-specific urinary symptoms like malodorous urine. –The Curbsiders
“Urinary tract infection” (UTI) is overdiagnosed. Antibiotics are overprescribed. UTIs are inappropriately blamed for geriatric syndromes (eg delirium) despite little supporting evidence. Our guest, Tom Finucane MD, Emeritus Professor of Medicine at Johns Hopkins will make you question everything. Topics: How can we diagnose “urinary tract infections”? Who needs treatment? Do urinary tract symptoms matter? Does urine odor correlate with infection? Who’s at risk for pyelonephritis and sepsis? Don’t miss this paradigm changing episode. And stop using the term “urinary tract infection” unless it’s prefaced by air quotes!
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Written and produced by: Matthew Watto MD
Hosts: Matthew Watto MD, Paul Williams MD
Edited by: Matthew Watto MD
Guest: Tom Finucane MD, MACP
NOTE: Our discussion with Dr Finucane pertains to “reasonably healthy people” who are not catheterized, or pregnant.
“The art of medicine consists in amusing the patient while nature cures the disease.”
Voltaire
“Are you willing to risk the uncertain benefit, but almost certain harm of antibiotics just to improve the olfactory quality of your urine?”
Tom Finucane MD
Dr Finucane’s term for “the medium that we move around in where things are just not known to us and we make up stories based on the things we do know about and see.” Dr Finucane points out that this leads to the transmission of bad information “due to our own ignorance”. For example, stool floats due to the gas content, NOT due to the steatorrhea. This was scientifically proven over 20 years ago [Levitt MD, Duane WC NEJM 1972]. Unfortunately, the erroneous belief that steatorrhea is the cause of floating stools remains part of the medical ignorome.
When white blood cells are present on a urine dipstick or microscopy– typically more than 10 WBCs per mm3 is considered pyuria [Wise GJ NEJM 2015].
Bacterial colony growth from a urine culture is termed bacteruria. Colony counts (CFUs) are arbitrarily called significant if above a certain threshold, usually when more than 100,000 CFUs [Finucane JAGS 2017 PMID 28542707].
An arbitrary and poorly defined term. It presupposes that the presence of detectable bacteruria and symptoms attributed to the urinary tract constitute a pathogenic state that requires treatment with antibiotics [Finucane JAGS 2017 PMID 28542707]. Dr Finucane notes that this term should be outlawed, or at least always spoken with air quotes!
This term typically describes a “urinary tract infection” occurring in healthy premenopausal, nonpregnant women without underlying urinary tract abnormalities.
NOTE: Most sources consider this a clinical diagnosis based on “typical” urinary tract symptoms like frequency and dysuria. Urinalysis and urine culture are not always needed and sources vary as to what constitutes a significant “infection” [Yawetz Dynamed Plus 2018]
Typically, this includes any patients who do not qualify as uncomplicated cystitis (see above).
NOTE: Some sources suggest calling any “UTI” complicated if suspected pyelonephritis or systemic signs and symptoms of infection are present regardless of immune status or urinary tract abnormalities [Hooton UpToDate 2018]
Listeners will challenge the convention that bacteriuria is a pathologic state that always requires treatment.
After listening to this episode listeners will…
Dr Finucane reports no relevant financial disclosures. The Curbsiders are sponsored by ACP for this episode.
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Comments
Would you be as patronizing toward patients and their caregivers with UTI symptoms if it was a condition more prevalent in men? The disrespect was disheartening.
The purpose of the show was to highlight that overprescribing antibiotics/treating for elderly patients with delirium for a UTI is a problem and often masks what the real issue is - no disrespect was intended.
Please mansplain some more about why we don’t need to treat honeymooners cystitis because it doesn’t lead to lack of ability for a woman to reproduce. What about her pain and discomfort? Her need to go to work? This show was offensive.
I agree 100%. I am a physician myself and a WOMAN and for some crazy reason have had MULTIPLE UTI’s in my lifetime and they can be HORRIBLY painful. This entire episode was just so distasteful
To add to medical ignorome, take a hard look at FEVER and antipyretics! Fever: The great strategy of the body to enhance local innate immunity and enhance antigen presentation in dendritic cells besides discouraging replication of certain virus in the cell. Why is any fever below 103 still being treated as a disease and why is the physiology of fever being abated ?
Another excellent curbsiders. My best accomplishment as medical director of a nursing home was to remove the dipsticks. The nurses were dipping every malodorous urine and all confused patients. I am glad you are helping dispel this mythology.
Excellant lecture
This will certainly change how I approach some of my patients with urinary complaints since I knew already that a significant percentage of UTIs remit spontaneously. However, I found a group of men talking condescendingly about symptoms that mostly afflict women pretty hard to swallow. I have had totally miserable and disabling cystitis before, and if you sent me away only with reassurance that it wouldn't kill me, I would have taken great pleasure in receiving a Press Ganey survey.
This show (unlike most of your episodes) left me with more questions than answers. Having had a "UTI", I can tell you that they are painful, interrupt normal activities, make it hard to concentrate on day to day activities, until the symptoms are gone. I am sensitive to the overuse of antibiotics. But there was nothing presented about what to do with the symptomatic female to resolve her symptoms. Or how long you should let her have symptoms without treating her with antibiotics. Here I am talking about how long you should let her be painful before treatment. Mainly, it was all men talking and so no one that had ever had the symptoms we are talking about here. So, can you help answer those questions, so I actually know what to tell a real patient in pain?
In response to some of the criticisms that we have received about our recent episode on UTI, our show notes have been updated with our apologies. http://thecurbsiders.com/podcast/134-uti-delirium-voltaire
I’d love to high five all the women in the above comments. Omg I almost cried during this episode. I have had cystitis and UTIs frequently and they are horrid.
In response to some of the criticisms that we have received about our recent episode on UTI, our show notes have been updated with our apologies. http://thecurbsiders.com/podcast/134-uti-delirium-voltaire
Could Curbsiders provide a reference for the correction of the medical ignorome asserting "If you start an antibiotic you should finish it"? Would love to read more about it!