#134 UTI, Delirium and Voltaire. Does odor matter?

January 7, 2019 | By Matthew Watto, MD

Stop Overdiagnosis and Overprescribing Antibiotics for “UTI”

Disclaimer / Apology

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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Credits

Written and produced by: Matthew Watto MD

Hosts: Matthew Watto MD, Paul Williams MD

Edited by: Matthew Watto MD

Guest: Tom Finucane MD, MACP

Time Stamps

• 00:00 Disclaimer, intro and guest bio
• 04:00 Guest one liner, book recommendation, career advice
• 08:22 The “medical ignorome”
• 13:40 ACP Internal Medicine Meeting 2019 details
• 16:20 Case of malodorous urine; Urine is NOT sterile; Defining terms
• 25:14 Stop saying UTI unless using air quotes
• 28:34 What symptoms or history matters in evaluation for “UTI”? And can we predict who will become systemically ill?
• 34:47 Voltaire and when treatment is warranted for “urinary tract infections”
• 37:15 Delirium in an older adult with possible UTI, how to work it up, and who warrants antibiotics
• 51:55 Take home points
• 53:38 Outro

“Urinary tract infection” Pearls

NOTE: Our discussion with Dr Finucane pertains to “reasonably healthy people” who are not catheterized, or pregnant.

1. The urinary tract has a microbiome (both bacteria and viruses are present). It is NOT sterile and never has been [Finucane JAGS 2017 PMID 28542707].
2. Malodorous urine does not correlate well with pathogenic infection of the urinary tract and should not be considered a symptom of “UTI” [Cortes-Penfield Infect Dis Clin North Am 2017 PMC 5802407 ].
3. Stop using the term “urinary tract infection” unless framed with air quotes. The phrase suggests a condition that needs treatment. BUT, in reality we cannot predict which patients will benefit from antibiotics or progress to systemic illness. -Dr Finucane
4. A high percentage of women and men (15-50%) in long term care have asymptomatic bacteruria [Finucane JAGS 2017 PMID 28542707]. Therefore, a urine sample sent for any reason may be positive by chance alone. Consequently, “UTI” often takes the blame for a wide variety of geriatric syndromes.
5. Acute uncomplicated cystitis – Antibiotic therapy ONLY results in a shorter duration of symptoms [Hooton NEJM 2014 PMID 22417256]. Dr. Finucane notes that this infection is too common to be dangerous and that only one study has suggested worse outcomes without treatment [Kronenberg BMJ 2017 PMID 29133285].
6. Helpful arguments against antibiotics: “We just happen to be able to see these things because they grow on agar. Remember that mom always has bacteria in the urinary tract.” “Are you willing to risk the uncertain benefit, but almost certain harm of antibiotics just to improve the olfactory quality of your urine?” -Dr Finucane
7. Suspected sepsis: Send cultures of blood, urine, and any other pertinent bodily fluids. Start the patient on empiric antibiotics. Stop the antibiotics in ~48 hours if nothing grows from culture. -Dr Finucane’s expert opinion

Delirium Pearls

1. Delirium in older adults: There’s no easy answer. Don’t just blame it on a “UTI”. Perform a complete history and physical exam. Check any pertinent labs or imaging studies based on your findings. Stop any potential culprit medications. Ensure close follow up. Don’t admit them to the hospital unless patient has an unstable social situation, unstable vital signs or appears systemically ill. -Dr Finucane’s expert opinion
2. Delirium Pearls: It is probably a marker of frailty. Over half the patients get better in one day [Rudberg Age Aging 1997 PMID 9223710]! Hence, common interventions that seem to “fix” delirium (e.g. brief hospitalization, IV fluids, and/or antibiotics to treat a “UTI”) probably have no effect. The patient will likely get better with no intervention. –Dr Finucane’s expert opinion
3. Prosthetic joint infection: A large observational trial found that preoperative asymptomatic bacteruria is associated with a three fold increased risk for postoperative infection [Sousa Clin Inf Dis 2014 PMID 24723280]. HOWEVER, treatment of asymptomatic bacteruria does not lower the risk for postoperative infection. Dr Finucane notes the asymptomatic bacteruria is probably a marker of frailty (and/or poor baseline health status), AND this explains the worse perioperative outcomes!

“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

Some Definitions

Medical ignorome

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.

Pyuria

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].

Bacteruria

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].

“Urinary tract infections”

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!

Uncomplicated cystitis (acute)

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]

Complicated cystitis

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]

Goals and Learning Objectives

Goal

Listeners will challenge the convention that bacteriuria is a pathologic state that always requires treatment.

Learning objectives

After listening to this episode listeners will…

1. Define common terms: urinary tract infections, pyuria, bacteriuria, complicated and uncomplicated cystitis
2. Recognize the limitations of diagnostic testing and symptoms in the diagnosis of “urinary tract infections”
3. Recognize the existence of the urinary tract microbiome
4. Develop an approach to the elderly patient with delirium and bacteriuria
5. Educate patients and have meaningful informed-consent discussions about antibiotic treatment of bacteriuria

Disclosures

Dr Finucane reports no relevant financial disclosures. The Curbsiders are sponsored by ACP for this episode.

Links from the show

Citations are embedded in text above

1. Absalom, Absalom (book) by William Faulkner
2. Finucane TE. “Urinary Tract Infection” – Requiem for a Heavyweight. J Am Geriatr Soc. 2017 Aug;65(8):1650-1655. doi: 10.1111/jgs.14907. Epub 2017 May 19.  (FREE)
3. Join ACP’s Internal Medicine Meeting 2019 April 11-13th in Philadelphia, PA. We’ll see you there!