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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