When I was growing up, there was a general sense among friends and family that, if someone was sick, antibiotics couldn’t hurt.
We know now, of course, how misguided that is, and how overprescription has led to antibiotic-resistant infections. In long-term care facilities, a common culprit has been prescribing an antibiotic for an alleged urinary tract infection.
In new guidelines released Thursday, the Infectious Diseases Society of America recommended against screening for or treating asymptomatic bacteria (the presence of bacteria in the urine without the symptoms of an infection) for community-dwelling seniors who are functionally impaired and for our long-term care facility residents. Their report was published in Clinical Infectious Diseases.
To start, about 50% of people with spinal injuries and 30% to 50% of nursing home residents have ASB, the researchers note.
“Asymptomatic bacteriuria is very common in skilled nursing facilities,” Lindsay E. Nicolle, M.D., told McKnight’s. She’s the chairwoman of the committee that developed the guidelines and professor emeritus at the Rady Faculty of Health Sciences at the University of Manitoba, Winnipeg. “This is one of many documents out there sending a message that says we are using way too many antibiotics.”
The goal is for clinicians to “think critically” before prescribing antibiotics, she says. In nursing homes, falls are among the events where, too often, clinicians jump to suspecting a UTI. Screening ensues, which can begin triggering a chain of events that leads to antibiotics.
The authors give their rationale for all of their recommendations, but the important part for providers to recognize is that the medications aren’t working for residents. In the case of long-term care, one study found only 16% of bacteriuria residents with advanced dementia met minimum criteria for a diagnosis of symptomatic UTI, but 75% of these received treatment.
The recommendation to avoid routine screening for this population is strong, the paper states, because of “evidence that there is no benefit and a high-quality evidence of harm.” Bluntly, Nicolle and researchers are saying we should stop doing what doesn’t work. Antibiotic treatment of ASB doesn’t reduce the risk of death or sepsis but can lead to adverse events.
“Antimicrobial therapy, regardless of route of administration, conferred no survival benefit, even when adjusted for functional status, highest recorded temperature, or mental status change,” the report says.
Several other groups shouldn’t be screened, the report stays, such as joint replacement and other surgical candidates. Traditionally, surgeons would run a urine culture and if it was positive, treat with antibiotics, Nicolle says. But it’s increasingly clear that a positive urine culture is likely not the cause of the infection.
Lessening screening not only potentially helps a rehab facility with reducing unnecessary antibiotic use, but it eases pressure on the lab, Nicolle says.
Ultimately, this also means nursing home providers need to examine other possible causes of symptoms that indicate a UTI. It’s a challenge, given how incontinence and other genitourinary problems are common problems for residents.
“Women, in particular, can have these symptoms, which can be associated with estrogen deficiency,” Nicolle notes.
And of course, many providers tell me that while they get it, families often insist that an infection should equal antibiotics.
“We need to send a clear, single message to families that there is nothing wrong with a positive urine culture,” Nicolle says. “We need to get the message through that there are harmful effects of antimicrobial treatments and you don’t want to use them unless there’s a benefit.”
Follow Senior Editor Elizabeth Newman @TigerELN.