From the Guidelines
Asymptomatic bacteriuria (ASB) in elderly patients should not be treated with antibiotics, as the risks of antimicrobial therapy, such as promoting resistance and adverse effects, outweigh the potential benefits in this population.
Management of ASB in Elderly Patients
- The diagnosis of ASB should be based on a urine culture, with a quantitative count of ≥10^5 cfu/mL for voided urine specimens and ≥10^2 cfu/mL for catheterized urine specimens 1.
- Pyuria accompanying ASB is not an indication for antimicrobial treatment 1.
- Screening for and treatment of ASB is not recommended for older persons living in the community or elderly, institutionalized subjects, unless they are undergoing a urologic procedure for which mucosal bleeding is anticipated 1.
- In older patients with functional and/or cognitive impairment with bacteriuria and delirium or falls, assessment for other causes and careful observation is recommended rather than antimicrobial treatment 1.
- The management of urinary tract infections (UTIs) in older patients generally aligns with the treatment for other patient groups, using the same antibiotics and treatment duration, unless complicating factors are present 1.
Key Considerations
- The high prevalence of ASB in elderly patients, particularly in those with functional and/or cognitive impairment, makes it essential to distinguish between ASB and UTI 1.
- The specificity of urine dipstick tests is low in the elderly, and negative results for nitrite and leukocyte esterase on dipsticks often suggest the absence of UTI 1.
- Antimicrobial stewardship programs have identified the treatment of ASB as an important contributor to inappropriate antimicrobial use, which promotes resistance 1.
From the Research
Management of Asymptomatic Bacteriuria (ASB) in Elderly Patients
The management of ASB in elderly patients is a complex issue, with various studies suggesting different approaches. The key aspects of management include:
- Antibiotic treatment: A systematic review and meta-analysis found that antibiotic treatment was associated with a higher number of adverse effects and bacteriological cure, but the harms and lack of clinical benefit may outweigh the benefits 2.
- Staff education: A study found that education provided to unit staff did not result in lasting changes in ASB management, suggesting that future systemic solutions are necessary to reduce the incidence of treated ASB in the geriatric population 3.
- Management strategies: A review of the current literature suggested four management strategies to decrease the negative impact of culturing the urine, including preventing urine testing in patients with extra-urinary tract reasons for their acute care, canceling urine cultures if the urine dipstick is negative, avoiding catheterization in stable patients, and withholding antibiotics in stable non-febrile elderly patients 4.
- Treatment recommendations: A study found that treatment of ASB is recommended only before urological procedures, and pyuria accompanying ASB is not an indication for antimicrobial treatment 5.
- Nursing management: Nursing management of elderly patients with ASB encompasses an array of basic and complex nursing observations and interventions to eliminate or reduce risk factors that contribute to persistent bacteriuria and to identify warning signs of an impending inflammatory response 6.
Key Considerations
When managing ASB in elderly patients, the following considerations are important:
- Risk factors: Elderly patients with ASB often have complicating factors, such as hormonal, anatomical, metabolic, and immunological changes, which can increase the risk of developing symptomatic urinary tract infections 5.
- Screening: Screening for ASB in elderly people is limited to those undergoing invasive urological procedures and surgical procedures with implant material 5.
- Antimicrobial treatment: If antimicrobial treatment is considered, concomitant factors that occur frequently in elderly people, such as renal insufficiency, must be taken into account 5.