From the Guidelines
The patient should not be treated with antibiotics for the UTI, but rather be monitored closely, as the current evidence suggests that treatment of asymptomatic bacteriuria (ASB) in older adults does not provide any benefit and may cause harm 1. The presence of ASB in elderly nursing home residents is common and generally does not require treatment. This patient's transient confusion has likely resolved and may be related to her Ativan use rather than the positive urine culture.
The key factors to consider in this case are:
- The absence of urinary symptoms
- Normal bloodwork
- Normal vitals
- Resolution of confusion These factors suggest that this is not a symptomatic UTI requiring antibiotics. Unnecessary antibiotic treatment can lead to adverse effects, Clostridioides difficile infection, and antimicrobial resistance, as highlighted in the 2019 clinical practice guideline for the management of asymptomatic bacteriuria by the Infectious Diseases Society of America 1.
Instead of antibiotic treatment, the focus should be on:
- Reducing Ativan use if possible
- Implementing good sleep hygiene practices
- Ensuring adequate hydration If confusion recurs or urinary symptoms develop (dysuria, frequency, urgency), then antibiotic treatment with an agent like nitrofurantoin or trimethoprim-sulfamethoxazole would be appropriate. The distinction between asymptomatic bacteriuria and true UTI is crucial in elderly patients to prevent antibiotic overuse while ensuring appropriate treatment when needed.
From the Research
Treatment of Asymptomatic Urinary Tract Infections
- The patient in question has a urine culture that grows pan-sensitive E. coli, but she has no urinary symptoms, entirely normal bloodwork, normal vitals, and her confusion resolves after one evening/night 2.
- The presence of asymptomatic bacteriuria (ASB) should be distinguished from symptomatic urinary tract infection (UTI) by the absence of signs and symptoms compatible with UTI 2.
- In the case of ASB, antimicrobial treatment is not indicated, and withholding antibiotics is recommended to avoid unnecessary use and promote antimicrobial stewardship 2.
Considerations for Antibiotic Treatment
- A study on older adults presenting to the emergency department with confusion found that patients who received antibiotics had higher admission rates and 30-day and six-month mortality, even in the absence of urinary symptoms 3.
- The choice of agent for treating uncomplicated UTIs should be based on the pharmacokinetic characteristics of the molecule to optimize clinical benefit and minimize the risk of antibacterial resistance 4.
- Nitrofurantoin, trimethoprim-sulfamethoxazole, and other oral antibiotics are effective for treating uncomplicated lower urinary tract infections, but their use should be guided by the patient's specific needs and the presence of symptoms 5, 4, 6.
Decision to Treat or Watch
- Given the patient's lack of urinary symptoms and the resolution of her confusion, it may be reasonable to consider watching and avoiding antibiotics, as the risk of antibiotic treatment may outweigh the benefits in this case 2, 3.
- However, the decision to treat or watch should be made on a case-by-case basis, taking into account the patient's individual needs and the potential risks and benefits of antibiotic treatment 5, 4, 6, 2, 3.