UTIs and Antibiotic Stewardship

From my perspective, antibiotic stewardship often advocates positions which are impossible to follow without harming patients. For example, we are not supposed to treat urinary tract infections (UTIs), but we are also not supposed to allow our patients to develop urosepsis either. Diagnosing and effectively treating UTIs is the first step in avoiding urosepsis. Treating a UTI for three to five days with Septra or Cipro costs far less than having to send a nursing home patient to the hospital intensive care unit for urosepsis resulting from untreated UTIs. But to prevent the trip to the hospital, I have to fight against antibiotic stewardship every day.

 

The Durkin et al. study, for example, uses insurance records to track antibiotics, records which do not reflect how a UTI was diagnosed or whether there were urine samples to determine the causative agent, much less a sensitivity test to determine the most effective antibiotic for the UTI. Without that information, generalizations about misuse and overuse of antibiotics are less than solid. From my perspective, antibiotic stewardship often advocates positions which are impossible to follow without harming patients. For example, we are not supposed to treat urinary tract infections (UTIs), but we are also not supposed to allow our patients to develop urosepsis either. Diagnosing and effectively treating UTIs is the first step in avoiding urosepsis. Treating a UTI for three to five days with Septra or Cipro costs far less than having to send a nursing home patient to the hospital intensive care unit for urosepsis resulting from untreated UTIs. But to prevent the trip to the hospital, I have to fight against antibiotic stewardship every day. The Durkin et al. study*, for example, uses insurance records to track antibiotics, records which do not reflect how a UTI was diagnosed or whether there were urine samples to determine the causative agent, much less a sensitivity test to determine the most effective antibiotic for the UTI. Without that information, generalizations about misuse and overuse of antibiotics are less than solid.

 

For patients in long-term care, antibiotic stewardship is too late. There can be many reasons for long-term patients having UTIs which could be avoided with good preventive care. UTIs are a result of bladder problems. The bladder has two functions: 1) to be filled with urine from the kidneys, and 2) emptying the bladder of urine. Patients can have trouble, including recurrent UTIs, for these two reasons. Either their bladder does not fill properly or their bladder doesn’t empty properly. To determine which problem a patient has, there needs to be either an ultrasound pre- and post- voiding or a urinary straight catheterization (catheter in until bladder emptied and then catheter removed). I order and recommend bladder scans on everybody in long-term care.