Treatment of bacteriuria without urinary signs, symptoms, or systemic infectious illness (S/S/S).

The title includes clinical conditions that justify treatment of bacteriuria with antibiotics. Asymptomatic bacteriuria can be detected in 35% of stable nursing home residents. Higher rates are detected in females and are associated with decline in functional status. 1 Atrophic vaginitis and incomplete bladder emptying from prostatic obstruction, cystocele, or denervation provide a fertile nitch for bacterial growth. Maintaining sterility in a stagnant, nutrient-rich site might be as frustrating as maintaining a sterile colon. The anatomy and patternofurineflowarevariableandmayincludeobstruction, stones,catheters, andbiofilm formation.A ‘‘complicated’’ urinarytractmayfacilitatethedevelopmentofurosepsis. 2 Inone large study, ‘‘complicated’’ individuals accounted for the excess mortality associated with bacteriuria. 3 Three controlled trials found that treating bacteriuria in clinically stable residents without catheters had no discernable positive clinical effect. 4‐6 Antibiotics have no proven value in an asymptomatic resident because of recolonization or recurrence and are dangerous because of the emergence of resistance or overgrowth of pathogens such as Clostridium difficile, gastrointestinal (GI) or central nervous system (CNS) intolerance, and drug interactions (coumadin). CRITERIA FOR TREATMENT The most contentious reason antibiotics are prescribed for bacteriuria is new ‘‘Geriatric Manifestations’’ such as falls or confusion from preexisting or evolving dementia in the absence of urinary signs/symptoms or a systemic infectious illness (mnemonic: S/S/S). Acute medical problems such as pneumonia, bacteremia, drug intoxication, or electrolyte abnormalities may present atypically. New-onset ‘‘Geriatric Manifestations’’ require consideration of multiple diagnoses and follow-up. Falsely attributing ‘‘Geriatric Manifestations’’ to urinary tract infection (UTI) can harm the resident by circumventing the search for the actual cause. If a physician casually prescribes an oral antibiotic for ‘‘UTI’’ without S/S/S, staffislikelytoattributeanysubsequent clinical deterioration to UTI. Falls or confusion may also signal the progression of Alzheimer’s disease or occur during the fluctuating course of Lewy body dementia. Since Geriatric Manifestations and bacteriuria are common, they often coexist. A long and powerful oral tradition/mythology indicates that ‘‘UTI’’ is a common cause of Geriatric Manifestations in the absence of S/S/S. Boscia et al 7 studied 72 subjects (mean age 85) with and without bacteriuria. There was no relationship between bacteriuria and Geriatric Manifestations. Ouslander et al 8 studied 71 residents with chronic incontinence. The eradication of bacteriuria had no effect on incontinence. Urinary catheters become coated with biofilm concretions that can cause obstruction ormucosal abrasions withbleeding when the catheter is ‘‘pistoned,’’ removed, or replaced. Obstruction or trauma especially with hematuria can produce urosepsis. 9‐11 An invasive device is a powerful risk factor for the development of multidrug-resistant urosepsis. 12 Minimum