key: cord-0881830-8yek2cug
authors: Reyes, Rodolfo; Bono, Gianni; Finucane, Tom
title: “Urinary Tract Infection” in the Era of COVID‐19
date: 2020-06-17
journal: J Am Geriatr Soc
DOI: 10.1111/jgs.16685
sha: dbc69522defdaa0648cabff998fb164ea7beb253
doc_id: 881830
cord_uid: 8yek2cug

nan

When a frail older adult with incident delirium is found to have bacteria in the urine, doctors often assume that the bacteriuria represents a urinary tract infection ("UTI"), and that the "UTI" is causing delirium, but bacteriuria is common in older adults who are otherwise clinically stable. Accordingly, guidelines from the Infectious Disease Society of America (IDSA) include a strong recommendation against antibiotic treatment when a frail older adult develops delirium and is found to have asymptomatic bacteriuria (ASB). (Table 1 ) "In older patients with functional and/or cognitive impairment with bacteriuria and delirium and without local genitourinary symptoms or other systemic signs of infection (eg, fever or hemodynamic instability), we recommend assessment for other causes and careful observation rather than antimicrobial treatment (strong recommendation, very low-quality evidence)". 1 ASB is defined as "the presence of 1 or more species of bacteria growing in the urine at specified quantitative counts (≥10 5 colony-forming units [CFU]/mL or ≥108 CFU/L), irrespective of the presence of pyuria, in the absence of signs or symptoms attributable to urinary tract infection". 1 Taken together, the recommendation and the definition imply that delirium is not itself attributable to "UTI." Nonetheless, inappropriate antibiotic treatment remains common in this situation.

When a patient is seriously ill with COVID-19, has become delirious and is discovered to have bacteriuria, the decision about antibiotic treatment is complex and challenging. Favoring treatment, the IDSA guideline against antibiotic treatment is not applicable because the patient does have "systemic signs of infection."

Favoring non-treatment (with careful observation) is the very low pretest likelihood that "UTI" is causing delirium, because delirium is so highly prevalent in patients with for reasons that are unrelated to the urinary tract. Delirium might be a direct effect of SARS-CoV-2, which may bind to ACE-2 receptors. 3 We suggest that if a patient has severe COVID-19 and develops delirium, the finding of ASB should not trigger antibiotic treatment. We echo the IDSA recommendation of "assessment for other causes and careful observation rather than antimicrobial treatment". 1 If the patient has urinary tract symptoms as well, antibiotics directed to urinary pathogens should be considered. If a "UTI" is suspected, urine cultures should be drawn. If the urine culture is negative, antibiotics should be withheld or discontinued. The absence of pyuria suggests against antibiotic treatment (the presence of pyuria does not provide support for treatment). 6 In conclusion, risks from antibiotic overtreatment are not reduced by the presence of COVID-19. No studies have shown benefit from antibiotic treatment for "UTI" in vulnerable older adults who become delirious and are found to have bacteriuria. The costs, bacterial resistance, destabilization of the generally beneficial microbiome and adverse drug effects including fatal diarrhea, may be harmful to patients with COVID-19. Dasgupta and colleagues observed a further functional loss in patients who received antibiotics compared to those who did not in a pre-COVID-19 study. Meticulous, ongoing evaluation in a delirious COVID-19 patient should allow a less harmful approach than antibiotic treatment of ASB. 

"In older, community-dwelling persons who are functionally impaired, we recommend against screening for or treating ASB (strong recommendation, low-quality evidence)".

"In older persons resident in long-term care facilities, we recommend against screening for or treating ASB (strong recommendation, moderate-quality evidence)".

"In older patients with functional and/or cognitive impairment with bacteriuria and delirium and without local genitourinary symptoms or other systemic signs of infection (eg, fever or hemodynamic instability), we recommend assessment for other causes and careful observation rather than antimicrobial treatment (strong recommendation, very low-quality evidence)".

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America

Treatment of asymptomatic UTI in older delirious medical in-patients: A prospective cohort study

COVID-19, Angiotensin Receptor Blockers, and the Brain

A Unique Presentation of Delirium in a Patient with Otherwise Asymptomatic COVID -19

Global COVID-19 clinical platform novel coronavius ( COVID-19) : rapid version

Pyuria as a screening test for detection of urinary tract infection in patients on long-term hemodialysis

Conflicts of Interest: The authors have declared no conflicts of interest for this article. Author Contributions: All authors participated in the literature review and manuscript drafting. Final version was approved by Tom Finucane. Sponsor's Role: There was no sponsor involvement in the development of this article.