by Dr. Alan Lindemann
I’m a 73-year old OB-GYN who started medical school 48 years ago in 1973. Currently I am the Chief of Staff at four nursing homes and also at the hospital associated with these nursing homes. I’ve seen improvements occur too late, like Group B testing in pregnant women, and I’ve seen improvements discarded too soon, such as the reaction against Vaginal Birth After C-Section (VBAC), which is finally coming back into official acceptance.
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.
If the problem is a small bladder, that is, one with a capacity of one or two ounces, then medications can be taken which will allow the bladder to enlarge. On the other hand, if the bladder is too large, that is, 700 ml or more, the patient may have to self-catheterize. Most patients, nurses, and family members find self-catheterization revolting. But in my experience, I’ve found even 95-year old patients can become adept at self-catheterization.
So rather than not treating UTIs, let’s talk about not having UTIs.
*Durkin, Michael J. et al.,, 2018. An assessment of inappropriate antibiotic use and guideline adherence for uncomplicated urinary tract infections. Open Forum Infectious Diseases, Aug 10;5(9):ofy198.