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Reply to Dr. Snustad

To the Editor: We appreciate the thoughtful comments of Dr. Snustad. Virtually no issue in geriatrics is as contentious, difficult, or controversial as defining what is truly a urinary tract infection (UTI) in residents of long-term care, and thus it is not surprising that recommendations provided regarding this issue generate exceptions to the rule. It is a certainty that no guideline will cover every circumstance or every patient; exceptions do occur, such as the illustrative case provided by Dr. Snustad. As pointed out in the preamble of the document, the guidelines are intended to be just that, guidelines, not hard-and-fast rules. Clinical judgment will always play a role and may override a given recommendation in a specific situation, although we tried to be evidence based in each recommendation provided and feel strongly that the best evidence (with references and justification outlined in the full guidelines) supports limiting urine cultures in most circumstances to subjects with pyuria or dipstick testing positive for nitrites or leukocyte esterase. Furthermore, the presence of fever or any other non-urinary tract symptom or sign in the presence of a positive culture does not necessarily mean that the bacteriuria isolated from the urine is the cause of these clinical manifestations (reviewed in). Additionally, the risks and benefits of antibiotic use in long-term care facilities (LTCFs) as a whole medical unit must be considered in recommendations for individual residents. A large number of studies has documented the overuse of antibiotics in LTCFs, a large percentage of which are provided for suspected UTI but in whom at least one-third are really prescribed for asymptomatic bacteria. Rates of asymptomatic bacteruria are 50% for women and 35% for men in long-term care residents (reviewed in) and essentially 100% of those with an indwelling catheter. LTCF residents are among the most likely to be colonized and infected with antibiotic-resistant organisms, particularly those with specific risk factors associated with UTI. Finally, we have shown in asymptomatic (for genitourinary symptoms) older ambulatory men that the presence of fewer than five white blood cells (WBCs) on urinalysis has a greater than 90% predictive accuracy of showing a negative urine culture. In women, this is less reliable because of WBC contamination from the perineum. Thus, although in any individual patient, a care-provider might make a decision to perform a urine culture outside the suggested guidelines, we feel strongly that the evidence supports limiting urine culture to subjects with a high index of suspicion for UTI as a cause of their clinical symptoms. The second issue raised by Dr. Snustad, that of ‘‘subtle’’ signs of infection in older LTCF residents is similarly contentious. With specific regard to UTI, a recent study examined the reliability of LTCF staff in evaluating changes in behavior that triggered evaluation for UTI. In that study, LTCF staff accurately assessed resisting care, periods of altered perception, disorganized speech, and lethargy, although the predictive value of those signs for UTI has not been established. We are unaware of any study examining the performance characteristics of the unilateral slump sign for UTI or any other specific infectious syndrome. A PubMed search using ‘‘slump sign’’ as the search term revealed only two references to this sign in the literature; both were brief reports and providing insufficient data to comment on the utility of the sign to predict infection.