October 19, 2016
Recently I was called to the emergency department to evaluate an elderly woman with a high fever, rash and abnormal blood work.
I suspected a severe reaction to a commonly used antibiotic-nitrofurantoin or Macrobid-that her doctor had prescribed for an apparent urinary tract infection. Despite stopping the antibiotic immediately, her condition deteriorated; she lapsed into kidney failure and died two days later. The cause was the adverse reaction that I had feared.
My patient never had any symptoms of a urinary tract infection such as burning on urination or the frequent need to void. Her infection was likely asymptomatic—i.e., bacteria in her urine, but no symptoms—possibly with pyuria (white blood cells in the urine), which is indicative of inflammation.
Pyuria is a generally benign manifestation of aging, but when detected, it often reflexively drives healthcare providers to prescribe antibiotics. Antibiotics may temporarily clear the infection, but it often returns, and with increasingly antibiotic resistant bacteria. In most cases, and contrary to common belief, treatment doesn’t prevent kidney infection or the progression to sepsis, which can be life threatening.
Antibiotic prescriptions for urinary tract infections are all too common in hospitals and nursing homes. The CDC estimates that 80 percent of nursing home residents receive at least one course of antibiotics each year and that up to 75 percent of these prescriptions are completely unnecessary; not surprisingly, many are for asymptomatic urinary tract infections.
The reasons for this state of affairs are several and interrelated. First, urine testing is noninvasive, easy to perform and often yields results in minutes. Urine tests are almost always included in the test battery that doctors order in emergency departments, regardless of why the patient came in. Nurses contribute too, by often incriminating the urine if it’s malodorous, and asking doctors to request a urine test.
A deeply entrenched myth also plays a part: a commonly held belief that urinary tract infections cause adverse behavior changes—dehydration, electrolyte imbalances, dementia or medication side effects are the usual culprits whose “true identity” is often concealed behind an abnormal urine test revealing white blood cells. For all these reasons, an abnormal urine test result can be a quick path to closure while the steps to a more accurate diagnosis are often more time consuming and arduous.
So, what’s the harm in a few days of an antibiotic? The answer is that the potential for harm is tremendous for both the patient and society. The nonchalant prescribing of antibiotics has contributed to both the rise in antibiotic resistance and Clostridium difficile infection, a potentially fatal diarrheal condition that disproportionately affects the elderly, and has emerged as the scourge of healthcare facilities.
Stopping the vicious cycle of antibiotic resistance isn’t easy, but progress is being made slowly through antibiotic stewardship programs. Educating healthcare providers to order urine testing only when absolutely necessary is critical, as is dispelling the behavioral change myth. Until then, patients will continue to receive treatments that are potentially harmful, society will suffer from the dwindling effectiveness of our current antibiotics, and Clostridium difficile will flourish. And others like the elderly woman I saw in the emergency department will continue to pay the ultimate price.
Neil Gaffin, MD
Ridgewood Infectious Disease Associates, PA
Ridgewood, NJ 07450
Image via Thomas Bjørkan (CC BY-SA 3.0)
