Jimmy Carter’s hospitalization shines light on common ailment

When former President Jimmy Carter was recently admitted to the hospital for treatment of a urinary tract infection, he was receiving treatment for a condition that is quite common in older Americans.

“We see urinary tract infections every day,” said geriatric specialist Arash Tadbiri, MD, at Bourne Primary Care. “It is the most common infection in the elderly.”

The way to diagnose a UTI is with a urinalysis and urine culture, but doctors need to be cautious about ordering them for elderly patients, Dr. Tadbiri said. That’s because it is very common for urine cultures to come back positive even when the patient does not have an actual UTI. The condition is called asymptomatic bacteriuria.

“It leads to prescribing unnecessary antibiotics,” Dr. Tadbiri said. “It is a very common thing that happens, especially in assisted living or nursing homes. If there is any change in mental status, nurses request urine tests.”

Nursing homes aren’t the only ones overprescribing antibiotics. A recent study of 2,733 seniors with asymptomatic bacteriuria at 46 hospitals in Michigan published in JAMA Internal Medicine revealed that 82.7 percent had received improper antibiotic therapy because of altered mental status and abnormal urinalysis. Antibiotic treatment was not correlated with improved outcomes and it increased the length of the patients’ hospital stay by 37 percent.

Altered mental status, agitation or aggressiveness can all occur with urinary tract infections, but they are also common as people age, especially if they have dementia, Dr. Tadbiri said. Dementia patients always have fluctuations in their cognition and behavior, especially at certain times of the day like when the sun goes down.

“UTIs are one of the conditions that is over diagnosed, especially in demented patients when the patient cannot communicate well,” he said.

In addition to altered mental status, there needs to be at least one other new symptom that is common with UTIs to warrant doing a urinalysis and culture, he added.

Common symptoms of UTIs:

• More frequent urination
• A burning sensation when urinating
• Blood in the urine
• Abdominal discomfort
• Foul-smelling urine
• Chills
• Fever

Take Them Seriously

UTIs can be very serious, so if an elderly person does have symptoms, especially a fever, they should go straight to the emergency department. Elderly patients do not spike a fever easily, which means that when their temperature is elevated, it could indicate serious, Dr. Tadbiri said.

There are several reasons why UTIs are so over diagnosed. The first is because they actually are very common in the elderly. Older people have weaker immune systems and their production of immunoglobulins, or antibodies, is lower. Since their defense mechanisms aren’t great, they are more prone to infection.

In addition, elderly people living in nursing homes almost always have asymptomatic bacteriuria because the bacteria are colonized in the residents’ bodies.

“This means the culture will come back positive if the patient doesn’t have any urinary symptoms,” Dr. Tadbiri said. “Just having bacteria in the urine doesn’t mean that you should treat.”

Sometimes cultures come back in the gray zone. You need a colony count of more than 100,000 to diagnose a urinary tract infection, he said. When the counts are between 50,000 and 100,000, it’s important to talk to a family member or someone who knows the patient well to determine whether there are additional symptoms.

“If there are any urinary symptoms, it is better to treat,” Dr. Tadbiri said. “If there are no urinary symptoms, it’s better not to treat, especially in demented patients. If there is any doubt about whether or not to treat, doctors should treat with a lower dose of antibiotics for a shorter amount of time.”

There are several reasons why the overuse of antibiotics is bad. One of the most serious complications is C. difficile, a virulent, hard to eradicate infection that can take a nursing home by storm and carries a serious risk of mortality. The Centers for Disease Control calls C. difficile a “major health threat.”

Bacterial antibiotic resistance is just as dangerous. The overuse of antibiotics has created a danger that antibiotics won’t work just when the patient needs them the most. The CDC’s Antibiotic Resistance Threats in the United States, 2019 report states that there are 2.8 million antibiotic-resistant infections every year in the U.S. and more than 35,000 people will die as a result.

“Every physician needs to be careful about prescribing antibiotics,” Dr. Tadbiri said. “As few as possible is best.”