In this episode, I’ll discuss the risk of bacteremia in patients with asymptomatic bacteriuria and altered mental status.
Perhaps one of the most frustrating scenarios dealing with antimicrobial stewardship is that of a patient with asymptomatic bacteriuria (meaning no systemic signs of infection) but altered mental status. Many clinicians will still want to treat with antibiotics in this case, despite IDSA guidelines giving a strong recommendation to assess “for other causes [of altered mental status] and careful observation rather than antimicrobial treatment.” The motivation to treat with antibiotics is the “what if” thought that the altered mental status might be the sole sign of infection and the patient may develop bacteremia, which if not treated initially, could result in a poor patient outcome.
To tackle this common line of reasoning that results in overtreatment of asymptomatic bacteriuria, a group of authors published a retrospective cohort study in JAMA. The authors took data from 68 hospitals over a 5 year period looking at non-ICU patients with asymptomatic bacteriuria who were not immunocompromised and did not have a second infection.
Over 11,000 patients with asymptomatic bacteriuria were included in the analysis. In the entire cohort, the rate of bacteremia from a presumed urinary source was 1.4%. However looking at just the 2126 patients who had both asymptomatic bacteriuria and altered mental status, the rate of bacteremia from a presumed urinary source was only 0.7%.
When multivariate analysis was performed, neither old age, altered mental status, or history of dementia were associated with an increased risk of bacteremia.
The authors recommend: “…if patients have altered mentation and cannot attest to having specific signs or symptoms of UTI, clinicians should assess for SIRS, leukocytosis, and pyuria when deciding who may possibly benefit from empiric antibiotic treatment. If the patient with ASB does not have systemic signs of infection, they have a very low risk of bacteremia from a urinary source.”
The findings of this study support the IDSA guideline recommendation to use watchful waiting rather than antibiotics in patients with asymptomatic bacteriuria even if they have altered mental status. Furthermore, it provides additional information that antimicrobial stewardship teams can use to educate clinicians and assuage their fears of missing a case of bacteremia in a patient with asymptomatic bacteriuria and altered mental status.
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