LETTER
Bacteriuria in Delirious Individuals To the Editor: With interest we read the commentary by McKenzie et al1 about bacteriuria and delirium. Although we believe the authors are absolutely correct in arguing for the lack of benefit of antibiotic therapy in asymptomatic bacteriuria in elderly patients, they may misinterpret the main impetus for antibiotic prescribing for delirious elderly patients with an abnormal urinalysis or a positive urine culture. Many, if not most, prescribers are cognizant of the lack of benefit in treating asymptomatic bacteriuria in the elderly. Based on our discussions with many colleagues who treat this patient population, their foremost concern is that of possible urosepsis with delirium as a manifestation, and not just an asymptomatic bacteriuria. Given the relative frequency with which septic elderly patients clinically present with lack of fever or leukocytosis, physicians are left with no sensitive and specific means of distinguishing early urosepsis with delirium from delirium of another etiology with accompanying irrelevant asymptomatic bacteriuria.
We suggest that routine use of a serum procalcitonin assay in this setting may allow physicians to avoid unnecessary antibiotic therapy in uninfected patients and to initiate appropriate treatment in early sepsis. Measurement of serum procalcitonin is relatively inexpensive and increasingly available in general practice. While this assay is not perfect in distinguishing elderly patients with a bacterial infection from uninfected patients, the assay may allow a physician greater confidence in a decision to withhold antibiotics.2 A randomized, controlled trial of procalcitonin use in such a setting would be very useful given the rising rates of resistance in uropathogenic bacteria. Michael S. Gelfand, MD Shirin A. Mazumder, MD Kerry O. Cleveland, MD Department of Medicine Division of Infectious Diseases University of Tennessee Health Science Center Memphis
http://dx.doi.org/10.1016/j.amjmed.2014.04.023
References Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript.
0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
1. McKenzie R, Stewart MT, Bellantoni MF, Finucane TE. Bacteriuria in individuals who become delirious. Am J Med. 2014;127:255-257. 2. Lee SH, Chan RC, Wu JY, et al. Diagnostic value of procalcitonin for bacterial infection in elderly patients e a systematic review and metaanalysis. Int J Clin Pract. 2013;67:1350-1357.
Bacteriuria in Delirious Individuals To the Editor: With interest we read the commentary by McKenzie et al1 about bacteriuria and delirium. Although we believe the authors are absolutely correct in arguing for the lack of benefit of antibiotic therapy in asymptomatic bacteriuria in elderly patients, they may misinterpret the main impetus for antibiotic prescribing for delirious elderly patients with an abnormal urinalysis or a positive urine culture. Many, if not most, prescribers are cognizant of the lack of benefit in treating asymptomatic bacteriuria in the elderly. Based on our discussions with many colleagues who treat this patient population, their foremost concern is that of possible urosepsis with delirium as a manifestation, and not just an asymptomatic bacteriuria. Given the relative frequency with which septic elderly patients clinically present with lack of fever or leukocytosis, physicians are left with no sensitive and specific means of distinguishing early urosepsis with delirium from delirium of another etiology with accompanying irrelevant asymptomatic bacteriuria.
We suggest that routine use of a serum procalcitonin assay in this setting may allow physicians to avoid unnecessary antibiotic therapy in uninfected patients and to initiate appropriate treatment in early sepsis. Measurement of serum procalcitonin is relatively inexpensive and increasingly available in general practice. While this assay is not perfect in distinguishing elderly patients with a bacterial infection from uninfected patients, the assay may allow a physician greater confidence in a decision to withhold antibiotics.2 A randomized, controlled trial of procalcitonin use in such a setting would be very useful given the rising rates of resistance in uropathogenic bacteria. Michael S. Gelfand, MD Shirin A. Mazumder, MD Kerry O. Cleveland, MD Department of Medicine Division of Infectious Diseases University of Tennessee Health Science Center Memphis
http://dx.doi.org/10.1016/j.amjmed.2014.04.023
References Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript.
0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
1. McKenzie R, Stewart MT, Bellantoni MF, Finucane TE. Bacteriuria in individuals who become delirious. Am J Med. 2014;127:255-257. 2. Lee SH, Chan RC, Wu JY, et al. Diagnostic value of procalcitonin for bacterial infection in elderly patients e a systematic review and metaanalysis. Int J Clin Pract. 2013;67:1350-1357.
