Year: 2014
Type: letter
Abstract: To the Editor: We are writing to comment on “Effectiveness of Cranberry Capsules to Prevent Urinary Tract Infections in Vulnerable Older Persons: A Double-Blind Randomized Placebo-Controlled Trial in Long-Term Care Facilities.”1 The authors concluded that taking cranberry capsules twice daily reduces the incidence of clinically defined urinary tract infection (UTI) in individuals at high risk. No reduction was found in low-risk individuals or in individuals when the use of a “strict” UTI definition was applied.1 We have concerns with the validity and specificity of both UTI definitions used in this trial. A clinical UTI required the presence of only one specific or nonspecific symptom or sign, a positive result on urinary dipstick (nitrite, leukocyte esterase) or culture, UTI reported in the medical record, or simply the prescription of an antimicrobial agent. The strict definition required the presence of one of the specific or nonspecific symptoms or signs plus a positive urinary dipstick or culture. The specific symptoms or signs were dysuria, urinary frequency, hematuria, temperature greater than 37.9°C or more than 1.5°C above baseline, chills, pain in the abdomen, foul smell, nausea, and vomiting. Nonspecific symptoms were anorexia, fatigue reduced mobility, and manifestations of delirium (e.g., confusion, deterioration in mental or functional status). The authors justified the use of this definition by noting that the diagnosis of UTI in the long-term care (LTC) setting is challenging. Although it is true that the diagnosis of UTI is challenging and relies on consensus criteria, it is also true that a broad consensus exists regarding what is not a UTI. For example, the presence of a positive urinary test result in the absence of any other symptom or status change is asymptomatic bacteriuria (ASB). An extensive body of evidence confirms that there is no benefit to treating this condition with antimicrobials, and treatment of ASB not only can, but does lead to direct harm through resistance, risk of adverse drug events, and Clostridium difficile infection.2-4 It is an unfortunate and dangerous myth that nonspecific symptoms or signs, with or without positive urinary test results, rule in the diagnosis of UTI in frail older adults. Any number of conditions or medications could cause this combination of findings. By using such a nonspecific definition of UTI, one risks missing the etiology of a LTC resident's change in condition and thus causing a delay in the correct diagnosis. It is for these reasons that the American Geriatrics Society (AGS) and American Medical Directors Association (AMDA) promulgated statements about inappropriate testing and treatment for UTI in their Choosing Wisely Campaign lists.5, 6 By using the clinical definition described in the article, it is not possible to infer any benefit from cranberry capsules in the prevention of UTI even in high-risk individuals. Researchers evaluating interventions to reduce UTI should use a more-specific UTI definition, preferably using one of the published consensus criteria.7, 8 Facilities faced with high rates of UTI, antibiotic-resistant organisms, or C. difficile infections should implement antibiotic stewardship programs that include more-specific minimum criteria for starting antibiotics, with protocols to monitor residents closely if antibiotics are withheld.4, 9 Admittedly, more work is needed to establish the safety and efficacy of specific minimum criteria for initiating antibiotics for UTI in LTC settings, especially in residents unable to report symptoms.10 The onslaught of antibiotic-resistant organisms and C. difficile illness gives this work high priority. We must not handicap ourselves by calling any change in clinical status in LTC a UTI. Conflict of Interest: Dr. Nace receives grant funding from Sanofi Pasteur for an investigator-initiated immunogenicity study of high- versus standard-dose influenza vaccine in long-term care residents. Dr. Nace receives support in relationship to this project from the Pittsburgh Claude D. Pepper Older Americans Independence Center (NIH) (P30 AG024827) and the Agency for Healthcare Research and Quality (AHRQ) (R01HS018721). Author Contributions: Both authors participated in the conception, drafting, and approval of the manuscript. Sponsor's Role: The Pittsburgh Claude D. Pepper Center and Agency for Healthcare Research and Quality played no role in the conception or preparation of the manuscript.
DOI: 10.1111/jgs.12950
Authors: David A. Nace, Paul J. Drinka
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2090812480