“Urinary Tract Infection”—Requiem for a Heavyweight

Abstract

“Urinary tract infection” (“UTI”) is an ambiguous, expansive, overused diagnosis that can lead to marked, harmful antibiotic overtreatment. “Significant bacteriuria,” central to most definitions of “UTI,” has little significance in identifying individuals who will benefit from treatment. “Urinary symptoms” are similarly uninformative. Neither criterion is well defined. Bacteriuria and symptoms remit and recur spontaneously. Treatment is standard for acute uncomplicated cystitis and common for asymptomatic bacteriuria, but definite benefits are few. Treatment for “UTI” in older adults with delirium and bacteriuria is widespread but no evidence supports the practice, and expert opinion opposes it. Sensitive diagnostic tests now demonstrate that healthy urinary tracts host a ubiquitous, complex microbial community. Recognition of this microbiome, largely undetectable using standard agar‐based cultures, offers a new perspective on “UTI.” Everyone is bacteriuric. From this perspective, most people who are treated for a “UTI” would probably be better off without treatment. Elderly adults, little studied in this regard, face particular risk. Invasive bacterial diseases such as pyelonephritis and bacteremic bacteriuria are also “UTIs.” Mindful decisions about antibiotic use will require a far better understanding of how pathogenicity arises within microbial communities. It is likely that public education and meaningful informed‐consent discussions about antibiotic treatment of bacteriuria, emphasizing potential harms and uncertain benefits, would reduce overtreatment. Emphasizing the microbiome's significance and using the term “urinary tract dysbiosis” instead of “UTI” might also help and might encourage mindful study of the relationships among host, aging, microbiome, disease, and antibiotic treatment.

Improving Management of Urinary Tract Infections in Older Adults: A Paradigm Shift or Therapeutic Nihilism?

“…A commentary in this issue of the Journal of the American Geriatrics Society adds to the growing number of articles targeting overdiagnosis and overtreatment of UTI in older adults. 3 There is much to agree with in this far-ranging commentary, but we believe some of the solutions proposed may be missing the mark. We address the various arguments and solutions advanced in the commentary and offer several alternative solutions for this challenging clinical problem.…”

“…Although there has been considerable focus on the need to improve the diagnosis and treatment of UTI in older adults, overdiagnosis of UTI remains a pervasive problem in this population. A commentary in this issue of the Journal of the American Geriatrics Society adds to the growing number of articles targeting overdiagnosis and overtreatment of UTI in older adults . There is much to agree with in this far‐ranging commentary, but we believe some of the solutions proposed may be missing the mark.…”

Genetic and Molecular Basis of Asymptomatic Bacteriuria in Children: What’s New?

“…сложившиеся и казавшиеся ранее незыблемыми принци-пы их лечения [3]. Современные чувствительные методы исследования демонстрируют, что здоровые мочевые пути нестерильны и представлены сложным микробным сооб-ществом.…”

“…Были иденти-фицированы не только внутриклеточные бактериальные колонии, а также «мочевой виром» -сообщество различ-ных вирусов, не обнаруживаемых ранее с использованием стандартных методов исследования. Finucane (2017), под-черкивая значимость микробиома мочевых путей, пред-лагает использование старого термина «дисбиоз мочевого тракта» вместо «инфекция мочевых путей». Такой подход, по мнению автора, может способствовать внимательному изучению взаимосвязей между старением, микробиомом, болезнями и антибиотикотерапией [3].…”

“…Finucane (2017), под-черкивая значимость микробиома мочевых путей, пред-лагает использование старого термина «дисбиоз мочевого тракта» вместо «инфекция мочевых путей». Такой подход, по мнению автора, может способствовать внимательному изучению взаимосвязей между старением, микробиомом, болезнями и антибиотикотерапией [3].…”