When it comes to treating elderly patients in hospitals and nursing homes, Dr. David Dosa, a geriatrician at Brown University, believes doctors should adhere to the mantra “less is more.” In a recent study published in the Archives of Internal Medicine, Dr. Dosa and his colleagues analyzed the medical records of 172 residents of two Rhode Island nursing homes who had been diagnosed with urinary tract infections (UTI). According to Dr. Dosa, the problem with treating UTIs is that too many physicians start prescribing broad-spectrum antibiotics based solely on a positive urinalysis, indicating the presence of bacteria, even though they may not actually be sick. Older patients more frequently undergo bladder catheterizations, which means a positive urinalysis is “normal for them,” says Dr. Dosa. So before doctors go for their big antibiotic guns, they should also ascertain that patients meet at least three out of the five McGeer criteria for a UTI: fever, increased frequency or urgency of urination or burning associated with it, pain behind or near the bladder, a cloudy or otherwise abnormal-appearing urine or a deteriorating function or mental state.
Even when all of these diagnostic criteria are met, Dr. Dosa points out that — more often than not — doctors continue to err by prescribing broad-spectrum instead of narrow-spectrum antibiotics, which can lead to the emergence of antibiotic-resistant bacteria. Moreover, two-thirds of patients were kept on the drugs for far longer than the indicated duration of use.
ACSH’s Dr. Gilbert Ross, however, has a few questions for Dr. Dosa. “What if a physician chooses the wrong narrow-spectrum antibiotic to begin with? Since it takes about two days to obtain bacterial culture results to identify the pathogen, physicians could be prescribing an inappropriate narrow-spectrum antibiotic in the interim. My advice would be to initially put the patient on a broad-spectrum antibiotic for the first two days, and then switch them to a more targeted, narrow-spectrum drug once the results are obtained.”
Dr. Dosa also preaches that a little undertreatment never hurt anyone: “Nobody in our sample who didn’t get an antibiotic had a bad outcome,” like a kidney infection, hospitalization or death.
Slightly taken aback by this bold statement, Dr. Ross says, “I hope what he meant to say was that nobody in the study who wasn’t prescribed an antibiotic because they did not meet the treatment guidelines had a bad outcome. Otherwise, I would interpret what he’s saying as ‘don’t give anyone with a UTI antibiotics.’ If that’s the case, Dr. Dosa is asking for trouble.”
