It’s been busy out there. I’ve heard a lot about people blaming behavior on bladder infections. Well, sometimes, but all I see is that elders going to the emergency room for agitation often come out with a prescription for antibiotics. What??? So no, antibiotics do not cure agitation. There is the idea that any bladder issue is THE cause of the agitation, and that is dangerous…
Dangerous to treat bladder infections? Again, no. But much of what I see treated out there is bacteria (bact) found or white blood cells (WBCs) found in the urine. And sometimes that can indicate an infection, but having them alone is not a sign.
Normal is reported as 0-5 WBCs. So, I see that having 6-10 WBCs, or very similar to 5 is reported as an infection and antibiotics given.
There actually is NO cut of between the number of WBCs or bact and an infection. There is an importance of epithelial cells (epis), if there are more than 5 then it is a contaminated specimen and the new clean specimen needs to be caught. Either after a shower or cleaning off with several wipes, then catching urine a bit after the start of flow.
What is Critical is the Symptoms. Not Agitation.
So, fever, pelvic pain, not eating, lethargy, or actual delirium (sudden onset of confusion, inattention that waxes and wanes) are signs of infection. Also, if someone has >100 WBCs and agitation, it is more likely related to infection than if they have only 10-20 WBCs.
It is critical to get a microscopy to see if there are WBCs, RBCs (red blood cells) in addition to the urine culture. I have seen cultures done without the microscopy… and microscopy without the culture…. and many still being treated with antibiotics (abx) without having the symptoms or with a few WBCs or no culture.
So? So Why Can’t We Just Treat?
We cannot just treat because, the behavior is not necessarily related to a bladder infection, it may be pain, or other medication side effects, or reacting to a caregiver, or they may be tired, or bored. We should only use abx on infections.
The reason is that when abx are used to treat “smelly urine” or behavior multiple times, you end up with multidrug resistant bacteria… ie, so treating without knowing there is an infection leads to making the bacteria found in the body resistant to the common abx. I saw this recently. I did not know this person was treated often with abx and was told she had “smelly urine” and was requested to treat. I got a straight catheter urine specimen… not easy, sometimes the elder needs medication to relax or sedate them to obtain the urine by putting a catheter in their bladder, and was shocked to see it was resistant to all oral abx. Then the question is, is the person sick enough to go to the hospital for IV abx.
The other problem for overusing abx is the development of clostridium difficile or c diff diarrhea. This is a bad bacteria that also can become quickly resistant and takes over when abx are used that kill most of the good gut bacteria. I have seen people die from this. This is another risk for long term abx as well.
So, yes, we want to make sure that elders don’t have untreated infections, but overtreating lab results when there was not an infection is not good either. Usually, I will treat for behavior or smelly urine once. If there is no change, we treat only if there is evidence by symptoms and lab results of an infection. Stay safe.
Elizabeth (Dr Liz) has over twenty years of experience in providing medical care to the elders. She is board-certified in Internal Medicine, Geriatric Medicine and Palliative Care Medicine. Dr Landsverk founded ElderConsult Geriatric Medicine, a house calls practice, to address the challenging medical and behavioral issues often facing older patients and their families.