Urinary Tract Infections or UTI’s as they are called in healthcare are very common. They affect women more than men and older people more than younger, they can be recurrent, and relatively minor events, or, they can be life threatening requiring admission to hospital and intensive care.
UTIs are one of the commonest causes for older people attending hospital – the other very common reason for an older person presenting at their local accident and emergency is following a fall.
Very often, the two are conjoined and explained away as the older person having fallen because they have a urine infection.
Patients are told they have urine infections by different people – doctors, nurses, carers and the level of evidence which is used to account for the presence of infection also varies depending on situation – care home, GP surgery or hospital ward, by this, I mean the tools used to diagnose the infection vary;
In care homes, the most flakey form of evidence is often used, with a carer phoning-up the GP and explaining that, ‘Mabel seems more confused,’ all the way through to the more complex forms of decision making that happen on my ward – balancing patient symptoms and signs with blood and urine culture results, temperature, blood pressure, state of nutrition, etc.
The evidence in older people is that only those infections which are causing symptoms should be treated – we call this ‘symptomatic bacteruria’ – many older people have bacteria in their normally sterile urine which is causing no harm or upset, treating this generally subjects an individual to the risks of antibiotics only for the bacteria to return shortly after the course has finished (usually in a slightly mutated and more drug-resistant form).
How many people receive treatment for urine infections that do not require this? It is difficult to estimate, certainly, it is accepted that if an older person attends A&E there is a significant risk that whatever has brought them there will be explained away as a ‘UTI’
And it is here that my concern lies; it is unlikely that we will ever be able to get to a situation where only gold-standard practice is in place in hospital and the community (unless there are more rigorous controls), what I believe is important is that we don’t treat the wrong thing.
If an older person falls and attends A&E, treating a non-existent urine infection is not going to result in a positive outcome for them if they fell because of a stroke, a drop in their blood pressure, a heart attack or a complication of medicine that they don’t need.
It is likely that a doctor, a nurse or carer admitting, ‘something is wrong, I don’t know what,’ is better than heading off down a therapeutic blind alley.
Very often the patient, the carers or the team will know what is wrong, what has caused the fall or the deterioration – unfortunately, in many instances, the pull of medicine, the medical model of care is so strong that everything else becomes drowned-out.