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

Antibiotics are among the most commonly prescribed medications in community-dwelling and institutionalized adults. Although antibiotics are undoubtedly beneficial in many clinical situations, their use is associated with an underappreciated risk of adverse drug reactions and acquisition of antibiotic-resistant bacteria and subsequent infections caused by Clostridium difficile. Much of the misuse of antibiotics in older adults stems from the treatment of suspected urinary tract infection (UTI). More than half of the antibiotics initiated for a UTI indication are unnecessary or inappropriate. 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. We address the various arguments and solutions advanced in the commentary and offer several alternative solutions for this challenging clinical problem.