On behalf of emergency physicians at Hamilton Health Sciences, we are compelled to respond to an article1 that appeared in the practice section of CMAJ. In a survey of our colleagues, 29 out of 30 respondents believed that the patient in the article by Vaisman and colleagues1 had a urinary tract infection. Only 1 respondent thought that the positive culture represented asymptomatic bacteriuria.
Because of the high mortality rate due to bacterial infection among older adults, and because systemic inflammatory response syndrome and septic shock were the most immediate and life-threatening possible diagnoses, most physicians would have likely treated the patient with antibiotics upon presentation.
Of the studies cited in the CMAJ article,1 one was a qualitative (i.e., tape-recorded interview) study of nurses and doctors describing their diagnostic and prescribing practices concerning bacteriuria within a nursing home setting,2 another was a self-report study from 1987 of 72 elderly participants’ (59 women and 13 men) symptoms and urine culture results, in which there was no control for cognitive ability to describe symptoms.3
Vaisman and colleagues1 justify their decision to deny the patient antibiotic therapy based on prevalence-biased diagnostic measures, low probability of disease in a different (i.e., otherwise healthy) population and by retroductive inference.
Because the patient presented in a shock state with evidence of urosepsis, she required immediate treatment for sepsis, including antibiotics, and, in our opinion, treating her otherwise was unacceptable.