What is your approach to the management of asymptomatic bacteriuria in an elderly patient without clear urinary symptoms but with cognitive changes and falls?

Asymptomatic bacteruria does not cause altered mental status. Data suggests that when we attribute acute changes to it, we will be wrong about 85% of the time, thereby missing the true etiology. It is a difficult thing to educate staff of senior living facilities and families who have been told it was the cause in the past. If you are ordering the workup, don't get the UA, unless there are new urinary symptoms. If someone else did, keep looking for the actual etiology.

Could not agree more with Dr. @Dr. First Last. It is very difficult to reeducate medical staff and patients who have been trained to attribute mental status changes alone to urinary findings.

We should look for the true culprit, such as underlying cognitive disease (dementia, Parkinson's, stroke), or polypharmacy, as the usual causes of these often transient mental status abnormalities. Many neurologic diseases just wax and wane on their own, and altered mental status alone should not be attribu...

This is probably the best question I've seen that is geared toward Hospital Medicine. Making the diagnosis of UTI is taught to be straightforward, but the actual practice is extremely nuanced.

The key to remember, even in geriatric patients, is that symptoms are key! If the only presentation is confusion, the guidelines are clear that even if the patient has an elevated WBC on UA, LE, or nitrite positive, we should not attribute the confusion to a UTI or start ABX.

The reason is that pyuria has ...

I 100% agree with others, and just wanted to share a paper I find helpful when I'm trying to change hearts and minds on this topic: Mayne et al., PMID 30717706.