Purple Urine Bag Syndrome as a Visual Trigger for Overtreatment: A Case Report and Aggregated Literature Analysis

Purple urine bag syndrome (PUBS) is an uncommon yet visually striking clinical phenomenon characterized by purple discoloration of urinary drainage systems in patients with indwelling urinary devices. Although alarming, it most often occurs in elderly or chronically ill patients with multiple risk factors for urinary bacterial colonization and does not typically represent a pathologic entity. PUBS is often accompanied by abnormal urine studies, which may prompt antimicrobial treatment even in the absence of clear clinical infection. We report a hospice patient with an indwelling urinary catheter who developed PUBS without localized urinary symptoms or systemic signs of infection. The patient remained clinically stable, and the treating hospice team did not initiate laboratory evaluation or antibiotic therapy. However, the long-term care facility subsequently administered intravenous ertapenem in response to urine culture results obtained during the episode. The purple discoloration resolved without clinical deterioration. This case illustrates how PUBS may trigger treatment escalation based on laboratory findings rather than clinical presentation, particularly in vulnerable patients, and was the impetus for a focused examination of management principles described in published reports. Careful interpretation of PUBS within the context of patient symptoms and goals of care may help avoid unnecessary interventions and support more judicious antimicrobial use and antibiotic stewardship.