Asymptomatic Bacteriuria

Richard Colgan; Gregory A. Jaffe; Lindsay E. Nicolle

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Jul 15, 2020 Issue

Asymptomatic Bacteriuria

RICHARD COLGAN, MD, University of Maryland School of Medicine, Baltimore, Maryland

GREGORY A. JAFFE, MD, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

LINDSAY E. NICOLLE, MD, University of Manitoba, Winnipeg, Manitoba, Canada

Am Fam Physician. 2020 Jul 15;102(2):99-104.

Author disclosure: No relevant financial affiliations.

Asymptomatic bacteriuria, defined as the presence of bacteria in the urine in the absence of urinary symptoms, is a common clinical finding that often warrants a decision about whether to initiate antimicrobial therapy. There are few indications to treat asymptomatic bacteriuria, and inappropriate treatment contributes to the development of antimicrobial resistance. In 2019, the Infectious Diseases Society of America revised its 2005 guidelines on asymptomatic bacteriuria, incorporating new evidence. The updated guidelines recommend screening and appropriate treatment for asymptomatic bacteriuria in pregnant women and in individuals undergoing endourological procedures associated with mucosal trauma. The guidelines recommend against screening and treatment in infants and children; healthy adults, including nonpregnant pre- and postmenopausal women; and patients with diabetes mellitus, long-term indwelling catheters, or spinal cord injuries. The guidelines also recommend against screening and treatment in patients undergoing nonurological surgery, patients who have had a kidney transplant more than one month prior, recipients of other solid organ transplants, or those with impaired voiding following spinal cord injury. Although delirium in older adults can be caused by a urinary tract infection, the guidelines recommend that patients with delirium and no urinary or systemic symptoms be assessed for other causes of delirium, rather than initiating treatment for asymptomatic bacteriuria, because treatment has not been shown to have any beneficial effect on clinical outcomes.

Urinary tract infections (UTIs) are among the most common reasons antimicrobials are prescribed. Often, however, clinicians prescribe antimicrobials for asymptomatic bacteriuria, which is defined as the presence of bacteria in the urine in the absence of urinary symptoms. Treating asymptomatic bacteriuria is not beneficial for most patients and may be detrimental. For example, a retrospective study of more than 2,700 patients with asymptomatic bacteriuria at 46 hospitals showed that antimicrobial treatment did not improve outcomes and was associated with longer hospitalization.1

WHAT'S NEW ON THIS TOPIC

A 2019 retrospective study of more than 2,700 patients with asymptomatic bacteriuria at 46 hospitals showed that antimicrobial treatment does not improve outcomes and is associated with longer hospitalization.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comments
Healthy nonpregnant premenopausal women should not be screened or treated for asymptomatic bacteriuria.^2–5	B	Observational studies, randomized controlled trials, expert opinion, and clinical guidelines
Pregnant women should be screened for asymptomatic bacteriuria early in pregnancy and treated appropriately.^2,6–8	B	Consistent, good-quality patient-oriented evidence from the Infectious Diseases Society of America, the U.S. Preventive Services Task Force, and a Cochrane review.
Older patients with functional or cognitive impairment and bacteriuria but no systemic signs of infection (e.g., genitourinary symptoms, fever, hemodynamic instability) who experience delirium or a fall should be assessed for other causes of delirium along with careful observation, rather than being treated with antimicrobials.^2,11–13	B	No studies of the benefits of screening and treatment in this population are available; recommendation based on lower-quality studies and clinical guideline
Patients with diabetes mellitus should not be screened or treated for asymptomatic bacteriuria.^2,14–16	B	Multiple studies have shown no benefit
Patients undergoing endourological procedures associated with mucosal trauma (e.g., transurethral surgery; ureteroscopy, including lithotripsy and percutaneous nephrolithotomy) should be screened for asymptomatic bacteriuria before the procedure and treated appropriately.^2,21,22	B	Small randomized trial, case series, and practice guideline

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comments
Healthy nonpregnant premenopausal women should not be screened or treated for asymptomatic bacteriuria.^2–5	B	Observational studies, randomized controlled trials, expert opinion, and clinical guidelines
Pregnant women should be screened for asymptomatic bacteriuria early in pregnancy and treated appropriately.^2,6–8	B	Consistent, good-quality patient-oriented evidence from the Infectious Diseases Society of America, the U.S. Preventive Services Task Force, and a Cochrane review.
Older patients with functional or cognitive impairment and bacteriuria

The Authors

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RICHARD COLGAN, MD, is a professor in the Department of Family and Community Medicine at the University of Maryland School of Medicine, Baltimore....

GREGORY A. JAFFE, MD, is a faculty development fellow in the Department of Family Medicine at the University of Pittsburgh (Pa.) Medical Center St. Margaret, and is a 2020 Masters of Science in Medical Education candidate at the University of Pittsburgh.

LINDSAY E. NICOLLE, MD, is professor emeritus of internal medicine and medical microbiology at the University of Manitoba Rady Faculty of Health Sciences, Winnipeg, Canada.

Address correspondence to Richard Colgan, MD, University of Maryland School of Medicine, 29 South Paca St., Baltimore, MD 21201 (email: rcolgan@som.umaryland.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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1. Petty LA, Vaughn VM, Flanders SA, et al. Risk factors and outcomes associated with treatment of asymptomatic bacteriuria in hospitalized patients. JAMA Intern Med. 2019;179(11):1519–1527....

2. Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68(10):e83–e110.

3. Epocrates. Accessed December 1, 2019. https://www.epocrates.com

4. Asscher AW, Sussman M, Waters WE, et al. Asymptomatic significant bacteriuria in the non-pregnant woman. II. Response to treatment and follow-up. Br Med J. 1969;1(5647):804–806.

5. Nicolle LE. The paradigm shift to non-treatment of asymptomatic bacteriuria. Pathogens. 2016;5(2):e38.

6. Smaill FM, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev. 2019;(8):CD000490.

7. U.S. Preventive Services Task Force. Asymptomatic bacteriuria in adults: screening. September 2019. Accessed February 1, 2020. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/asymptomatic-bacteriuria-in-adults-screening

8. Owens DK, Davidson KW, Krist AH, et al. Screening for asymptomatic bacteriuria in adults: U.S. Preventive Services Task Force recommendation statement. JAMA. 2019;322(12):1188–1194.

9. American Academy of Family Physicians. Clinical preventive service recommendation. Asymptomatic bacteriuria in adults: screening. Accessed February 21, 2020. https://www.aafp.org/patient-care/clinical-recommendations/all/bacteriuria.html

10. Colgan R, Nicolle LE, McGlone A, et al. Asymptomatic bacteriuria in adults. Am Fam Physician. 2006;74(6):985–990. Accessed May 6, 2020. https://www.aafp.org/afp/2006/0915/p985.html

11. Das R, Towle V, Van Ness PH, et al. Adverse outcomes in nursing home residents with increased episodes of observed bacteriuria. Infect Control Hosp Epidemiol. 2011;32(1):84–86.

12. Sundvall PD, Ulleryd P, Gunnarsson RK. Urine culture doubtful in determining etiology of diffuse symptoms among elderly individuals: a cross-sectional study of 32 nursing homes. BMC Fam Pract. 2011;12:36.

13. Potts L, Cross S, MacLennan WJ, et al. A double-blind comparative study of norfloxacin versus placebo in hospitalised elderly patients with asymptomatic bacteriuria. Arch Gerontol Geriatr. 1996;23(2):153–161.

14. Geerlings SE, Stolk RP, Camps MJ, et al. Consequences of asymptomatic bacteriuria in women with diabetes mellitus. Arch Intern Med. 2001;161(11):1421–1427.

15. Semetkowska-Jurkiewicz E, Horoszek-Maziarz S, Galiński J, et al. The clinical course of untreated asymptomatic bacteriuria in diabetic patients—14-year follow-up. Mater Med Pol. 1995;27(3):91–95.

16. Harding GK, Zhanel GG, Nicolle LE, et al. Antimicrobial treatment in diabetic women with asymptomatic bacteriuria. N Engl J Med. 2002;347(20):1576–1583.

17. Goetz LL, Cardenas DD, Kennelly M, et al. International spinal cord injury urinary tract infection basic data set. Spinal Cord. 2013;51(9):700–704.

18. Massa LM, Hoffman JM, Cardenas DD. Validity, accuracy, and predictive value of urinary tract infection signs and symptoms in individuals with spinal cord injury on intermittent catheterization. J Spinal Cord Med. 2009;32(5):568–573.

19. Nicolle LE, Bradley S, Colgan R, et al.; Infectious Diseases Society of America; American Society of Nephrology; American Geriatrics Society. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults [published correction appears in Clin Infect Dis. 2005;40(10):1556]. Clin Infect Dis. 2005;40(5):643–654.

20. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med. 2000;160(5):678–682.

21. Grabe M, Forsgren A, Hellsten S. The effect of a short antibiotic course in transurethral prostatic resection. Scand J Urol Nephrol. 1984;18(1):37–42.

22. Grabe M, Forsgren A, Björk T, et al. Controlled trial of a short and a prolonged course with ciprofloxacin in patients undergoing transurethral prostatic surgery. Eur J Clin Microbiol. 1987;6(1):11–17.

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