What are the implications of asymptomatic Urinary Tract Infection (UTI)?

From the Guidelines

Asymptomatic urinary tract infections (UTIs) should not be treated with antibiotics in most cases, as the risks of treatment outweigh the benefits, according to the strongest and most recent evidence. This is because asymptomatic bacteriuria (ASB) is generally considered a colonization rather than a true infection requiring intervention 1. The Infectious Diseases Society of America recommends against treating ASB due to the lack of benefit and the potential harm caused by antibiotics, including adverse effects, increased costs, and contribution to antimicrobial resistance 1.

Key Considerations

• ASB is uncommon in infants and boys, and occurs in about 1%–3% of healthy girls 1
• There is no evidence that treatment of ASB prevents symptomatic UTI, including pyelonephritis, renal scarring, or renal insufficiency 1
• The American Urological Association also recommends against treating ASB in patients, except for pregnant women and those undergoing invasive urinary tract procedures 1
• Clinicians should omit surveillance urine testing, including urine culture, in asymptomatic patients with recurrent UTIs 1

Exceptions and Special Considerations

• Pregnant women should be treated for ASB to prevent complications, with a 3-7 day course of antibiotics like nitrofurantoin, amoxicillin-clavulanate, or cephalexin typically recommended
• Treatment may also be considered before urologic procedures to prevent infection spread
• Patients with certain underlying medical conditions, such as diabetes mellitus, or those residing in long-term care facilities, do not require additional evaluation or antimicrobial treatment for ASB 1

From the Research

Asymptomatic UTI

• Asymptomatic urinary tract infections (UTIs) are not typically treated with antimicrobial therapy 2, 3
• Antimicrobial therapy is usually indicated for amelioration of symptoms, and asymptomatic infection is not usually a concern for treatment 2
• However, there are special considerations in the management of UTI among selected populations, including postmenopausal and pregnant women, and for women with frequent recurrent UTIs 2
• The management of asymptomatic UTIs is focused on preventing complications and avoiding the development of antimicrobial resistance 3

Treatment Options

• First-line treatment options for symptomatic UTIs include nitrofurantoin, fosfomycin, trimethoprim, and trimethoprim/sulfamethoxazole 4, 2, 5
• Alternative treatment options include fluoroquinolones, oral cephalosporins, and β-lactams 4, 2
• Treatment options for UTIs due to extended-spectrum β-lactamases (ESBLs)-producing Enterobacteriales and carbapenem-resistant Enterobacteriales (CRE) include carbapenems, ceftazidime-avibactam, and fosfomycin 4

Diagnosis and Management

• Urine culture and susceptibility testing should be reserved for patients with recurrent infection, treatment failure, history of resistant isolates, or atypical presentation 5
• Symptomatic treatment with nonsteroidal anti-inflammatory drugs and delayed antibiotics may be considered for patients with uncomplicated UTIs 5
• Increased fluids, intake of cranberry products, and methenamine hippurate can prevent recurrent infections 5
• Antibiotic prophylaxis is also effective in preventing recurrence but has a risk of adverse effects and antimicrobial resistance 5