From the Guidelines
Asymptomatic bacteriuria discovered during preoperative examination should be treated only in patients undergoing endoscopic urologic procedures associated with mucosal trauma, as recommended by the Infectious Diseases Society of America 1. This recommendation is based on moderate-quality evidence and prioritizes the avoidance of serious postoperative complications such as sepsis.
Key Considerations
- For patients undergoing endoscopic urologic procedures, a urine culture should be obtained prior to the procedure and targeted antimicrobial therapy prescribed rather than empiric therapy, as suggested by 1.
- A short course (1 or 2 doses) of antimicrobial therapy is recommended rather than more prolonged therapy for patients with asymptomatic bacteriuria undergoing urologic procedures 1.
- Antimicrobial therapy should be initiated 30–60 minutes before the procedure, as noted in 1.
Rationale
The rationale behind these recommendations is that asymptomatic bacteriuria represents colonization rather than infection in most patients, and the bacteria present typically have low virulence and do not pose a significant risk during most surgical procedures. However, in the context of endoscopic urologic procedures with mucosal trauma, the risk of postoperative complications such as sepsis is substantial, and therefore, treatment is recommended 1. Unnecessary antibiotic treatment can lead to adverse effects, increased healthcare costs, and antimicrobial resistance.
Clinical Implications
In clinical practice, it is essential to weigh the benefits and risks of treating asymptomatic bacteriuria in the preoperative setting. For most surgical populations, including orthopedic implant surgery, routine screening and treatment of asymptomatic bacteriuria are not recommended, as they do not reduce surgical site infections or other postoperative complications 1. However, for patients undergoing endoscopic urologic procedures with mucosal trauma, targeted antimicrobial therapy based on culture and sensitivity results should be administered prior to the procedure to minimize the risk of postoperative complications.
From the Research
Evidence-Based Recommendations
The following are evidence-based recommendations regarding asymptomatic bacteriuria discovered in preoperative exams:
- Asymptomatic bacteriuria (ASB) does not predict infective complications, including urosepsis, in patients undergoing holmium laser enucleation of the prostate (HoLEP) 2.
- The preoperative presence of ASB is not associated with a higher incidence of postoperative symptomatic urinary tract infections (UTIs) in patients undergoing urologic surgical procedures who receive antimicrobial prophylaxis in accordance with European Association of Urology guidelines 3.
- Treating ASB before cardiothoracic surgery does not reduce the risk of postoperative infections, and the risk of haematogenous spread of bacteria from the urinary tract seems to be non-existent in patients not treated with antibiotics preoperatively 4.
- Specific patient populations, such as neonates, preschool children, pregnant women, and nonelderly men, should be treated for ASB, while others, including school-age children, nonpregnant nonelderly women, and elderly men and women with normal urinary tracts, do not require antimicrobial treatment 5.
- Asymptomatic bacteriuria is not associated with surgical site infection (SSI) in patients undergoing cardiovascular surgery, and screening with urinalysis or urine culture is not recommended for these patients 6.
Patient Populations
The following patient populations have specific recommendations:
- Neonates and preschool children: should be treated for ASB 5.
- Pregnant women: should be treated for ASB 5.
- Nonelderly men: should be treated for ASB 5.
- School-age children, nonpregnant nonelderly women, and elderly men and women with normal urinary tracts: do not require antimicrobial treatment for ASB 5.
- Patients undergoing cardiothoracic surgery: do not require treatment for ASB 4.
- Patients undergoing cardiovascular surgery: do not require screening for ASB 6.
Surgical Procedures
The following surgical procedures have specific recommendations:
- Holmium laser enucleation of the prostate (HoLEP): ASB does not predict infective complications 2.
- Urologic surgical procedures: preoperative presence of ASB is not associated with a higher incidence of postoperative symptomatic UTIs 3.
- Cardiothoracic surgery: treating ASB does not reduce the risk of postoperative infections 4.
- Cardiovascular surgery: ASB is not associated with SSI 6.