Should an asymptomatic patient with a positive Urinalysis (UA) result be treated before elective surgery?

From the Guidelines

Asymptomatic patients with a positive Urinalysis (UA) result should be treated before elective surgery only if they are undergoing urologic procedures associated with mucosal trauma, as this reduces the risk of postoperative sepsis. According to the 2019 clinical practice guideline for the management of asymptomatic bacteriuria by the Infectious Diseases Society of America 1, screening for and treating asymptomatic bacteriuria (ASB) prior to surgery is recommended for patients undergoing endoscopic urologic procedures associated with mucosal trauma. This recommendation is based on moderate-quality evidence and places a high value on the avoidance of serious postoperative complications.

For patients undergoing urologic procedures, a urine culture should be obtained prior to the procedure, and targeted antimicrobial therapy should be prescribed rather than empiric therapy, as suggested by the same guideline 1. A short course of antimicrobial therapy, typically 1 or 2 doses, is also recommended for patients with ASB who will undergo a urologic procedure, with treatment initiated 30-60 minutes before the procedure.

However, for most asymptomatic bacteriuria cases, preoperative antibiotic treatment is unnecessary and may contribute to antimicrobial resistance, as noted in the best practice statement on urologic procedures and antimicrobial prophylaxis 1. Elective procedures should be deferred in the presence of symptoms consistent with an active infection until an antimicrobial course is complete and associated symptoms have improved.

Key considerations for treatment include:

• The type of surgical procedure, with urologic procedures involving mucosal trauma requiring treatment
• The presence of specific risk factors, such as pregnancy, neutropenia, or immunosuppressive therapy
• The results of urine culture and sensitivity tests, which should guide the selection of antibiotics
• The potential risks and benefits of antibiotic treatment, including the risk of antimicrobial resistance and adverse effects.

In general, asymptomatic bacteriuria represents colonization rather than infection, and unnecessary antibiotics increase the risk of adverse effects and resistant organisms. Therefore, treatment should be selective and based on individual patient risk factors and the type of surgical procedure.

From the Research

Asymptomatic Bacteriuria in Elective Surgery

• The presence of asymptomatic bacteriuria, as indicated by a positive Urinalysis (UA) result with WBC, nitrites, and leukocytes, poses a consideration for treatment before elective surgery.
• However, the decision to treat asymptomatic bacteriuria is not straightforward and depends on various factors, including the type of surgery, patient's overall health, and risk of complications.

Treatment Considerations

• Studies have shown that asymptomatic bacteriuria can be effectively treated with antibiotics, but the risk of recurrence and resistance is a concern 2, 3.
• A study comparing amoxicillin-clavulanate and ciprofloxacin for the treatment of uncomplicated cystitis found that ciprofloxacin was more effective, but the use of fluoroquinolones should be discouraged due to increasing resistance rates 3, 4.
• Single-dose trimethoprim-sulfamethoxazole has been shown to be effective in treating lower urinary tract infections, with cure rates similar to those of 10-day treatment regimens 5, 6.

Elective Surgery and Asymptomatic Bacteriuria

• There is limited evidence to suggest that asymptomatic bacteriuria poses a significant risk for complications during elective surgery.
• However, some studies suggest that treating asymptomatic bacteriuria before surgery may reduce the risk of post-operative urinary tract infections 2.
• The decision to treat asymptomatic bacteriuria before elective surgery should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.

Recommendations

• Further research is needed to determine the optimal approach to managing asymptomatic bacteriuria in patients undergoing elective surgery.
• In the absence of clear guidelines, clinicians should consider the individual patient's risk factors, medical history, and the type of surgery when deciding whether to treat asymptomatic bacteriuria 2, 3, 4, 5, 6.