Do you treat asymptomatic Extended-Spectrum Beta-Lactamase (ESBL) bacteriuria?

Management of Asymptomatic ESBL Bacteriuria

Asymptomatic ESBL bacteriuria should not be treated with antimicrobials in most patient populations, as treatment provides no clinical benefit and increases the risk of antimicrobial resistance. 1

General Recommendation

The Infectious Diseases Society of America (IDSA) provides clear guidance on this issue in their 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria. The guidelines strongly recommend against screening for or treating asymptomatic bacteriuria in most patient populations, regardless of the organism involved (including ESBL-producing organisms).

Patient Populations Where Treatment is NOT Recommended:

• Healthy non-pregnant women (premenopausal or postmenopausal) 1
• Patients with diabetes 1
• Elderly persons living in the community or long-term care facilities 1
• Patients with spinal cord injury 1
• Patients with indwelling catheters (short-term <30 days or long-term) 1
• Patients undergoing elective non-urologic surgery 1
• Patients with renal transplant >1 month post-transplantation 1
• Patients with non-renal solid organ transplants 1
• Patients with implanted urologic devices 1

Exceptions Where Screening and Treatment ARE Recommended:

1. Pregnant women - All pregnant women should be screened for bacteriuria in early pregnancy and treated if positive, including ESBL-producing organisms 1, 2

2. Patients undergoing invasive urologic procedures with mucosal trauma - Screen and treat prior to procedure 1

   • For these patients, obtain a urine culture prior to the procedure
   • Provide targeted antimicrobial therapy based on susceptibility results
   • Short-course therapy (1-2 doses) is suggested rather than prolonged treatment
   • Initiate antimicrobials 30-60 minutes before the procedure

Rationale for Non-Treatment

1. Lack of benefit: Multiple studies show no improvement in clinical outcomes with treatment of asymptomatic bacteriuria 3, 4, 5

2. Potential harms:

   • Increased risk of antimicrobial resistance 3, 6
   • Adverse drug effects 4
   • Increased costs 5
   • Possible increased risk of symptomatic UTI after treatment 6
   • Selection of multidrug-resistant bacteria 6

3. Protective effect: Some evidence suggests asymptomatic bacteriuria may even play a protective role in preventing symptomatic episodes in certain populations, particularly women with recurrent UTIs 6

Special Considerations for ESBL-Producing Organisms

While the guidelines don't specifically address ESBL-producing organisms in asymptomatic bacteriuria, the same principles apply. In fact, there are additional reasons to avoid unnecessary treatment of ESBL bacteriuria:

• ESBL-producing organisms are already resistant to multiple antibiotics
• Treatment options are often limited to carbapenems or other broad-spectrum agents
• Unnecessary use of these agents contributes to further antimicrobial resistance
• The clinical significance of ESBL bacteriuria is no different from other organisms in asymptomatic patients

Common Pitfalls to Avoid

1. Treating based on culture results alone - The presence of bacteria in urine without symptoms is not an indication for treatment in most populations

2. Misinterpreting non-specific symptoms - In elderly patients with cognitive impairment, delirium or falls should prompt assessment for other causes rather than automatic treatment of bacteriuria 1

3. Treating catheter-associated bacteriuria - Nearly all patients with long-term catheters will develop bacteriuria, which should not be treated unless symptomatic 1

4. Treating prior to catheter removal - Evidence does not support routine treatment of asymptomatic bacteriuria at the time of catheter removal 1

5. Treating based on pyuria - The presence of pyuria with bacteriuria does not indicate need for antimicrobial treatment in the absence of symptoms

In conclusion, asymptomatic ESBL bacteriuria should only be treated in pregnant women and before invasive urologic procedures with anticipated mucosal bleeding. In all other patient populations, treatment should be avoided to prevent antimicrobial resistance and other adverse outcomes.