Does lactobacillus bacteriuria in urine need to be treated?

Management of Lactobacillus in Urine

Asymptomatic lactobacillus bacteriuria does not require treatment as it is not associated with adverse clinical outcomes and treating it may lead to antimicrobial resistance and other complications. 1

Understanding Lactobacillus in Urine

Lactobacillus species are part of the normal vaginal flora in women and are typically considered contaminants when isolated from urine specimens. When found in urine cultures without accompanying symptoms, this represents asymptomatic bacteriuria with Lactobacillus, which falls under the broader category of asymptomatic bacteriuria (ASB).

Evidence-Based Management Algorithm

For Asymptomatic Patients:

• No screening or treatment is recommended for asymptomatic bacteriuria, including Lactobacillus, in:
  • Premenopausal, non-pregnant women 1
  • Diabetic women 1
  • Older persons living in the community 1
  • Elderly, institutionalized subjects 1
  • Persons with spinal cord injury 1
  • Catheterized patients while the catheter remains in place 1

For Symptomatic Patients:

• Treatment is only indicated when Lactobacillus is causing symptomatic urinary tract infection, which is extremely rare 2
• Symptoms that would warrant treatment include:
  • Dysuria
  • Frequency
  • Urgency
  • Suprapubic pain
  • Fever and flank pain (in cases of upper UTI)

Special Circumstances

Pre-Urologic Procedures:

• If a patient with Lactobacillus bacteriuria requires urologic procedures with mucosal bleeding:
  • Antimicrobial treatment should be initiated shortly before the procedure 1
  • Treatment should not be continued after the procedure unless an indwelling catheter remains in place 1

Catheter-Related Considerations:

• For women with catheter-acquired Lactobacillus bacteriuria that persists 48 hours after catheter removal, treatment may be considered, though evidence is limited 1

Clinical Rationale

The Infectious Diseases Society of America (IDSA) guidelines strongly recommend against treating asymptomatic bacteriuria in most populations 1. This recommendation applies to all bacterial species, including Lactobacillus. The rationale includes:

1. Treatment does not reduce morbidity or mortality
2. Treatment increases the risk of antimicrobial resistance
3. Treatment may disrupt normal flora and predispose to infection with more pathogenic organisms
4. Treatment exposes patients to unnecessary medication side effects

Important Caveats and Pitfalls

• Do not mistake Lactobacillus in urine as always being a contaminant - while rare, symptomatic UTI caused by Lactobacillus has been documented 2, 3
• Do not screen for asymptomatic bacteriuria in populations where treatment is not indicated 1
• Pyuria (presence of WBCs in urine) accompanying asymptomatic bacteriuria is not an indication for treatment 1
• Lactobacillus may actually have a protective role against recurrent UTIs when used as a probiotic 4, 5, though evidence suggests it may be inferior to trimethoprim-sulfamethoxazole for UTI prevention 6

By following these evidence-based guidelines, clinicians can avoid unnecessary antibiotic use while ensuring appropriate treatment when truly indicated.