Do you treat asymptomatic bacteriuria with antibiotics?

Management of Asymptomatic Bacteriuria

Asymptomatic bacteriuria should NOT be treated with antibiotics in most patient populations, with the exception of pregnant women and patients undergoing urologic procedures with risk of mucosal bleeding. 1

Patient Populations Where Treatment IS Recommended

Pregnant Women

• Screen all pregnant women in the first trimester for asymptomatic bacteriuria 2, 1
• Treatment significantly reduces:
  • Risk of pyelonephritis (from 20-35% to 1-4%) 2
  • Incidence of low birth weight 2
  • Preterm delivery 2
• Screening method: Urine culture (gold standard) 2, 1
  • Positive result: ≥10^5 CFU/mL of a single uropathogen in a midstream clean-catch specimen 2

Patients Undergoing Urologic Procedures

• Screen and treat before procedures with risk of mucosal bleeding 1
• Particularly important before transurethral resection of the prostate 1, 3
• Treatment reduces risk of post-operative UTI 3

Patient Populations Where Treatment is NOT Recommended

Non-pregnant Adults

• Do not screen or treat asymptomatic bacteriuria in:
  • Non-pregnant women 2, 1
  • Men 2, 1
  • Diabetic patients 1, 4
  • Community-dwelling older adults 1
  • Institutionalized elderly 3
  • Patients with renal transplants 3
  • Patients prior to joint replacement/orthopedic surgery 3, 5
  • Patients with spinal cord injury/neurogenic bladder 2, 1
  • Patients with indwelling catheters 1, 4

Patients with Recurrent UTIs

• Treatment of asymptomatic bacteriuria is actually harmful in patients with recurrent UTIs 3
• May increase risk of symptomatic infection with resistant organisms 5

Rationale for Not Treating Asymptomatic Bacteriuria

1. Lack of clinical benefit:

   • No evidence of improved outcomes in most populations 3, 5
   • Natural course of asymptomatic bacteriuria is generally benign 5

2. Potential harms of treatment:

   • Adverse effects from antibiotics 2
   • Development of antimicrobial resistance 2, 4
   • Risk of Clostridioides difficile infection 4
   • Increased healthcare costs 4
   • Recurrence of bacteriuria with more resistant strains 2

3. Antibiotic stewardship:

   • Inappropriate treatment of asymptomatic bacteriuria is a major target for antimicrobial stewardship programs 5, 4
   • AUA/SUFU guidelines specifically recommend against treating asymptomatic bacteriuria in patients with neurogenic lower urinary tract dysfunction 2

Diagnostic Criteria for Asymptomatic Bacteriuria

• Women: Two consecutive voided specimens with ≥10^5 CFU/mL of the same bacterial strain 1
• Men: Single clean-catch specimen with ≥10^5 CFU/mL of one bacterial species 1
• Catheterized specimens: ≥10^2 CFU/mL 1

Common Pitfalls to Avoid

1. Treating based on positive urinalysis or dipstick alone:

   • Urine culture is the gold standard for diagnosis 1
   • Pyuria alone is not an indication for treatment 1

2. Treating elderly patients with nonspecific symptoms:

   • Confusion, falls, or functional decline alone are not indications for treatment

3. Treating catheterized patients routinely:

   • Long-term catheterized patients should not receive treatment for asymptomatic bacteriuria 6

4. Failing to distinguish between asymptomatic bacteriuria and UTI:

   • UTI requires both bacteriuria AND symptoms (dysuria, frequency, urgency, suprapubic pain) 1

Remember that the prevalence of asymptomatic bacteriuria increases with age (>15% in older women, up to 50% in long-term care facilities) 4, making inappropriate treatment a significant concern for antimicrobial stewardship.