What are the indications for treating asymptomatic urinary tract infections (UTIs)?

Indications for Treating Asymptomatic UTI

Asymptomatic bacteriuria should only be treated in pregnant women and patients undergoing urological procedures that breach the mucosa. 1

Definition of Asymptomatic Bacteriuria (ASB)

• ASB is defined as bacterial growth >10^5 CFU/mL in two consecutive urine samples in women or a single sample in men, without any urinary tract symptoms 1
• ASB represents commensal colonization rather than infection and may actually provide protection against symptomatic UTIs 1, 2

Recommended Indications for Treatment

Pregnancy

• Screen for and treat ASB in pregnant women, preferably in the first trimester 1, 3
• Treatment reduces the risk of pyelonephritis during pregnancy 3
• Use standard short-course treatment (4-7 days) or single-dose fosfomycin trometamol 1
• Note: A recent Dutch study suggests non-treatment may be acceptable for selected low-risk pregnant women, but further evaluation is needed 1

Urological Procedures

• Screen for and treat ASB before urological procedures that breach the mucosa 1
• Treatment reduces the risk of infectious complications following these invasive procedures 1

Populations Where ASB Should NOT Be Treated

The following populations should NOT be screened for or treated for ASB:

• Women without risk factors 1
• Patients with well-regulated diabetes mellitus 1
• Postmenopausal women 1
• Elderly institutionalized patients 1
• Patients with dysfunctional and/or reconstructed lower urinary tract 1
• Patients with renal transplant (>1 month post-transplant) 1
• Patients with non-renal solid organ transplant 1
• Patients before arthroplasty surgery 1
• Patients with recurrent UTIs 1
• Older patients with functional/cognitive impairment who experience delirium or falls 1

Special Considerations

Cardiovascular Surgery

• Do not screen or treat ASB in patients before cardiovascular surgeries (weak recommendation) 1

Renal Transplant Recipients

• No screening or treatment is recommended for patients >1 month post-transplant 1
• Insufficient evidence exists regarding management within the first month following transplantation 1

Neutropenia

• No specific recommendation for or against screening/treatment in high-risk neutropenia (absolute neutrophil count <100 cells/mm³, ≥7 days duration following chemotherapy) due to knowledge gap 1

Rationale for Not Treating ASB in Most Populations

• Treatment of ASB has not been shown to improve clinical outcomes in most populations 2
• Unnecessary antibiotic use leads to:
  • Increased antimicrobial resistance 2, 4
  • Risk of Clostridioides difficile infection 1, 2
  • Adverse drug effects 1, 2
  • Eradication of potentially protective bacterial strains 1, 4
  • Higher healthcare costs 2

Clinical Pearls and Pitfalls

• Never perform surveillance urine testing in asymptomatic patients with recurrent UTIs 1
• Do not confuse genitourinary symptoms in elderly women with UTI, as these symptoms may not be related to cystitis 1
• ASB is common in older adults (>15% in older women, up to 50% in long-term care facilities) and should not be treated 2
• In patients with symptoms, obtain urine culture before initiating antibiotics to guide therapy 1
• Treatment of ASB in patients with diabetes, spinal cord injuries, or indwelling catheters does not improve outcomes 2

By following these evidence-based guidelines for ASB management, clinicians can help reduce unnecessary antibiotic use while ensuring appropriate treatment for populations that truly benefit.