Should a 62-year-old patient with Chronic Kidney Disease (CKD) and an asymptomatic urinary tract infection be treated?

Management of Asymptomatic Bacteriuria in a 62-Year-Old Patient with CKD

Asymptomatic bacteriuria in a 62-year-old patient with chronic kidney disease should not be treated with antibiotics. 1

Rationale for Not Treating Asymptomatic Bacteriuria in CKD

Definition and Clinical Context

• Asymptomatic bacteriuria is defined as isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen obtained from a person without symptoms or signs referable to urinary infection 1
• In patients with CKD, asymptomatic bacteriuria is common but does not require antimicrobial treatment 1

Evidence-Based Recommendations

• The 2019 Infectious Diseases Society of America (IDSA) guidelines strongly recommend against screening for or treating asymptomatic bacteriuria in older, community-dwelling persons who are functionally impaired 1
• The American Urological Association (AUA) and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) guidelines specifically state that clinicians should not treat asymptomatic bacteriuria in patients with neurogenic lower urinary tract dysfunction 1
• The IDSA 2005 guidelines specifically recommend against screening for or treatment of asymptomatic bacteriuria in elderly institutionalized residents of long-term care facilities 1

Potential Harms of Treating Asymptomatic Bacteriuria

Antimicrobial Resistance

• Treatment of asymptomatic bacteriuria leads to early recurrence of bacteriuria with more resistant bacterial strains 1
• CKD patients are already at increased risk for antimicrobial resistance in urinary pathogens 2
• Studies show higher levels of antibiotic resistance among urinary isolates in CKD patients, particularly to beta-lactam antibiotics 3

Adverse Effects of Antibiotics

• Treatment can lead to adverse drug effects, including Clostridioides difficile infection 1
• The elderly population is particularly vulnerable to adverse effects of antimicrobial therapy 1

Special Considerations in CKD Patients

Monitoring Approach

• Routine surveillance urine cultures in asymptomatic patients with CKD are not recommended 1
• Urinalysis and urine cultures should be obtained only when symptoms suggestive of UTI are present 1

When Treatment IS Indicated

• Treatment is indicated only for symptomatic UTI with signs such as fever, dysuria, gross hematuria, new or worsening urinary incontinence, or suspected bacteremia 1
• In patients with suspected urosepsis (high fever, shaking chills, hypotension), urine and blood cultures should be obtained before initiating antibiotics 1

Exceptions to the Recommendation

• Treatment of asymptomatic bacteriuria is recommended in:
  • Pregnant women 1
  • Prior to urologic procedures where mucosal bleeding is anticipated 1

Conclusion

Asymptomatic bacteriuria in a 62-year-old patient with CKD should not be treated with antibiotics as per current guidelines. Treatment would likely lead to selection of resistant organisms and adverse drug effects without providing clinical benefit. Focus should be on monitoring for development of symptomatic infection and treating only when clinically indicated.