Am I safe if I have no symptoms of a urinary tract infection (UTI)?

Urinary Tract Infections: When No Symptoms Are Present

If you have no symptoms of a urinary tract infection (UTI), you do not need screening or treatment as asymptomatic bacteriuria generally does not require antibiotics. 1

Understanding Asymptomatic Bacteriuria

Asymptomatic bacteriuria (ASB) is defined as the presence of bacteria in the urine (≥105 colony-forming units/mL) without any signs or symptoms attributable to a UTI 1. This condition is common in certain populations but typically does not require treatment.

Who Should Not Be Screened or Treated for ASB:

• Older adults with functional or cognitive impairment who have no UTI symptoms 1
• Patients with diabetes 1
• Renal transplant recipients beyond one month post-transplant 1
• Most healthy adults without specific risk factors 1
• Infants and children 1

Recognizing True UTI Symptoms

It's important to understand the difference between having bacteria in your urine (bacteriuria) and having an actual infection that requires treatment. True UTI symptoms include:

• Dysuria (painful urination) 1, 2
• Urinary frequency 2, 3
• Urgency 2, 3
• Suprapubic pain 2
• Hematuria (blood in urine) 1
• New or worsening urinary incontinence 1

When to Seek Medical Attention:

• If you develop any of the symptoms listed above 1, 2
• If you have fever, shaking chills, or hypotension along with urinary symptoms (possible urosepsis) 1
• If you are pregnant and have urinary symptoms 3
• If you have a urinary catheter and develop fever or other systemic symptoms 1

Common Misconceptions

Non-specific Symptoms Are Often Misattributed to UTI:

• Changes in mental status or confusion in older adults are frequently not caused by UTIs, despite common belief 1
• Falls in older adults are often incorrectly attributed to UTIs 1
• Low-grade fever, increased confusion, incontinence, anorexia, or functional decline alone are not reliable indicators of UTI 1

Diagnostic Considerations

If you do develop symptoms and seek medical care, your healthcare provider may use the following to diagnose a UTI:

• Urinalysis for leukocyte esterase and nitrite level using a dipstick 1
• Microscopic examination for white blood cells (pyuria) 1
• Urine culture with antimicrobial susceptibility testing if pyuria or positive dipstick results are present 1

Important Caveats:

• Pyuria (white blood cells in urine) alone does not indicate infection and is common in older adults without infection 3
• A negative test for pyuria can generally exclude UTI 1
• Urine cultures should not be performed for asymptomatic individuals 1

Treatment Principles

• Antibiotics should only be given for symptomatic UTIs, not for asymptomatic bacteriuria 1
• Treating ASB increases risk of antibiotic-associated diarrhea, Clostridioides difficile infection, and antimicrobial resistance 1
• If symptoms develop, appropriate antibiotics may include nitrofurantoin, fosfomycin, or trimethoprim-sulfamethoxazole, depending on local resistance patterns 2, 3

Special Circumstances

Catheterized Patients:

• Asymptomatic bacteriuria is universal in patients with long-term indwelling catheters and should not be treated 1
• If symptoms develop in a catheterized patient, the catheter should be replaced before collecting specimens and starting antibiotics 1

Older Adults:

• The high prevalence of ASB in older adults (up to 50%) means urine cultures often show bacteria even without infection 1
• Non-specific symptoms like confusion or falls should not trigger antibiotic treatment for presumed UTI without specific urinary symptoms 1

In conclusion, if you have no symptoms of a UTI, you are generally safe and do not require screening or treatment for bacteria that may be present in your urine 1. Treatment of asymptomatic bacteriuria can lead to unnecessary antibiotic use and associated harms without providing benefit 1.