Treatment of Asymptomatic Bacteriuria in Elderly Males
Screening for or treatment of asymptomatic bacteriuria is not recommended for elderly males. 1
Definition and Diagnosis
- Asymptomatic bacteriuria (ASB) is defined as the presence of bacteria in the urine without local genitourinary symptoms or other systemic signs of infection 1
- In men, bacteriuria is defined as a single, clean-catch voided urine specimen with one bacterial species isolated in a quantitative count ≥10^5 cfu/mL 1
- The presence of pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment 1, 2
Evidence-Based Recommendations for Elderly Males
- The Infectious Diseases Society of America (IDSA) strongly recommends against screening for or treating asymptomatic bacteriuria in older persons living in the community (strong recommendation, low-quality evidence) 1
- IDSA also strongly recommends against screening for or treating asymptomatic bacteriuria in elderly, institutionalized subjects (strong recommendation, moderate-quality evidence) 1
- Treatment of ASB in elderly males likely does not reduce the risk of death or sepsis, but increases the risk of adverse effects including Clostridioides difficile infection and antimicrobial resistance 1
- Prospective studies of ambulatory elderly men have shown that asymptomatic bacteriuria often resolves spontaneously without treatment, and no consistent pattern of bacteriuria is evident 3
Special Considerations
- In older patients with functional and/or cognitive impairment with bacteriuria and delirium (acute mental status change, confusion) without local genitourinary symptoms or other systemic signs of infection, assessment for other causes and careful observation rather than antimicrobial treatment is recommended 1
- In older patients with bacteriuria who experience a fall without local genitourinary symptoms or other systemic signs of infection, assessment for other causes and careful observation rather than antimicrobial treatment is recommended 1
- For elderly males with bacteriuria and fever or other systemic signs potentially consistent with severe infection (sepsis) without a localizing source, broad-spectrum antimicrobial therapy directed against urinary and non-urinary sources should be initiated 1
Exceptions Where Treatment is Recommended
- Screening for and treatment of asymptomatic bacteriuria is recommended before transurethral resection of the prostate 1
- Screening for and treatment of asymptomatic bacteriuria is recommended before other urologic procedures for which mucosal bleeding is anticipated 1
- For urologic procedures, antimicrobial therapy should be initiated shortly before the procedure and should not be continued after the procedure unless an indwelling catheter remains in place 1
Common Pitfalls to Avoid
- Treating bacteriuria based solely on laboratory findings without clinical symptoms 2, 4
- Failing to recognize that pyuria without bacteriuria may indicate non-infectious conditions 2
- Overtreatment of asymptomatic bacteriuria in long-term care facilities, which contributes to antimicrobial resistance 4, 5
- Misinterpreting non-specific symptoms (such as confusion or falls) as signs of urinary tract infection in elderly patients with bacteriuria 1, 6
Implementation Strategies
- Develop clinical pathways to help healthcare providers better assess, manage, and monitor residents with suspected UTIs 5
- Prevent unnecessary urine testing in patients with non-urinary tract symptoms 6
- Avoid catheterization in stable patients who cannot provide a urine specimen on demand 6
- Withhold antibiotics in stable non-febrile elderly patients who do not have new local urinary tract symptoms 6