How is asymptomatic bacteriuria (presence of bacteria in urine without symptoms) typically managed?

Management of Asymptomatic Bacteriuria

Asymptomatic bacteriuria should generally NOT be treated except in pregnant women and patients undergoing urologic procedures with mucosal bleeding. 1

Definition and Diagnosis

Asymptomatic bacteriuria (ASB) is defined as:

• The presence of bacteria in urine without symptoms attributable to urinary tract infection 1
• For women: Two consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts ≥10^5 CFU/mL 1
• For men: A single clean-catch voided specimen with one bacterial species isolated in a quantitative count ≥10^5 CFU/mL 1
• For catheterized specimens: A single specimen with one bacterial species isolated in a quantitative count ≥10^2 CFU/mL 1

Prevalence

Prevalence varies significantly across different populations:

• Healthy premenopausal women: 1.0-5.0% 1
• Pregnant women: 1.9-9.5% 1
• Postmenopausal women aged 50-70 years: 2.8-8.6% 1
• Diabetic women: 9.0-27% 1
• Diabetic men: 0.7-11% 1
• Community-dwelling elderly women: 10.8-16% 1
• Community-dwelling elderly men: 3.6-19% 1
• Long-term care facility residents: 25-50% (women) and 15-40% (men) 1
• Patients with spinal cord injuries: 23-89% 1
• Patients with long-term indwelling catheters: 100% 1

Management Recommendations

DO NOT Screen or Treat ASB in:

• Premenopausal, non-pregnant women 1
• Diabetic patients 1
• Older persons living in the community 1
• Elderly institutionalized patients 1
• Persons with spinal cord injury 1
• Patients with indwelling catheters while the catheter remains in place 1
• Patients with renal transplants 1
• Patients before arthroplasty surgery 1, 2
• Patients before cardiovascular surgeries 1
• Patients with recurrent urinary tract infections 1, 2

DO Screen and Treat ASB in:

1. Pregnant women 1

   • Screen with urine culture at least once in early pregnancy 1
   • Treat if results are positive 1
   • Duration of antimicrobial therapy: 3-7 days 1
   • Periodic screening for recurrent bacteriuria should follow therapy 1
   • Treatment reduces risk of pyelonephritis, preterm birth, and low birth weight 1, 2

2. Patients undergoing urologic procedures with mucosal bleeding 1

   • Screen before transurethral resection of the prostate 1
   • Screen before other urologic procedures where mucosal bleeding is anticipated 1
   • Obtain assessment for bacteriuria before the procedure 1
   • Initiate antimicrobial therapy shortly before the procedure 1
   • Do not continue antimicrobial therapy after the procedure unless an indwelling catheter remains in place 1

Important Clinical Considerations

• Pyuria accompanying asymptomatic bacteriuria is NOT an indication for antimicrobial treatment 1

• Treatment of ASB in most populations does not reduce morbidity or mortality and may lead to adverse outcomes 2, 3

• Adverse consequences of unnecessary treatment include:

  • Increased antimicrobial resistance 3
  • Clostridioides difficile infection 3
  • Increased healthcare costs 3
  • Adverse drug effects 4
  • Potential elimination of protective bacterial strains 1

• In older patients with functional or cognitive impairment who have bacteriuria and delirium or falls, assess for other causes rather than treating the bacteriuria 1

Common Pitfalls to Avoid

• Treating ASB based solely on the presence of pyuria 1
• Treating ASB in catheterized patients while the catheter remains in place 1
• Confusing nonspecific symptoms (e.g., delirium, falls) in elderly patients with symptomatic UTI 1
• Screening populations where treatment has not been shown to be beneficial 5, 3
• Failing to distinguish between ASB and symptomatic UTI in populations with high prevalence of bacteriuria 1

By following these evidence-based guidelines, clinicians can avoid unnecessary antimicrobial use while ensuring appropriate treatment for populations that benefit from ASB management 3.