When to Treat Asymptomatic Bacteriuria
Asymptomatic bacteriuria should only be treated in pregnant women, patients undergoing urologic procedures with mucosal bleeding, and may be considered in women with catheter-acquired bacteriuria that persists 48 hours after catheter removal. 1
Definition and Diagnosis
- Asymptomatic bacteriuria is defined as isolation of bacteria in an appropriately collected urine specimen from a person without symptoms or signs of urinary infection 1
- For asymptomatic women, bacteriuria is defined as 2 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 urine specimen with 1 bacterial species isolated in a quantitative count ≥10^5 CFU/mL identifies bacteriuria 1
- A single catheterized urine specimen with 1 bacterial species isolated in a quantitative count ≥10^2 CFU/mL identifies bacteriuria in women or men 1
Populations Where Treatment IS Recommended
Pregnant Women
- Pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy and treated if results are positive 1
- Treatment duration should be 3-7 days 1
- Periodic screening for recurrent bacteriuria should be undertaken following therapy 1
Before Urologic Procedures
- Screen for and treat asymptomatic bacteriuria before transurethral resection of the prostate 1
- Antimicrobial therapy should be initiated shortly before the procedure and not continued after unless an indwelling catheter remains in place 1
- Screen for and treat asymptomatic bacteriuria before other urologic procedures where mucosal bleeding is anticipated 1
Post-Catheterization
- Antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria that persists 48 hours after indwelling catheter removal may be considered 1
Populations Where Treatment IS NOT Recommended
- Premenopausal, nonpregnant women 1, 2
- Diabetic women 1
- Older persons living in the community 1
- Elderly, institutionalized subjects 1, 3
- Persons with spinal cord injury 1
- Catheterized patients while the catheter remains in situ 1
- Patients with well-regulated diabetes mellitus 1
- Postmenopausal women 1
- Patients with dysfunctional and/or reconstructed lower urinary tract 1
- Patients with renal transplants 1
- Patients before arthroplasty surgery 1, 4
- Patients with recurrent urinary tract infections 1
- Patients before cardiovascular surgeries 1
Important Considerations
- Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment 1, 5
- Treatment of asymptomatic bacteriuria in non-indicated populations may lead to adverse outcomes including 2, 4:
Common Pitfalls to Avoid
- Treating bacteriuria based solely on laboratory findings without clinical symptoms 5
- Failing to recognize that pyuria without bacteriuria may indicate non-infectious conditions 5
- Inappropriate antimicrobial treatment of asymptomatic bacteriuria has been identified as a major issue for antimicrobial stewardship programs 4
- Treating asymptomatic bacteriuria in patients with indwelling catheters, which provides no benefit and increases resistance 2
Diagnostic Algorithm
- Determine if patient has urinary symptoms (if yes, not asymptomatic bacteriuria)
- Confirm bacteriuria with appropriate urine cultures based on gender:
- Women: Two consecutive specimens with same organism ≥10^5 CFU/mL
- Men: Single specimen with ≥10^5 CFU/mL
- Assess if patient belongs to a population where treatment is indicated:
- Pregnant women
- Pre-urologic procedure with anticipated mucosal bleeding
- Women within 48 hours after catheter removal with persistent bacteriuria
- If not in these specific populations, treatment is not recommended regardless of other conditions (diabetes, age, institutionalization, etc.)