How should asymptomatic bacteriuria (presence of bacteria in urine without symptoms) be treated?

Management of Asymptomatic Bacteriuria

Asymptomatic bacteriuria should NOT be treated in most patient populations except for pregnant women and patients undergoing urologic procedures with anticipated mucosal bleeding. 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, diagnosis requires 2 consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts ≥10^5 CFU/mL 2
• For men, a single clean-catch voided urine specimen with 1 bacterial species isolated in a quantitative count ≥10^5 CFU/mL identifies bacteriuria 2
• A single catheterized urine specimen with 1 bacterial species isolated in a quantitative count ≥10^2 CFU/mL identifies bacteriuria in women or men 2

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 for pregnant women should be 3-7 days 2
• Periodic screening for recurrent bacteriuria should be undertaken following therapy in pregnant women 2
• Treatment in pregnancy decreases risk of symptomatic UTI, low birthweight, and preterm delivery 3

Urologic Procedures

• Patients undergoing transurethral resection of the prostate should be screened and treated for bacteriuria 2
• Patients undergoing other urologic procedures with anticipated mucosal bleeding should be screened and treated 2
• Antimicrobial therapy should be initiated shortly before the procedure and not continued after unless an indwelling catheter remains in place 1

Post-Catheter Removal

• Antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria that persists 48 hours after indwelling catheter removal may be considered 2

Populations Where Treatment IS NOT Recommended

Pyuria accompanying asymptomatic bacteriuria is NOT an indication for antimicrobial treatment 4

Treatment is NOT recommended for the following populations:

• Premenopausal, nonpregnant women 1
• Diabetic women 1
• Older persons living in the community 1
• Elderly, institutionalized individuals 2
• Persons with spinal cord injury 2
• Catheterized patients while the catheter remains in situ 2

Rationale for Non-Treatment

• In most scenarios, asymptomatic bacteriuria does not lead to urinary tract infections 5
• Treatment of asymptomatic bacteriuria has not been shown to improve patient outcomes in non-indicated populations 5
• Unnecessary treatment is associated with adverse consequences including:
  • Increased antimicrobial resistance 5
  • Clostridioides difficile infection 5
  • Increased healthcare costs 5
  • Short-term increased frequency of symptomatic infection post-treatment 6

Common Pitfalls to Avoid

• Treating bacteriuria based solely on laboratory findings without clinical symptoms 4
• Failing to recognize that pyuria without bacteriuria may indicate non-infectious conditions 4
• Treating asymptomatic bacteriuria in patients with indwelling catheters 2
• Treating elderly patients with asymptomatic bacteriuria due to misinterpretation of nonspecific symptoms as UTI 1

Clinical Decision Algorithm

1. Confirm true asymptomatic bacteriuria with appropriate urine culture technique 2
2. Determine if patient belongs to a population where treatment is indicated:
   • Pregnant women → Treat for 3-7 days 2
   • Pre-urologic procedure with mucosal bleeding → Treat shortly before procedure 2
   • Post-catheter removal with persistent bacteriuria in women → Consider treatment 2
3. For all other populations → Do NOT treat 1
4. If pyuria is present without symptoms, this alone is NOT an indication for treatment 4