Why are asymptomatic urinary tract infections (UTIs) not typically treated in patients with Polycystic Kidney Disease (PKD)?

Why Asymptomatic UTIs Are Not Treated in ADPKD

Asymptomatic bacteriuria should not be treated in ADPKD patients because treatment provides no clinical benefit, promotes antibiotic resistance, and increases the risk of adverse drug effects—the same evidence-based approach used for the general population applies equally to ADPKD. 1

Core Rationale

The 2025 KDIGO ADPKD guidelines explicitly state that healthcare providers should not treat asymptomatic bacteriuria in ADPKD patients, aligning with recommendations from the American Urological Association, Canadian Urological Association, and Society of Urodynamics 1. This recommendation is based on several key principles:

Lack of Clinical Benefit

• Asymptomatic bacteriuria in ADPKD patients with normal kidney function occurs at similar rates (2%) as in healthy controls (4%), showing no increased predisposition 2
• Treatment of asymptomatic bacteriuria does not prevent symptomatic UTIs or slow kidney disease progression 3
• No evidence demonstrates that treating asymptomatic bacteriuria improves morbidity, mortality, or quality of life outcomes 3

Harms of Treatment

• Treating asymptomatic bacteriuria leads to early recurrence with more resistant bacterial strains, making future symptomatic infections harder to treat 3
• Antibiotic exposure increases risk of adverse drug effects, including Clostridioides difficile infection 3
• Given that ADPKD patients already show high rates of antibiotic resistance (94.67% to ampicillin, 89% to ceftriaxone), unnecessary antibiotic use further compounds this problem 4

When Treatment IS Indicated

Treatment should be reserved exclusively for symptomatic infections in ADPKD 1:

Symptomatic Lower UTI (Cystitis)

• Dysuria, frequency, urgency, or suprapubic pain 1
• First-line therapy: nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin (based on local resistance patterns) 1
• Duration: generally no longer than 7 days 1
• Always obtain urine culture before starting antibiotics 1

Suspected Upper UTI or Cyst Infection

• Fever, acute flank/abdominal pain, elevated WBC (>11 × 10⁹/L), or CRP ≥50 mg/L 1
• Obtain blood cultures if upper UTI or cyst infection suspected 1
• Critical distinction: Cyst infections may present with negative urine cultures in 40% of cases, requiring clinical diagnosis based on fever, pain, and inflammatory markers 5
• Treatment requires 4-6 weeks of lipid-soluble antibiotics (trimethoprim-sulfamethoxazole or fluoroquinolones) for adequate cyst penetration 1

Common Pitfalls to Avoid

Don't Confuse Asymptomatic Bacteriuria with Symptomatic Infection

• The presence of bacteria in urine without symptoms does NOT require treatment 1, 3
• Routine surveillance urine cultures in asymptomatic ADPKD patients are not recommended 3

Don't Mistake Other Conditions for UTI

• Cyst hemorrhage can mimic UTI with hematuria and pain but requires different management 1
• Nephrolithiasis is common in ADPKD and can present similarly to UTI 1

Recognize When Cyst Infection Diagnosis is Challenging

• 40% of cyst infections have negative urine cultures 5
• Blood cultures are positive in only 10% of cases 5
• FDG-PET/CT may be needed for definitive diagnosis when clinical suspicion is high despite negative cultures 6

Special Exceptions

Treatment of asymptomatic bacteriuria IS indicated in only two scenarios:

• Pregnant women with ADPKD 3
• Prior to urologic procedures where mucosal bleeding is anticipated 3