How to manage asymptomatic Urinary Tract Infection (UTI)?

Management of Asymptomatic Bacteriuria

Do not screen for or treat asymptomatic bacteriuria in most populations, with the critical exception of pregnant women and patients undergoing urologic procedures that breach the mucosa. 1, 2

Key Principle: When NOT to Treat (Most Patients)

Treatment of asymptomatic bacteriuria (ASB) provides no clinical benefit in the vast majority of patients and causes significant harm through antimicrobial resistance, Clostridioides difficile infection, adverse drug effects, and elimination of potentially protective bacterial strains. 1, 2

Populations Where Treatment is NOT Recommended:

• Premenopausal and postmenopausal women without pregnancy: Treatment does not reduce symptomatic UTI frequency and may actually increase risk (hazard ratio 3.09) of developing symptomatic infection. 1

• Elderly patients (community-dwelling or institutionalized): No reduction in mortality (relative difference 13 per 1000) or sepsis risk, but high rates of adverse effects including CDI and antimicrobial resistance. 1, 2

• Patients with diabetes mellitus (well-controlled): No demonstrated benefit regardless of glycemic control status. 2

• Patients with recurrent UTIs: Persistent ASB may actually protect against symptomatic episodes; treatment increases risk of symptomatic UTI. 1

• Kidney transplant recipients (>1 month post-transplant): No evidence of benefit beyond the immediate post-operative period. 2

• Patients with indwelling catheters or neurogenic bladder: Bacteriuria is universal with long-term catheterization; treatment is futile and promotes resistance. 2

• Children: Screening would result in approximately 20,000 false-positives per 100,000 children screened, with no reduction in symptomatic infection rates. 1

Critical Exception: When Treatment IS Indicated

Pregnant Women (Strong Recommendation)

Screen all pregnant women for ASB, preferably in the first trimester, and treat when detected. 1, 2

Rationale: Treatment reduces critical pregnancy complications:

• Pyelonephritis prevention: Untreated ASB leads to pyelonephritis in pregnancy, a major cause of maternal hospitalization. 1, 3
• Preterm birth reduction: Antibiotics reduce preterm birth risk from 53 per 1000 to 14 per 1000 (risk difference -39,95% CI -47 to -20). 1
• Low birth weight prevention: Treatment reduces very low birth weight from 137 per 1000 to 88 per 1000 (risk difference -49,95% CI -75 to -10). 1

Treatment approach:

• Use short-course therapy (4-7 days) with pregnancy-safe antibiotics. 2
• First-line options: Fosfomycin-trometamol (single dose), nitrofurantoin, or beta-lactams (ampicillin, cephalexin). 1, 2, 4
• Avoid fluoroquinolones and trimethoprim in first trimester. 4

Patients Undergoing Urologic Procedures

Screen and treat ASB only before procedures that breach the urinary tract mucosa (e.g., transurethral resection, stone manipulation). 2

Do NOT treat before:

• Cardiovascular surgery 2
• Arthroplasty or orthopedic procedures 2
• Non-urologic surgeries 2

Common Diagnostic Pitfalls to Avoid

Elderly Patients with Delirium or Falls

Do NOT treat bacteriuria in cognitively impaired elderly patients presenting with isolated delirium, confusion, or falls without focal genitourinary symptoms or fever. 1, 2

• Delirium and falls are not symptoms of UTI in the absence of dysuria, frequency, urgency, or fever. 1
• Search for alternative causes (medication effects, metabolic derangements, neurologic events). 1
• Exception: If patient has fever AND hemodynamic instability without localizing source, initiate broad-spectrum antibiotics covering urinary and non-urinary sources. 1

Pyuria Does Not Equal Infection

Pyuria and inflammatory markers (including urine IL-6) do not distinguish ASB from symptomatic UTI and should not trigger treatment in asymptomatic patients. 1

Screening Practices: What NOT to Do

Never perform surveillance urine cultures in asymptomatic patients, including those with:

• History of recurrent UTIs 2
• Indwelling catheters 2
• Diabetes 2
• Advanced age 1

Obtaining unnecessary urine cultures drives inappropriate antimicrobial use regardless of symptoms, as positive results often prompt reflexive treatment. 1

Antimicrobial Stewardship Considerations

The treatment of ASB represents a major target for antimicrobial stewardship programs, as it:

• Promotes extended-spectrum beta-lactamase and carbapenemase-producing organisms 1
• Increases individual and community antimicrobial resistance 1
• Provides no measurable improvement in morbidity or mortality 1
• Increases healthcare costs without benefit 2