Do you treat asymptomatic bacteriuria (ASB) in males?

Management of Asymptomatic Bacteriuria in Males

Do not screen for or treat asymptomatic bacteriuria in males in nearly all clinical scenarios. 1, 2

General Approach for Males

The 2019 IDSA guidelines provide clear direction that asymptomatic bacteriuria (ASB) in males should not be treated in the vast majority of situations. 1 The fundamental principle is that treatment causes more harm than benefit through increased antimicrobial resistance, Clostridioides difficile infection risk, adverse drug effects, and healthcare costs without improving clinical outcomes. 2, 3

Populations Where Treatment is NOT Recommended

Do not treat ASB in the following male populations:

• Diabetic men: Strong recommendation against screening or treatment, though this is inferred from studies primarily in women. 1 No evidence shows treatment improves outcomes, and the risks of antimicrobial therapy outweigh any theoretical benefits. 1

• Older community-dwelling men: Strong recommendation against screening or treatment, even if functionally impaired. 1 The prevalence of ASB in older men ranges from 3.6-19% in the community and 15-40% in long-term care facilities, but treatment does not prevent symptomatic UTI or improve outcomes. 1

• Men with spinal cord injury: Strong recommendation against screening or treatment. 1 Clinical signs of UTI may differ from classic symptoms in these patients, requiring careful clinical judgment about what constitutes true infection versus colonization. 1

• Men with indwelling catheters (short-term <30 days or long-term): Strong recommendation against screening or treatment. 1 Bacteriuria is nearly universal with catheterization and treatment does not prevent symptomatic infection. 1

• Renal transplant recipients >1 month post-transplant: Strong recommendation against screening or treatment based on high-quality evidence. 1 There is insufficient evidence regarding the first month post-transplant, representing a knowledge gap. 1

• Men with implanted urologic devices (artificial urinary sphincter, penile prosthesis): Weak recommendation against screening or treatment. 1 Device infections are typically caused by skin flora rather than urinary pathogens, and one retrospective study showed similar infection rates (3% vs 4.3%) in men with or without preoperative ASB. 1

The Two Exceptions: When to Treat ASB in Males

1. Endoscopic urologic procedures with mucosal trauma:

• Strong recommendation to screen and treat ASB prior to procedures like TURP. 1, 2 This is the most important exception. 1

• Obtain a preoperative urine culture and provide targeted antimicrobial therapy based on culture results rather than empiric treatment. 1

• Studies show that perioperative antimicrobial treatment reduces postoperative sepsis from 16.7% to 5.4% compared to methenamine treatment. 1

• A short course of antimicrobials is likely as effective as prolonged courses, with less cost and fewer adverse effects. 1

2. Artificial urinary sphincter or penile prosthesis implantation:

• Weak recommendation against screening or treatment, but all patients should receive standard perioperative antimicrobial prophylaxis. 1

• This represents a nuanced situation where routine screening is not recommended, but prophylaxis at the time of surgery is standard practice. 1

Diagnostic Criteria for ASB in Males

• A single urine specimen with ≥10⁵ CFU/mL is diagnostic of ASB in men (unlike women who require two consecutive positive specimens). 2, 4

• The presence of pyuria alone is not an indication for treatment. 2 Pyuria commonly accompanies ASB and does not change management. 2

Common Clinical Pitfalls to Avoid

Do not treat based on:

• Positive urine culture alone without urinary symptoms or systemic signs of infection. 2, 3 This is the most common error in clinical practice. 3

• Pyuria accompanying bacteriuria: Pyuria does not convert ASB into a symptomatic infection requiring treatment. 2

• Delirium or altered mental status in older men: Assess for other causes and observe carefully rather than treating bacteriuria. 1 Treatment of ASB does not improve delirium outcomes. 1

• Falls in older men: No recommendation exists for or against treatment, representing a knowledge gap, but the default should be non-treatment given lack of evidence for benefit. 1

• Colony count alone: Clinical context is essential; high colony counts without symptoms do not require treatment. 2

Rationale for Non-Treatment

The evidence consistently demonstrates that treating ASB in males (outside the two exceptions above) leads to:

• Increased antimicrobial resistance for the individual, institution, and community. 1, 2
• Higher risk of C. difficile infection. 1, 2
• Adverse drug effects without clinical benefit. 1, 2
• Increased healthcare costs. 2, 3
• No reduction in progression to symptomatic UTI or improvement in morbidity/mortality. 5

Studies in elderly men show that 76% of ASB cases resolve spontaneously, with intermittent patterns common, further supporting non-intervention. 6