Do Not Treat This Patient
In this asymptomatic elderly female patient with bacteriuria, you should not treat with antibiotics, regardless of her empagliflozin use. 1, 2
Rationale for No Treatment
The 2019 IDSA guidelines provide a strong recommendation with moderate-quality evidence against screening for or treating asymptomatic bacteriuria (ASB) in elderly community-dwelling persons who are functionally impaired, and an even stronger recommendation (strong recommendation, moderate-quality evidence) against treatment in elderly persons residing in long-term care facilities. 1
Key Points About This Case:
The patient meets diagnostic criteria for ASB: A single urine culture with ≥10^5 CFU/mL of E. coli in an elderly female without urinary symptoms confirms asymptomatic bacteriuria. 2, 3
Empagliflozin does not change management: While SGLT2 inhibitors like empagliflozin increase genital mycotic infections, the IDSA guidelines specifically recommend against screening for or treating ASB in patients with diabetes (strong recommendation, moderate-quality evidence). 1 This recommendation applies regardless of diabetes medications being used.
The presence of bacteria and pyuria is expected and not harmful: The "2 plus bacteria" finding does not indicate need for treatment in asymptomatic patients. 2, 4
Why Treatment Would Be Harmful
No mortality or morbidity benefit: Multiple studies demonstrate that treating ASB in elderly patients does not reduce symptomatic UTI rates, mortality, or improve quality of life. 5, 6
Significant harms from treatment: Antibiotic treatment of ASB leads to adverse drug events, increased antimicrobial resistance, higher rates of Clostridioides difficile infection, and paradoxically increased risk of recurrent symptomatic UTI. 7, 5
Elimination of protective flora: Treatment may eliminate bacterial strains that actually protect against more virulent organisms. 2
Common Pitfall to Avoid
Do not confuse nonspecific symptoms with UTI: If this patient develops delirium, falls, or other nonspecific symptoms while on empagliflozin, the IDSA recommends assessing for other causes and careful observation rather than attributing these to bacteriuria and treating with antibiotics (strong recommendation, very low-quality evidence). 1, 2
When You WOULD Treat This Patient
The only scenarios where this patient would require treatment are:
If she becomes symptomatic with dysuria, urgency, frequency, suprapubic pain, or fever—then she would have a symptomatic UTI requiring treatment. 1
If she requires endoscopic urologic procedures with mucosal trauma (e.g., cystoscopy with biopsy, transurethral resection)—then screen and treat shortly before the procedure to prevent postoperative sepsis. 1, 4