Treatment of Moderate Bacteriuria (Bacteria in Urine)
Do not treat moderate bacteriuria (asymptomatic bacteriuria) in most patients, as treatment provides no clinical benefit and causes harm through adverse drug effects and antibiotic resistance. 1, 2
When Treatment IS Required
Treatment is indicated only in these specific situations:
Pregnant Women
- Screen all pregnant women with urine culture at least once in early pregnancy and treat if positive 1, 2
- Use 3-7 days of antimicrobial therapy 1, 2
- Perform periodic screening for recurrent bacteriuria following treatment 1, 2
- First-line options include nitrofurantoin, fosfomycin, trimethoprim-sulfamethoxazole, or beta-lactams (amoxicillin-clavulanate) 3, 4, 5
Before Urologic Procedures with Mucosal Bleeding
- Screen before transurethral resection of the prostate or other procedures where mucosal bleeding is anticipated 1, 2
- Initiate antimicrobial therapy the night before or immediately before the procedure 1, 2
- Discontinue antibiotics immediately after the procedure unless an indwelling catheter remains in place 1
- If catheter remains post-procedure, continue antibiotics until catheter removal 1, 2
Post-Catheter Removal in Women
- Consider treatment for asymptomatic women with catheter-acquired bacteriuria persisting 48 hours after catheter removal 1, 2
When Treatment IS NOT Recommended
Do not treat asymptomatic bacteriuria in the following populations, as treatment increases adverse events and antibiotic resistance without reducing symptomatic UTI or mortality: 1, 2, 6
- Premenopausal, nonpregnant women 1, 2
- Diabetic women 1, 2
- Older persons living in the community 1, 2
- Elderly institutionalized patients 1, 2
- Patients with spinal cord injury 1, 2
- Catheterized patients while the catheter remains in place 1, 2, 7
- Renal transplant recipients 8
Critical Diagnostic Considerations
Pyuria Is NOT an Indication for Treatment
- Pyuria accompanying asymptomatic bacteriuria does not warrant antimicrobial treatment 1, 2, 8
- Pyuria is commonly found without infection, especially in older adults with incontinence 5
Diagnostic Criteria for Bacteriuria
- Women: Two consecutive voided specimens with same organism ≥10^5 CFU/mL 1, 2
- Men: Single clean-catch specimen with one organism ≥10^5 CFU/mL 1, 2
- Catheterized specimens: Single specimen with one organism ≥10^2 CFU/mL 1, 2
Harms of Inappropriate Treatment
Treating asymptomatic bacteriuria in non-indicated populations causes significant harm: 6, 9
- 3.77-fold increased risk of adverse drug events 6
- Reinfection with antibiotic-resistant organisms 2, 6, 9
- No reduction in symptomatic UTI, complications, or mortality 6, 9
- Elimination of protective bacterial strains 8
Common Pitfalls to Avoid
- Do not treat based solely on positive urine culture without symptoms 1, 2
- Do not treat catheterized patients for bacteriuria while catheter remains in place 1, 7
- Do not confuse nonspecific symptoms (delirium, falls) in elderly with symptomatic UTI 8
- Do not obtain urine specimens from catheter tubing or collection bags—these yield unreliable results 7