What is the best course of treatment for a patient with a urinary tract infection caused by Group B Streptococcus (GBS), as indicated by urinalysis results showing leukocyte esterase positive, white blood cell (WBC) count of 6-10, and a culture of 10,000-49,000 colony-forming units per milliliter (cfu/ml) of GBS, who is scheduled for surgery and has normal renal function?

Management of Preoperative Group B Streptococcus Bacteriuria

Do not treat this asymptomatic bacteriuria before non-urologic surgery. The IDSA strongly recommends against screening for or treating asymptomatic bacteriuria in patients undergoing elective non-urologic surgery 1, 2.

Key Clinical Decision Point

This patient has asymptomatic bacteriuria (ASB), not a urinary tract infection, based on:

• Low colony count (10,000-49,000 CFU/mL, below the diagnostic threshold of ≥100,000 CFU/mL for ASB) 2
• Minimal pyuria (WBC 6-10) 3
• High squamous cell count (6-10) suggesting possible contamination 3
• No mention of urinary symptoms 1

Evidence-Based Rationale

Why Treatment is NOT Indicated

• The IDSA 2019 guidelines provide a strong recommendation against screening for or treating ASB in patients undergoing elective non-urologic surgery (strong recommendation, low-quality evidence) 1
• This applies to all non-urologic procedures including cardiac surgery, orthopedic surgery, vascular surgery, and general abdominal surgery 3
• There is no evidence that treating ASB before non-urologic procedures provides any benefit in preventing surgical site infections or other complications 2

Harms of Unnecessary Treatment

• Treatment promotes reinfection with antimicrobial-resistant organisms 2
• Increases risk of Clostridioides difficile infection 2, 3
• Causes unnecessary drug adverse effects and healthcare costs 3
• Does not reduce surgical site infections or mortality in non-urologic surgery 3

When Treatment WOULD Be Indicated

Treatment of bacteriuria is only recommended for 1, 3:

• Endoscopic urologic procedures with mucosal trauma (TURP, TURBT, ureteroscopy with lithotripsy, percutaneous stone surgery) 3
• Pregnant women 2
• Symptomatic urinary tract infection (dysuria, frequency, urgency, fever, flank pain) 2

Appropriate Perioperative Management

• Administer standard perioperative antimicrobial prophylaxis for the planned surgical procedure according to established surgical protocols, regardless of urine culture results 2
• The prophylaxis should be given 30-60 minutes before the procedure 1
• Do not add additional antibiotics targeting the GBS bacteriuria 2

Important Caveats

• Pyuria accompanying ASB is not an indication for treatment in any surgical context 3
• If the patient develops urinary symptoms (dysuria, frequency, urgency, suprapubic pain, fever), then treatment would be indicated as symptomatic UTI 2
• The presence of GBS in urine may signal underlying urinary tract abnormalities in non-pregnant adults, but this does not change preoperative management 4