Does Streptococcus gallolyticus bacteriuria require treatment?

Does Streptococcus gallolyticus in the Urine Require Treatment?

In most cases, Streptococcus gallolyticus bacteriuria does NOT require treatment unless the patient has symptoms of urinary tract infection or is undergoing specific urologic procedures with mucosal trauma.

Clinical Decision Algorithm

Step 1: Assess for Symptoms of UTI

If the patient has NO urinary symptoms (no dysuria, frequency, urgency, suprapubic pain, costovertebral angle tenderness, fever, or systemic signs):

• Do not treat - this represents asymptomatic bacteriuria (ASB) 1
• The IDSA provides a strong recommendation against screening for or treating ASB in most patient populations 1
• Treatment of ASB increases antimicrobial resistance, Clostridioides difficile infection risk, and adverse drug effects without improving outcomes 2

If the patient HAS urinary symptoms (new dysuria, flank pain, fever with genitourinary symptoms):

• Treat as a urinary tract infection with appropriate antimicrobials 1
• S. gallolyticus subspecies pasteurianus has been documented to cause symptomatic UTI, particularly in patients with underlying urinary tract disease 3
• Use first-line agents (nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin) based on local antibiogram 1
• S. gallolyticus is typically 100% sensitive to cefotaxime and vancomycin but highly resistant to clindamycin, erythromycin, and tetracycline 4

Step 2: Evaluate for Specific High-Risk Scenarios

Pregnant patients:

• Treat ASB even without symptoms - strong recommendation 1
• Use 4-7 days of antimicrobial therapy 1

Patients undergoing endoscopic urologic procedures with mucosal trauma:

• Screen for and treat ASB prior to surgery - strong recommendation 1
• Obtain urine culture before the procedure and use targeted therapy 1
• Administer 1-2 doses of antimicrobials 30-60 minutes before the procedure 1

All other surgical procedures (including non-urologic surgery):

• Do not screen for or treat ASB - strong recommendation 1, 2

Step 3: Consider Underlying Malignancy Screening

Critical caveat: S. gallolyticus (formerly S. bovis) has a well-established association with colorectal cancer and other gastrointestinal pathologies 5, 4, 6:

• 59.5% of patients with S. gallolyticus bacteremia had underlying gastrointestinal pathologies 4
• The organism is strongly associated with colorectal carcinoma, even in asymptomatic patients 5, 6
• Recommend colonoscopy and evaluation for hepatobiliary-pancreatic pathology in patients with S. gallolyticus isolated from urine, regardless of whether you treat the bacteriuria 4
• This cancer screening recommendation applies even when the bacteriuria is asymptomatic 3, 4

Populations Where Treatment is NOT Recommended

The following patient groups should not be treated for ASB, even with S. gallolyticus 1:

• Patients with diabetes mellitus
• Patients with spinal cord injury
• Patients with short-term indwelling catheters (<30 days)
• Patients with long-term indwelling catheters
• Older adults in long-term care facilities
• Community-dwelling older adults with functional impairment
• Renal transplant recipients >1 month post-transplant

Common Pitfalls to Avoid

• Do not attribute confusion or delirium to UTI without focal genitourinary symptoms or systemic signs of infection 7
• Treating ASB in delirious patients leads to worse functional outcomes (adjusted OR 3.45) and increased C. difficile risk (OR 2.45) 7
• Do not order routine urinalysis in asymptomatic patients, as this leads to unnecessary findings that prompt inappropriate treatment 2
• Do not assume all bacteriuria requires treatment - the vast majority of ASB should be left untreated 1

Key Takeaway for S. gallolyticus Specifically

While S. gallolyticus bacteriuria may have clinical significance when isolated in patients with underlying urinary tract disease and symptoms 3, the standard ASB guidelines apply: treat only if symptomatic or in the specific high-risk scenarios outlined above 1. However, always pursue cancer screening given the strong association with colorectal malignancy 5, 4, 6.