Do you treat asymptomatic bacteriuria (presence of bacteria in urine), regardless of the urine culture results colony-forming unit (CFU) count, in patients with possible underlying candiduria (fungal infection of the urine) and other risk factors such as elderly age, diabetes, immunocompromised status, or history of urinary tract infections?

Do Not Treat Asymptomatic Bacteriuria Regardless of CFU Count (With Two Exceptions)

Asymptomatic bacteriuria should NOT be treated in the vast majority of patients, regardless of the CFU count, with only two clear exceptions: pregnant women and patients undergoing urologic procedures with anticipated mucosal bleeding. 1, 2

When Treatment is NOT Indicated

The Infectious Diseases Society of America explicitly recommends against screening or treating asymptomatic bacteriuria in the following populations, even with high CFU counts 1:

• Elderly patients (community-dwelling or institutionalized) - randomized trials showed no difference in symptomatic UTI or mortality, but significantly more adverse drug events and resistant organisms in treated patients 1, 2
• Diabetic patients (including women with diabetes) 1, 2
• Immunocompromised patients (except solid organ transplant recipients, where evidence is insufficient) 1
• Patients with spinal cord injuries - 78% had positive cultures but minimal symptomatic episodes, all responding promptly when actually symptomatic 1, 2
• Catheterized patients while the catheter remains in situ - 100% eventually develop bacteriuria due to biofilm formation 1, 2
• Premenopausal, nonpregnant women 1, 2
• Patients with history of recurrent UTIs (asymptomatic bacteriuria does not predict future symptomatic infections) 3

When Treatment IS Indicated

Only two populations require screening and treatment 1, 2:

1. Pregnant women:

   • Screen with urine culture at least once in early pregnancy 1, 2
   • Treat if positive with 3-7 days of antibiotics 1, 2
   • Perform periodic screening for recurrent bacteriuria after therapy 1

2. Patients undergoing urologic procedures with mucosal bleeding:

   • Screen before transurethral resection of prostate or other procedures breaching mucosa 1, 2
   • Initiate antimicrobials 30-60 minutes before the procedure 2
   • Discontinue immediately after unless indwelling catheter remains 1, 2

Special Consideration: Post-Catheter Removal

Antimicrobial treatment may be considered for asymptomatic women with catheter-acquired bacteriuria persisting 48 hours after catheter removal, as one trial showed improved outcomes at 14 days 1, 2

CFU Count is Irrelevant for Treatment Decisions

The CFU count (whether ≥10² CFU/mL for catheterized specimens or ≥10⁵ CFU/mL for voided specimens) is only relevant for diagnosing asymptomatic bacteriuria, not for determining treatment 1, 4. Once asymptomatic bacteriuria is diagnosed using appropriate thresholds, the decision to treat depends entirely on the patient population, not the bacterial burden 1, 2.

Critical Pitfalls to Avoid

• Do not treat based on pyuria alone - pyuria accompanying asymptomatic bacteriuria is NOT an indication for treatment, even with high CFU counts 1, 2
• Do not use dipstick testing to guide treatment - routine dipstick or urinalysis should not be used for screening in at-risk populations 1, 4
• Recognize the harms of unnecessary treatment - treating asymptomatic bacteriuria leads to increased antimicrobial resistance, Clostridioides difficile infection, adverse drug events, and disruption of normal microbiome 2, 5, 6

Candiduria Context

The question mentions possible candiduria, but this does not change the management of bacterial asymptomatic bacteriuria. The same principles apply: do not treat asymptomatic bacteriuria regardless of CFU count, except in pregnant women and before mucosal urologic procedures 1, 2.