Do Not Treat Asymptomatic Bacteriuria in This 6-Year-Old Girl
The Infectious Diseases Society of America (IDSA) makes a strong recommendation against treating asymptomatic bacteriuria in healthy children, including school-aged girls, based on moderate-quality evidence showing no benefit and high-quality evidence of harm. 1
Why Treatment Should Be Avoided
No Clinical Benefit Demonstrated
Multiple randomized controlled trials in school-aged girls (5-7 years old) showed that antibiotic treatment (nitrofurantoin, ampicillin, or TMP-SMX) provided no differences in renal scarring compared to untreated controls at 4-year follow-up. 1
A British cohort study of 110 girls with asymptomatic bacteriuria treated with antibiotics for 7-14 days found no differences in subsequent UTI symptoms, resolution of vesicoureteral reflux, kidney growth, or renal scarring compared to untreated girls. 1
Treatment does not prevent symptomatic UTI, pyelonephritis, renal scarring, or renal insufficiency in children. 1
Evidence of Actual Harm from Treatment
A Swedish study of 66 school-aged girls with long-term asymptomatic E. coli bacteriuria found that when penicillin eradicated the bacteriuria, 6 girls developed acute pyelonephritis and 1 developed cystitis within 5 months—suggesting that antimicrobial treatment that resolves stable bacteriuria may actually increase the risk of symptomatic infection. 1, 2
Treatment causes adverse drug effects, increases healthcare costs, and contributes to antimicrobial resistance. 1, 2
Antibiotics disrupt the protective bladder and gut microbiome, potentially selecting for more resistant organisms. 2
The Natural History Is Benign
Asymptomatic bacteriuria occurs in only 1-3% of healthy girls and is even less common in boys and infants. 1, 2
Long-term follow-up studies of Swedish schoolgirls with asymptomatic bacteriuria showed that 47% remained bacteriuric after 3 years, yet renal growth and concentrating capacity remained normal. 1
While symptomatic UTI may occur slightly more frequently in bacteriuric children, there is no evidence of higher risk for subsequent renal scarring or renal insufficiency. 1
When Treatment WOULD Be Indicated
This 6-year-old should only receive antibiotics if:
She develops symptoms of UTI (fever, dysuria, urinary frequency, suprapubic pain, or flank pain). 2
She is scheduled to undergo an invasive urological procedure where mucosal bleeding is anticipated. 1, 3
Common Pitfalls to Avoid
Do not confuse asymptomatic bacteriuria with UTI—the presence of bacteria alone without symptoms does not constitute infection requiring treatment. 2, 4
Do not treat based on pyuria alone—pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment. 1
Do not screen for asymptomatic bacteriuria in healthy children—screening leads to unnecessary treatment and false-positive results (estimated 20,000 false-positives per 100,000 children screened). 1
Recognize that this recommendation applies specifically to otherwise healthy children—children with neuromuscular disorders, immunocompromised states, or anatomic urinary tract abnormalities may require individualized assessment, though evidence remains limited. 1