From the Guidelines
Asymptomatic bacteriuria in males should only be treated in specific circumstances, such as before urologic procedures that may cause mucosal bleeding, due to the risk of selecting antimicrobial resistance and eradicating a potentially protective bacteriuria strain. Treatment is recommended before procedures like transurethral resection of the prostate or prostate biopsy, where antimicrobial therapy should be initiated shortly before the procedure and discontinued promptly afterward 1. For pre-procedural prophylaxis, a single dose of trimethoprim-sulfamethoxazole (160mg/800mg), ciprofloxacin (500mg), or levofloxacin (500mg) is typically sufficient.
Outside of these specific scenarios, treating asymptomatic bacteriuria in males is not recommended as it does not reduce complications or prevent symptomatic urinary tract infections, and unnecessary antibiotic use contributes to antimicrobial resistance and potential side effects 1. The presence of bacteria in urine without symptoms represents colonization rather than infection in most cases, and the immune system typically manages this colonization without intervention. Even in elderly men with or without indwelling catheters, treatment of asymptomatic bacteriuria has not been shown to improve outcomes and may actually lead to recolonization with more resistant organisms. Key considerations include:
- The spectrum of bacteria in asymptomatic bacteriuria is similar to species found in uncomplicated or complicated UTIs 1
- Clinical studies have shown that asymptomatic bacteriuria may protect against superinfecting symptomatic UTI 1
- Cystoscopy and/or imaging of the upper urinary tract is not mandatory if the medical history is otherwise unremarkable 1
- For men, digital rectal examination should be performed to investigate the possibility of prostate diseases 1
From the Research
Treatment of Asymptomatic Bacteriuria in Males
- Asymptomatic bacteriuria is a common clinical condition that often leads to unnecessary treatment 2
- The incidence of asymptomatic bacteriuria increases with age and is more prominent in women than men 2
- In most scenarios, asymptomatic bacteriuria does not lead to urinary tract infections, and therefore, antibiotic treatment of asymptomatic bacteriuria has not been shown to improve patient outcomes 2
- The Infectious Disease Society of America (IDSA) updated its asymptomatic bacteriuria management guidelines in 2019, which emphasized on the risks and benefits of treating the condition 2
- Treating asymptomatic bacteriuria in individuals with diabetes, neutropenia, spinal cord injuries, indwelling urinary catheters, and so on has not been found to improve clinical outcomes 2
- Unnecessary treatment is often associated with unwanted consequences including but not limited to increased antimicrobial resistance, Clostridioides difficile infection, and increased health care cost 2, 3
Risk Factors and Outcomes
- Hospitalized patients with asymptomatic bacteriuria commonly receive inappropriate antibiotic therapy 3
- Antibiotic treatment did not appear to be associated with improved outcomes; rather, treatment may be associated with longer duration of hospitalization after urine testing 3
- Factors associated with asymptomatic bacteriuria treatment included older age, dementia, acutely altered mental status, urinary incontinence, leukocytosis, positive urinalysis, and urine culture with a bacterial colony count greater than 100 000 colony-forming units per high-power field 3
Antibiotic Resistance
- Resistance to trimethoprim-sulfamethoxazole (TMP-SMX) was the most common antibiotic resistance in patients with uncomplicated urinary tract infections 4
- The use of TMP-SMX as Pneumocystis jiroveci pneumonia prophylaxis was associated with an increase in TMP-SMX resistance among renal allograft recipients 5
- Prior urinary infection/colonisation with TMP-SMX-resistant Enterobacteriaceae and TMP-SMX use within the past 12 months were predictors of TMP-SMX resistance among urinary isolates 6