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bacteriuria

Etiology: - urinary tract infection - urinary tract colonization - between episodes of urinary tract infections (UTI) in men with prostatitis [22] Epidemiology: 1) prevalence increases with age 2) 5-10% of women > 60 years of age 3) 20-30% of women > 80 years of age 4) 5-10% of men > 70 years of age 5) 17-55% of institutionalized women 6) 15-31% of institutionalized men Clinical manifestations: - mild confusion, delirum & dark urine do not meet qualifications for symptoms of urinary tract infection (also see management below) Laboratory: 1) urinalysis a) 90% of asymptomatic bacteriuria is associated with pyuria b) 30% of non-bacteriuric elderly have pyuria 2) urine culture a) E coli (most common in community) b) Proteus mirabilis c) Klebsiella pneumonia d) coagulase-negative Staphylococci e) Enterococci: E faecalis about as common as E coli [5] f) withholding culture results results in less treatment of asymptomatic bacteriuria [9] 3) do not screen asymptomatic bacteriuria with urine cultures in pediatric population [8] or geriatric population [2] 4) urine culture indicated in pregnant patients & before & after invasive urologic procedures [4] Complications: 1) urinary tract infection [3] - dysuria alone or fever plus urinary frequency, urinary urgency, flank pain, suprapubic pain, gross hematuria, rigors, or new onset urinary incontinence in institutionalized elderly [3] 2) 8-16% of elderly patients with asymptomatic bacteriuria will develop symptomatic infection within 6 months 3) in the absence of urinary obstruction, does NOT lead to renal failure 4) increased risk of postoperative joint prosthesis infection after arthroplasty, but antibiotics not helpful* [10] 5) no association with mortality in the elderly 6) treatment of asymptomatic bacteriuria in hospitalized patients is associated with longer hospital stays (4 vs 3 days) & no difference in mortality, readmissions, emergency room visits, or C difficile infections [19] 7) urosepsis is rare even in patients with altered mental status [24] * risk not diminished by antibiotics & organisms isolated from infected joint never the same as organism isolated from preoperative urine [10] Differential diagnosis: - men with prostatitis may have normal digital rectal examination, especially between UTI episodes or during treatment [22] Management: 1) most bacteriuria is asymptomatic & does not require treatment - includes patients with diabetes mellitus [2,11]) - cognitively impaired adults who fall & are found to have bacteriuria without signs of infection [17] - includes asymptomatic bacteriuria in adults > 65 years with delirium [20,25] - includes patients undergoing non-urological procedures,& patients with immune disorders & those taking immunosuppressive agents [4] - includes patients with indwelling urinary catheters & suprapubic catheters 2) no benefit in treatment except a) where GU instrumentation is to be performed b) pregnant women - urine culture for pregnant women - 4-7 days of treatment for pregnant women [17] c) women who have had an indwelling catheter removed d) patients with urinary tract obstruction [4] e) men with prostatitis (recurrent urinary tract infections) [22] 3) bacteriuria, pyuria & altered mental status should not prompt empiric antibiotic treatment for urinary tract infection (UTI) unless unless other signs & symptoms of UTI are present [15,20]* - no need to change indwelling urinary catheter for bacteriuria & pyruria 4) in institutionalized patients, bacteriuria occurs rapidly once antibiotics are stopped 5) treatment of bacteriuria does not improve incontinence 6) treatment of asymptomatic bacteriuria promotes antibiotic resistance [13] 7) may be slight benefit in cranberry juice 8) screening: a) USPSTF recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12-16 weeks gestation or at the first prenatal visit, if later [4] - preterm birth not diminished by treatment - pyelonephritis lower (2.5% vs 0.6%) with treatment [12] b) recommended for patients that are: - pregnant - about to undergo an invasive urologic procedure - women who have recently had a urinary catheter removed c) USPSTF recommends against screening for asymptomatic bacteriuria in men & nonpregnant women [5] d) no recommendation is made for high-risk afebrile neutropenic patients * treatment of recurrent bacteriuria with antibiotics is associated with emergence of multidrug-resistant gram-negative rods [16]

Interactions

disease interactions

Related

urinalysis (UA) urinary tract infection (UTI)

General

sign/symptom

References

  1. Norman D, UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Journal Watch 23(1):9, 2003 Harding GKM et al Antimicrobial treatment in diabetic women with asymptomatic bacteriuria. N Engl J Med 347:1576, 2002 PMID: 12432044 - Andriole VT Asymptomatic bacteriuria in patients with diabetes-enemy or innocent visitor? N Engl J Med 347:1617, 2002 PMID: 12432051
  3. Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, Zoutman D, Smith S, Liu X, Walter SD. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ. 2005 Sep 24;331(7518):669. Epub 2005 Sep 8. PMID: 16150741 http://bmj.bmjjournals.com/cgi/content/full/331/7518/669
  4. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2018, 2021.
  5. Cai T et al. The role of asymptomatic bacteriuria in young women with recurrent urinary tract infections: To treat or not to treat? Clin Infect Dis 2012 Sep 15; 55:771 PMID: 22677710 - Wagenlehner FME and Naber KG. Asymptomatic bacteriuria - Shift of paradigm. Clin Infect Dis 2012 Sep 15; 55:778 PMID: 22677709
  6. Lin E, Bhusal Y, Horwitz D, et al. Overtreatment of enterococcal bacteriuria. Arch Intern Med 2012; 172:33-38 PMID: 22232145
  7. Nicolle LE, Bradley S, Colgan R, et al Infectious Disease Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria. Clin Infect Dis 2005; 40:643-654 PMID: 15714408
  8. Choosing Wisely American Academy of Pediatrics Ten Things Physicians and Patients Should Question. http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-pediatrics/ - AGS Choosing Wisely Workgroup. American Geriatrics Society identifies five things that healthcare providers and patients should question. J Am Geriatr Soc. 2013;61:622-631. PMID: 23469880
  9. Leis JA et al. Reducing antimicrobial therapy for asymptomatic bacteriuria among noncatheterized inpatients: A proof-of-concept study. Clin Infect Dis 2014 Apr 1; 58:980. PMID: 24577290 http://cid.oxfordjournals.org/content/58/7/980 - Naik AD and Trautner BW. Doing the right thing for asymptomatic bacteriuria: Knowing less leads to doing less. Clin Infect Dis 2014 Apr 1; 58:984. PMID: 24577289 http://cid.oxfordjournals.org/content/58/7/984
  10. Sousa R et al. Is asymptomatic bacteriuria a risk factor for prosthetic joint infection? Clin Infect Dis 2014 Jul 1; 59:41. PMID: 24723280 http://cid.oxfordjournals.org/content/59/1/41 - Duncan RA. Prosthetic joint replacement: Should orthopedists check urine because it's there? Clin Infect Dis 2014 Jul 1; 59:48 PMID: 24723277 http://cid.oxfordjournals.org/content/59/1/48
  11. Choosing Wisely. Feb 23, 2015 Infectious Diseases Society of America Five Things Physicians and Patients Should Question http://www.choosingwisely.org/doctor-patient-lists/infectious-diseases-society-of-america/
  12. Kazemier BM et al Maternal and neonatal consequences of treated and untreated asymptomatic bacteriuria in pregnancy: a prospective cohort study with an embedded randomised controlled trial. Lancet Infectious Diseases. Aug 5, 2015 PMID: 26255208 http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2815%2900070-5/abstract - Nicolle LE Management of asymptomatic bacteriuria in pregnant women. Lancet Infectious Diseases. Aug 5, 2015 PMID: 26255209 http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2815%2900145-0/abstract
  13. Cai T et al. Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections. Clin Infect Dis 2015 Dec 1; 61:1655. PMID: 26270684 http://cid.oxfordjournals.org/content/61/11/1655 - Wagenlehner FM, Naber KG. Treatment of asymptomatic bacteriuria might be harmful. Clin Infect Dis 2015 Dec 1; 61:1662 PMID: 26270681 http://cid.oxfordjournals.org/content/61/11/1662
  14. Nicolle LE. Asymptomatic bacteriuria. Curr Opin Infect Dis. 2014 Feb;27(1):90-6. Review. PMID: 24275697
  15. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  16. Das R, Towle V, Van Ness PH, Juthani-Mehta M. Adverse outcomes in nursing home residents with increased episodes of observed bacteriuria. Infect Control Hosp Epidemiol. 2011 Jan;32(1):84-6. PMID: 21091203 Free PMC Article
  17. Nicolle LE, Gupta K, Bradley SF et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis 2019 Mar 21; PMID: 30895288 https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciy1121/5407612
  18. U.S. Preventive Services Task Force (USPSTF) Cabana M, Caughey AB, Doubeni CA et al Screening for Asymptomatic Bacteriuria in Adults. US Preventive Services Task Force Recommendation Statement. JAMA. 2019;322(12):1188-1194 PMID: 31550038 https://jamanetwork.com/journals/jama/fullarticle/2751726 - Nicolle LE. Updated guidelines for screening for asymptomatic bacteriuria. JAMA 2019 Sep 24; 322:1152. PMID: 31550011 https://jamanetwork.com/journals/jama/article-abstract/2751693 - Henderson JT, Webber Bean SI. U.S. Preventive Services Task Force (USPSTF) Screening for Asymptomatic Bacteriuria in AdultsUpdated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2019;322(12):1195-1205. PMID: 31550037 https://jamanetwork.com/journals/jama/fullarticle/2751725 - Gupta K, Trautner BW The 2019 USPSTF Report on Screening for Asymptomatic Bacteriuria - Lessons From History. JAMA Netw Open. 2019;2(9):e1912522 PMID: 31550043 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2751864
  19. Petty LA, Vaughn VM, Flanders SA et al. Risk factors and outcomes associated with treatment of asymptomatic bacteriuria in hospitalized patients. JAMA Intern Med 2019 Aug 26; PMID: 31449295
  20. Krinitski D, Kasina R, Kloppel S, Lenouvel E Associations of delirium with urinary tract infections and asymptomatic bacteriuria in adults aged 65 and older: A systematic review and meta-analysis. J Am Geriatr Soc. 2021. Aug 27 PMID: 34448496 https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.1741
  21. Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. 2019:68(10);1611-1615 PMID: 31506700 https://academic.oup.com/cid/article/68/10/e83/5407612
  22. Gill BC, Shoskes DA. Bacterial prostatitis. Curr Opin Infect Dis. 2016;29:86-91. PMID: 26555038
  23. Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68:e83-e110. PMID: 30895288
  24. Advani SD et al. Bacteremia from a presumed urinary source in hospitalized adults with asymptomatic bacteriuria. JAMA Netw Open 2024 Mar 4; 7:e242283 PMID: 38477915 PMCID: PMC10938177 Free PMC article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2816027
  25. Stall NM, Kandel C, Reppas-Rindlisbacher C, et al. Antibiotics for delirium in older adults with pyuria or bacteriuria: A systematic review. J Am Geriatr Soc. 2024 Jun 19. PMID: 38895992 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18964