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Asymptomatic Bacteriuria in Adults RICHARD COLGAN, M.D, University of Maryland School of Medicine, Baltimore, Maryland LINDSAY E

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Asymptomatic Bacteriuria in Adults RICHARD COLGAN, M.D, University of Maryland School of Medicine, Baltimore, Maryland LINDSAY E Asymptomatic Bacteriuria in Adults RICHARD COLGAN, M.D, University of Maryland School of Medicine, Baltimore, Maryland LINDSAY E. NICOLLE, M.D., University of Manitoba, Winnipeg, Canada ANDREW MCGLONE, M.D., University of Maryland School of Medicine, Baltimore, Maryland THOMAS M. HOOTON, M.D., University of Washington School of Medicine, Seattle, Washington A common dilemma in clinical medicine is whether to treat asymp- tomatic patients who present with bacteria in their urine. There are few scenarios in which antibiotic treatment of asymptomatic bacter- uria has been shown to improve patient outcomes. Because of increas- ing antimicrobial resistance, it is important not to treat patients with asymptomatic bacteriuria unless there is evidence of potential ben- efit. Women who are pregnant should be screened for asymptomatic bacteriuria in the first trimester and treated, if positive. Treating asymptomatic bacteriuria in patients with diabetes, older persons, patients with or without indwelling catheters, or patients with spinal cord injuries has not been found to improve outcomes. (Am Fam Physician 2006;74:985-90. Copyright © 2006 American Academy of Family Physicians.) rinary tract infections (UTIs) with asymptomatic bacteriuria will be influ- are one of the most common enced by patient variables: healthy persons infections for which antibiotics will likely have E. coli, whereas a nursing are prescribed. The Infectious home resident with a catheter is more likely to UDiseases Society of America (IDSA) issued have multi-drug–resistant polymicrobic flora guidelines for the treatment of uncomplicated (e.g., P. aeruginosa). Enterococcus species and acute bacterial cystitis and acute pyelonephri- gram-negative bacilli are common in men.9,10 tis in women.1 The presence of bacteria in the urine of an asymptomatic patient is known Diagnosis as asymptomatic bacteriuria. The IDSA also The presence of a significant quantity of bac- has published guidelines on indications for teria in a urine specimen properly collected the screening and treatment of asymptomatic from a person without symptoms or signs bacteriuria in various patient populations.2 of a UTI characterizes asymptomatic bacte- riuria.11 Quantitative criteria for identifying Epidemiology significant bacteriuria in an asymptomatic Asymptomatic bacteriuria is common, with person are: (1) at least 100,000 colony-form- varying prevalence by age, sex, sexual activity, ing units (CFUs) per mL of urine in a voided and the presence of genitourinary abnormali- midstream clean-catch specimen; and (2) at ties (Table 13-8). In healthy women, the preva- least 100 CFUs per mL of urine from a cath- lence of bacteriuria increases with age, from eterized specimen9,12,13 (Table 2). Accord- about 1 percent in females five to 14 years ing to the IDSA guideline, the diagnosis of age to more than 20 percent in women at of asymptomatic bacteriuria in women is least 80 years of age living in the community.3 appropriate only if the same species is pres- Escherichia coli is the most common organ- ent in quantities of at least 100,000 CFUs ism isolated from patients with asymptomatic per mL of urine in at least two consecutive bacteriuria. Infecting organisms are diverse voided specimens.2,3 and include Enterobacteriaceae, Pseudomonas The leukocyte esterase and nitrite tests aeruginosa, Enterococcus species, and group B often are used in primary care settings to streptococcus. Organisms isolated in patients evaluate urinary symptoms; however, they Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2006 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Asymptomatic Bacteriuria SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Pregnant women should be screened for asymptomatic bacteriuria A 23, 24 in the first trimester of pregnancy. Pregnant women who have asymptomatic bacteriuria should be B 2 treated with antimicrobial therapy for three to seven days. Pyuria accompanying asymptomatic bacteriuria should not be C 3, 14 treated with antimicrobial therapy. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 906 or http://www.aafp.org/afpsort.xml. are not useful for diagnosing UTI in an other inflammatory disorders of the geni- asymptomatic patient. A urine dipstick leu- tourinary tract (e.g., vaginitis). Urinalysis kocyte esterase test showing trace or more with microscopic examination for bacteria white blood cells has a sensitivity of 75 to remains a useful test for the identification 96 percent and specificity of 94 to 98 per- of bacteriuria. cent for detecting pyuria14; however, pyuria Limitations of the dipstick nitrite test is not specific for UTI and may occur with in diagnosing bacteriuria include: infec- tion with non-nitrite–producing pathogens; delays between obtaining and testing the TABLE 1 sample; and insufficient time since the last Prevalence of Asymptomatic Bacteriuria void for nitrites to appear at detectable lev- in Selected Populations els. Combining the leukocyte esterase and nitrite tests results in higher specificity than Population Prevalence (%) using either test alone. Healthy premenopausal women3 1.0 to 5.0 Premenopausal, Nonpregnant Women Pregnant women3 1.9 to 9.5 Postmenopausal women (50 to 70 years of age)3 2.8 to 8.6 Premenopausal, nonpregnant women with Patients with diabetes asymptomatic bacteriuria experience no Women4 9.0 to 27.0 adverse effects and usually will clear their Men4 0.7 to 1.0 bacteriuria spontaneously. However, these Older community-dwelling patients women are more likely to experience subse- Women (older than 70 years)3 > 15.0 quent symptomatic UTI than women who 15 Men4 3.6 to 19.0 do not have asymptomatic bacteriuria. Older long-term care residents One study randomized women with bacte- Women4 25.0 to 50.0 riuria to receive one week of nitrofurantoin Men4 15.0 to 40.0 (Furadantin) or placebo; those receiving the Patients with spinal cord injuries antibiotic had a significantly lower preva- Intermittent catheter5 23.0 to 89.0 lence of bacteriuria at six months, but not 16 Sphincterotomy and condom catheter6 57.0 at one year. The patients treated with Patients undergoing hemodialysis7 28.0 antibiotics were just as likely as those in the Patients with an indwelling catheter placebo arm to have a symptomatic UTI Short-term8 9.0 to 23.0 in the year after therapy. Although women Long-term8 100 with asymptomatic bacteriuria are more likely to have subsequent symptomatic UTIs, Information from references 3 through 8. treatment of asymptomatic bacteriuria does not decrease the frequency of symptomatic 986 American Family Physician www.aafp.org/afp Volume 74, Number 6 ◆ September 15, 2006 Asymptomatic Bacteriuria or trimethoprim/sulfamethoxazole (TMP/ TABLE 2 SMX; Bactrim, Septra) compared with those Diagnostic Criteria for treated with continuous antimicrobial ther- Asymptomatic Bacteriuria apy to the end of pregnancy.20 The IDSA recommends a course of three to seven Midstream clean-catch urine specimen: days of antimicrobial therapy for pregnant For women, two consecutive specimens with women with asymptomatic bacteriuria.2 A isolation of the same species in quantitative Cochrane systematic review found insuffi- counts of at least 100,000 CFUs per mL of urine. cient evidence to determine whether a single For men, a single specimen with one bacterial dose regimen is as effective as treatments of species isolated in a quantitative count of at longer duration.21 least 100,000 CFUs per mL. Because leukocyte esterase and nitrite Catheterized urine specimen: tests have low sensitivity for identifying In women or men, a single specimen with one bacteriuria in women who are pregnant, bacterial species isolated in a quantitative these patients should be screened with urine count of at least 100 CFUs per mL. cultures22; however, the optimal frequency of urine culture screening has not been CFU = colony-forming unit. established. A single urine culture at the end of the first trimester generally is recom- mended based on clinical outcomes and cost- UTI or prevent further episodes of bacte- effectiveness.23,24 Women with asymptomatic riuria. Asymptomatic bacteriuria has not bacteriuria or symptomatic UTI during preg- been shown to be associated with detri- nancy should be treated (Table 3) and should mental long-term outcomes (e.g., hyperten- undergo periodic screening for the duration sion, renal failure, genitourinary cancer, or of their pregnancy. The IDSA makes no rec- decreased survival). For these reasons, the ommendations for subsequent screening of IDSA does not recommend screening for or treatment of asymptomatic bacteriuria in premenopausal nonpregnant women.2 TABLE 3 Oral Antibiotics for Treatment of Pregnant Women Pregnant Women with Asymptomatic Bacteriuria Women with asymptomatic bacteriuria dur- ing pregnancy are more likely to deliver pre- FDA Pregnancy Category B: Safety for use in pregnancy has not been established mature or low-birth-weight infants and have Amoxicillin a 20- to 30-fold increased risk of develop- Amoxicillin/clavulanate (Augmentin) ing pyelonephritis during pregnancy
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