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UTI Or Bacteriuria? INFECTION CONTROL To Treat or Not to Treat: UTI or Bacteriuria? RAUL MACIAS-GIL, MD; EMILY O’NEILL, PharmD; MELISSA M. GAITANIS, MD 31 35 EN INTRODUCTION hemodynamic instability may present with changes in men- An 85-year-old male nursing home resident with dementia tal status. However, altered mental status, change in urine is admitted with altered mental status and decreased oral color, cloudy urine or foul-smelling urine alone should NOT intake in the last 3 days. There has been a recent medication be used to diagnose a UTI.1 change and his dose of quetiapine had to be decreased due Urine is often easy to collect and is often “positive.” The to a prolonged QT interval. He was afebrile and hemody- bladder is not as sterile as we are taught, particularly in the namically stable. On exam, he was found disoriented to time elderly. We have relied on using pyuria for the definition of and place. He had no costovertebral or suprapubic tenderness UTI and although its absence is associated with a 96% neg- on palpation. His complete blood count showed a WBC of ative predictive value (NPV) for bacteriuria, its presence has 7000 per microliter. The staff noted some cloudiness in the a low (39%) positive predictive value (PPV) for bacteriuria. urine the day prior to admission. Urine was sent for urinalysis About 75–90% of patients with asymptomatic bacteriuria (UA) showing +Leukocyte esterase (LE), pyuria [40–60 white (ASB) do not develop a systemic inflammatory response or blood cells (WBCs)], and few bacteria. Reflex urine culture other signs or symptoms to suggest infection. Treatment of grew >100,000 colony-forming units (CFU)/mL of E. coli. ASB does not effectively prevent symptomatic UTI. a. Start ciprofloxacin for E. coli UTI The clinical significance of asymptomatic bacteriuria in catheterized patients is undefined. A significant proportion, b. Start broad-spectrum antibiotics pending infectious 15-25% of hospitalized patients, may receive indwelling work-up catheters. In many cases, catheters are placed for inappropri- c. Restart the higher dose of quetiapine and give Haldol ate indications and healthcare providers are often unaware to calm the patient down that their patients have catheters, leading to prolonged d. Hold antibiotics, hydrate and continue a careful work- unnecessary use. National data from NHSN acute care hos- up for metabolic issues and medication side effects. pitals in 2006 showed a range of a pooled mean CAUTI rates This case may seem familiar to many of us in medicine. of 3.1–7.5 infections per 1000 catheter days. The highest When we see a patient with a positive urine test, there is an rates of CAUTIs were in burn ICUs followed by inpatient automatic need to react to it. As a result, many patients like medical wards and neurosurgical wards. The lowest rates are the one described above end up receiving unnecessary anti- in med-surg ICUs. An estimated 17–69% of CAUTI may be biotics. Inappropriate use of antibiotics is associated with preventable with recommended infection control measures, an increased risk for complications affecting not only our up to 380,000 infections and 9000 deaths related to CAUTI patients but also healthcare systems. per year could be prevented. This article provides a summary of UTIs, catheter-asso- In addition, catheters may be used disproportionately in ciated UTIs, and asymptomatic bacteriuria. Understanding long-term care (LTC) facilities. The rate of catheter use for the difference between these etiologies is crucial for appro- managing chronic voiding dysfunction in LTC residents priate diagnosis and management. ranges from 7–10%.2 In non-catheterized residents, asymp- tomatic bacteriuria has been estimated at 18% to 57% for women and 19% to 38% for men. URINARY TRACT INFECTIONS (UTIS) To accurately diagnose a UTI, patients must have symp- toms with or without a positive urine culture. Symptoms ASYMPTOMATIC BACTERIURIA (ASB) of UTI include dysuria, urgency, hesitance, frequency, new Asymptomatic bacteriuria (ASB) is defined as the absence of incontinence. Other constitutional symptoms such as fever, clinical symptoms suggesting a UTI in the setting of pres- chills, can also be present in the acute setting. An infec- ence of at least one type of bacteria in the urine at a concen- tion of the lower urinary tract can progress in an ascending tration of >10^5 cfu/mL or >10^8 cfu/mL, independent of fashion until reaching the kidneys, causing pyelonephri- the presence of white blood cells. tis. Patients with significant constitutional symptoms and The estimated prevalence of ASB varies based on the age RIMJ ARCHIVES | MARCH ISSUE WEBPAGE | RIMS MARCH 2020 RHODE ISLAND MEDICAL JOURNAL 31 INFECTION CONTROL cohort and patient population. ASB is more prevalent in Table 1. men and women living in a long-term care facility (up to Group Recommendation 50%) followed by elderly persons (>70 years old) living in the community (10.8 to 16% in women and 3.6 to 19% in Screening Treatment men).3 Persons with spinal cord injury requiring intermit- Healthy, premenopausal, NO screen NO tent catheterization and sphincterotomy/condom cath- non-pregnant women eter was as high as 69% and 57%, respectively.4,5 One study has even reported a 100% prevalence of asymptomatic Pregnant women YES, YES bacteriuria in persons with indwelling catheters.6 screen with urine The risk of developing bacterial colonization in patients culture (UCX) with indwelling catheters is directly proportional to the Older person (men or NO screen NO length of time the catheter will remain in place. Bacteriuria women) functionally impared due to catheterization is acquired at a rate of 3–10% per day, or living in long-term care the majority of whom are asymptomatic.7 By 30 days, 100% facilities of patients with a catheter will show bacteria in a urine Older person (men or NO screen NO specimen. The duration of catheterization and antibiotic use women) functionally or -->Look for also influences the incidence of bacteriuria and candiduria. cognitively impaired and non- other causes of As we describe in the recommendations below, the vast localizing symptoms for UTI delirium majority of people with asymptomatic bacteriuria do not need screening or treatment, except for two groups: preg- Diabetic patients NO screen NO nant women (rates of asymptomatic bacteriuria can be as Patients who have received NO screen NO 8 high as 9.5%) and patients undergoing invasive urological a kidney transplant procedures. Urological procedures can be classified as low, (>1 month prior) intermediate and high risk, depending on mucosal irritation, length of procedure, or potential invasion of colorectal space Patients s/p non-renal NO screen NO solid organ transplant (class III/contaminated procedures as transrectal prostate bx). Patients with high-risk Recommendation Recommendation neutropenia [absolute deferred deferred IDSA RECOMMENDATIONS FOR neutrophil count (ANC) <100 MANAGEMENT OF ASB cells/mm3, ≥7 days’ duration The Infectious Diseases Society of America (IDSA) guide- following chemotherapy] lines for asymptomatic bacteriuria were released in March Patients with spinal cord NO screen NO 2019. These guidelines highlight the importance of identi- injury (SCI) leading to fying patients in whom screening for ASB is needed in order impaired voiding to prevent UTIs. Most importantly, they provide recom- Patients with a short-term NO screen NO mendations regarding which groups should or should not be (<30 days) indwelling screened for the presence of bacteria in the urine. urethral catheter Table 1 summarizes these recommendations, which include different groups of adults with asymptomatic bac- Patients undergoing elective NO screen NO teriuria. In regard to the management of asymptomatic can- non-urologic surgeries diduria, which are not included in these guidelines, IDSA Patients undergoing YES, YES 9 guidelines for the management of candidiasis, recommends endoscopic urinary tract screen with UCX Short course removal of predisposing factors (ie indwelling catheter), when procedures/manipulation (1-2 doses) feasible. No antifungal treatment is recommended unless (Prior to transurethral of targeted patient is at risk for disseminated infection (neutropenic resection of the prostate antimicrobial patients or patients undergoing urologic invasive procedure). (TURP) or any other urologic therapy 30-60 Compared to 2005 guidelines, current guidelines highlight procedure with a risk of min prior to the importance of recognizing non-focal symptoms that his- mucosal bleeding) procedure torically have been attributed to a UTI. Many patients, espe- Patients planning to undergo NO screen NO cially the elderly, are at higher risk for delirium, changes in surgery for an artificial urinary mental status, and falls. Similarly, these people are at higher sphincter or penile prosthesis risk for having bacteriuria. This association has led to many implantation overdiagnosis of UTIs, thus overutilization of antibiotics and higher likelihood for patients to develop complications. RIMJ ARCHIVES | MARCH ISSUE WEBPAGE | RIMS MARCH 2020 RHODE ISLAND MEDICAL JOURNAL 32 INFECTION CONTROL Outcomes or concerns include but are not limited to adverse days. The preferred antibiotic should have high bioavailabil- drug reactions (ADRs), drug-to-drug interactions, polyphar- ity and great penetration. In these scenarios, fluoroquinolo- macy, increased risk for antimicrobial resistance, and other nes are frequently preferred by many providers due to their (sometimes lethal) complications
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