Continuing Education Activity

Asymptomatic bacteriuria is the presence of bacteria in the properly collected urine of a patient that has no signs or symptoms of a urinary tract infection. Asymptomatic bacteriuria is very common in clinical practice and its incidence increases with age. The incidence is 15 percent or greater in women and men age 65 to 80 years and as high as 40 to 50 percent after age 80. Most patients with asymptomatic bacteriuria will never develop symptomatic urinary tract infections and will have no adverse consequences from asymptomatic bacteriuria. Only patients with asymptomatic bacteriuria that will benefit from treatment should be treated, and most patients will not benefit from treatment. There are, however, a few exceptions. There is sufficient evidence that a pregnant woman with asymptomatic bacteriuria should be treated. Also, patients undergoing urologic procedures in which mucosal bleeding is expected and patients who are in the first three months following renal transplantation should be treated for asymptomatic bacteriuria.This activity reviews the evaluation and management of asymptomatic bacteriuria and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance outcomes for affected patients.

Objectives:

• Explain how the diagnosis of asymptomatic bacteriuria is made.
• Outline the reasons for treating asymptomatic bacteriuria with antibiotics.
• Summarize the reasons for avoiding unnecessary treatment of asymptomatic bacteriuria.
• Describe how an optimally functioning interprofessional team would coordinate care to enhance outcomes for patients with asymptomatic bacteriuria.

Introduction

Asymptomatic bacteriuria is the presence of bacteria in the properly collected urine of a patient that has no signs or symptoms of a urinary tract infection. Asymptomatic bacteriuria is very common in clinical practice. While few infants and toddlers have asymptomatic bacteriuria, the incidence increases with age. The incidence is up to 15% or greater in women and men age 65 to 80 years and as high as 40% to 50% after age 80.  Most patients with asymptomatic bacteriuria will never develop symptomatic urinary tract infections and will have no adverse consequences from asymptomatic bacteriuria.  In an age when decreasing unnecessary antibiotic use is emphasized, the important clinical question is this:  Which patients with asymptomatic bacteriuria benefit from treatment? The answer is that most patients with asymptomatic bacteriuria do not benefit from treatment. There are, however, a few exceptions. There is sufficient evidence that a pregnant woman with asymptomatic bacteriuria should be treated.  [1][2][3] Also, patients undergoing urologic procedures in which mucosal bleeding is expected and patients who are in the first three months following renal transplantation should probably be treated for asymptomatic bacteriuria.

Etiology

The etiology of asymptomatic bacteriuria has not been conclusively determined. Asymptomatic bacteriuria is more common among women than among men probably because of the shorter female urethra, which gives bacteria from the urethral meatus and the perineum a shorter distance to the bladder. In fact, most women have transient bacteriuria after sexual intercourse, but few of these women will develop symptomatic infections because the body's normal defense mechanisms prevent symptomatic infection in most cases.  In the elderly, it is thought that incomplete bladder emptying contributes to the increased incidence of asymptomatic bacteriuria.[4]

Epidemiology

Asymptomatic bacteriuria is a common clinical finding. While less than 0.5% of infants and toddlers have asymptomatic bacteriuria, the incidence increases with age. The incidence is 5% or less among healthy premenopausal women, up to 15% or greater in women and men age 65-80 years, and it continues to climb after age 80 to as high as 40% to 50% of long-term care residents. At any age, the incidence of asymptomatic bacteriuria is higher among females than among males. Escherichia coli is the most common bacteria identified in asymptomatic bacteriuria.[5]

History and Physical

Patients with asymptomatic bacteriuria are, by definition, asymptomatic. They have no symptoms that can be attributed to bacteria in the urine. This is completely different from the evaluation and management of symptomatic bacteriuria or urinary tract infections.  Several factors are thought to increase the likelihood of asymptomatic bacteriuria.[6]  These include:

• obstructive uropathy (stones, prostatic hypertrophy, cystocele, etc.),
• fecal soiling of the perineum (especially in women),
• indwelling urinary catheters, and
• frequent instrumentation of the urinary tract.

Evaluation

Diagnosis of asymptomatic bacteriuria is made by urine culture. Either a properly collected clean-catch specimen or a catheterized specimen is acceptable. The Infectious Diseases Society of America (IDSA) has established criteria for diagnosing asymptomatic bacteriuria.

Midstream clean catch urine specimen:

• For women, two consecutive specimens with isolation of the same bacteria species with at least 100,000 colony-forming units (CFUs) per ml of urine.
• For men, a single specimen with isolation of one bacteria species with at least 100,000 CFUs per ml of urine.

Catheterized specimen:

• For women or men, a single specimen with isolation of one bacteria species with at least 100 CFUs per ml of urine.

Urine dipstick for leukocyte esterase will reliably identify pyuria, but it is not specific for asymptomatic bacteriuria. (Pyuria may result from other inflammatory disorders of the genitourinary tract.) Urinary dipstick for nitrites is also of limited usefulness because of infection with non-nitrite-producing organisms, the delay between collection and testing of the specimen, and insufficient time since the last voiding for nitrites to be produced at detectable levels. The combination of the dipstick for leukocyte esterase and nitrites is more specific for asymptomatic bacteriuria than either test alone. Urinalysis with microscopic exam for bacteria is a useful, but non-quantitative, way to identify bacteriuria.  

Pregnant women should be screened for asymptomatic bacteriuria with a urine culture. The optimal timing and frequency of screening urine cultures in pregnancy have not been established, but obtaining a screening urine culture at the end of the first trimester of pregnancy is recommended.  

Other than in pregnancy, there are few indications to screen for asymptomatic bacteriuria. Two possible clinical scenarios in which a screening urine culture might be appropriate include patients undergoing urological procedures in which mucosal bleeding is expected, such as resection of the prostate, and patients who are in the first three months following renal transplantation.[7]

Treatment / Management

Most patients with asymptomatic bacteriuria will not develop symptomatic urinary tract infections and will have no adverse consequences from asymptomatic bacteriuria.  Specifically, children, patients with diabetes, older patients, patients with spinal cord injuries, and patients with indwelling urinary catheters do not benefit from treatment with antibiotics for asymptomatic bacteriuria. Treatment in these patients does not decrease the incidence of symptomatic urinary tract infections or improve survival. However, it does increase the likelihood of adverse effects from antibiotics and the development of antibiotic-resistant bacteria.

In contrast, treatment of pregnant women with asymptomatic bacteriuria has been shown to be beneficial. Antimicrobial treatment of asymptomatic bacteriuria in pregnancy decreases the risk of pyelonephritis, low-birthweight infants, and preterm delivery.  In addition, patients undergoing urologic procedures in which mucosal bleeding is expected, such as with resection of the prostate, and patients who are in the first three months following renal transplantation probably should be treated. There is evidence that treatment of asymptomatic bacteriuria in these patients decreases the risk of symptomatic urinary tract infection.    

Treatment should be guided by the results of urine culture and sensitivity. Amoxicillin, amoxicillin/clavulanate, cefuroxime, cephalexin, and nitrofurantoin are considered safe for use in pregnancy. [7][8][9] Treatment duration should be for 3 to 7 days for pregnant women, and at least one follow-up urine culture should be performed. 

Differential Diagnosis

• Acute pyelonephritis

• Bladder cancer

• Chlamydia (chlamydial genitourinary infections)

• Cystitis (nonbacterial)

• Herpes simplex

• Interstitial cystitis

• Pelvic inflammatory disease

• Renal and perirenal abscess

• Urethritis

• Vaginitis

Pearls and Other Issues

Cost-effective use of health care resources necessitates careful scrutiny to avoid unnecessary tests and treatments.  "Antibiotic stewardship," or the appropriate use of antibiotics in a way that improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multi-drug-resistant organisms, is essential.  As such, a rational and evidence-based approach to the evaluation and treatment of asymptomatic bacteriuria is important.  It is not appropriate to routinely order a urinalysis and urine culture and sensitivity test on every patient admitted to the hospital unless there is a clinical reason to suspect a symptomatic or an occult urinary tract infection. Additionally, when the clean-catch urine culture of a 70-year-old female (who is admitted for a diagnosis unrelated to her urinary tract and has no urinary symptoms) increases to >100,000 CFU/ml of Escherichia coli, which it often will, it is appropriate to resist the temptation to treat the culture results. [10][11] Treatment is unnecessary, and may even be harmful. 

Enhancing Healthcare Team Outcomes

The management of asymptomatic bacteriuria is not simple and requires clinical acumen. When encountering such patients, an interprofessional approach with an infectious disease expert, emergency department physician, nurse practitioner, internist, pharmacist, and a nurse is recommended.

Most patients with asymptomatic bacteriuria will not develop symptomatic urinary tract infections and will have no adverse consequences from asymptomatic bacteriuria.  Specifically, children, patients with diabetes, older patients, patients with spinal cord injuries, and patients with indwelling urinary catheters do not benefit from treatment with antibiotics for asymptomatic bacteriuria. Treatment in these patients does not decrease the incidence of symptomatic urinary tract infections or improve survival. However, it does increase the likelihood of adverse effects of antibiotics and the development of antibiotic-resistant bacteria.

In contrast, treatment of pregnant women with asymptomatic bacteriuria has been shown to be beneficial. [12][1]There is evidence that treatment of asymptomatic bacteriuria in these patients decreases the risk of symptomatic urinary tract infection.  

The nurse should focus on assisting with patient education and assisting the family in learning to help the patient. The pharmacist may provide guidance to the clinician regarding medication choices as needed and help prevent drug-drug interactions. The clinical team of pharmacist, nurse, and clinician working together to educate and assist the patient and family will result in the best outcomes. [Level V]

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References

1.

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Averbeck MA, Rantell A, Ford A, Kirschner-Hermanns R, Khullar V, Wagg A, Cardozo L. Current controversies in urinary tract infections: ICI-RS 2017. Neurourol Urodyn. 2018 Jun;37(S4):S86-S92. [PubMed: 30133791]

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Wullt B, Sundén F, Grabe M. Asymptomatic Bacteriuria is Harmless and Even Protective: Don't Treat if You Don't Have a Very Specific Reason. Eur Urol Focus. 2019 Jan;5(1):15-16. [PubMed: 30030090]

4.

Bigotte Vieira M, Alves M, Costa J, Vaz-Carneiro A. [Bacteriuria. Cochrane Database Syst Rev. 2015;4:CD009534.]. Acta Med Port. 2018 Feb 28;31(2):76-79. [PubMed: 29596766]

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Dahiya A, Goldman RD. Management of asymptomatic bacteriuria in children. Can Fam Physician. 2018 Nov;64(11):821-824. [PMC free article: PMC6234948] [PubMed: 30429177]

6.

Albu S, Voidazan S, Bilca D, Badiu M, Truţă A, Ciorea M, Ichim A, Luca D, Moldovan G. Bacteriuria and asymptomatic infection in chronic patients with indwelling urinary catheter: The incidence of ESBL bacteria. Medicine (Baltimore). 2018 Aug;97(33):e11796. [PMC free article: PMC6112905] [PubMed: 30113467]

7.

Moore A, Doull M, Grad R, Groulx S, Pottie K, Tonelli M, Courage S, Garcia AJ, Thombs BD., Canadian Task Force on Preventive Health Care. Recommendations on screening for asymptomatic bacteriuria in pregnancy. CMAJ. 2018 Jul 09;190(27):E823-E830. [PMC free article: PMC6041243] [PubMed: 29986858]

8.

Medley N, Vogel JP, Care A, Alfirevic Z. Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 2018 Nov 14;11(11):CD012505. [PMC free article: PMC6516886] [PubMed: 30480756]

9.

Coussement J, Maggiore U, Manuel O, Scemla A, López-Medrano F, Nagler EV, Aguado JM, Abramowicz D., European Renal Association-European Dialysis Transplant Association (ERA-EDTA) Developing Education Science and Care for Renal Transplantation in European States (DESCARTES) working group and the European Study Group for Infections in Compromised Hosts (E. COLLABORATORS (IN ALPHABETICAL ORDER). European Renal Association-European Dialysis Transplant Association (ERA-EDTA) Developing Education Science and Care for Renal Transplantation in European States (DESCARTES) working group and the European Study Group for Infections in Compromised Hosts (ESGICH) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). Diagnosis and management of asymptomatic bacteriuria in kidney transplant recipients: a survey of current practice in Europe. Nephrol Dial Transplant. 2018 Sep 01;33(9):1661-1668. [PubMed: 29635410]

10.

Kulchavenya E. Editorial Comment to Role of increasing leukocyturia for detecting the transition from asymptomatic bacteriuria to symptomatic infection in women with recurrent urinary tract infections: A new tool for improving antibiotic stewardship. Int J Urol. 2018 Sep;25(9):806-807. [PubMed: 30008187]

11.

Keller SC, Feldman L, Smith J, Pahwa A, Cosgrove SE, Chida N. The Use of Clinical Decision Support in Reducing Diagnosis of and Treatment of Asymptomatic Bacteriuria. J Hosp Med. 2018 Jun 01;13(6):392-395. [PMC free article: PMC6329386] [PubMed: 29856886]

12.

Skelton F, Martin LA, Evans CT, Kramer J, Grigoryan L, Richardson P, Kunik ME, Poon IO, Holmes SA, Trautner BW. Determining Best Practices for Management of Bacteriuria in Spinal Cord Injury: Protocol for a Mixed-Methods Study. JMIR Res Protoc. 2019 Feb 14;8(2):e12272. [PMC free article: PMC6393777] [PubMed: 30762584]

Disclosure: Donald Givler declares no relevant financial relationships with ineligible companies.

Disclosure: Amy Givler declares no relevant financial relationships with ineligible companies.