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By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
Dr. Deresinski reports no financial relationships relevant to this field of study.
SYNOPSIS: New guideline recommendations indicate that the only unequivocal indications for screening and treatment of asymptomatic bacteriuria are pregnancy and undergoing endoscopic urologic procedures associated with mucosal injury.
SOURCE: Nicolle LE, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis 2019; March 21. doi: 10.1093/cid/ciy1121. [Epub ahead of print].
The Infectious Diseases Society of America has published its recommendations, which are few in number, regarding the indications for screening and treatment of asymptomatic bacteriuria. Groups to screen and treat are:
Groups for whom screening and treating asymptomatic bacteriuria is not recommended include:
The guideline authors were unable to provide a recommendation for the following because of inadequate evidence:
Older patients with functional and/or cognitive impairment (with or without a fall) who have known bacteriuria but without local urinary symptoms or systemic signs of infection but with acute mental status change should undergo evaluation for other causes of their symptoms rather than antibiotic administration. For patients who present with sepsis syndrome and no localizing source, broad-spectrum antimicrobial therapy directed at both urinary and non-urinary pathogens is indicated.
The prevalence of asymptomatic bacteriuria is approximately 1% in school-age girls, almost 5% in sexually active premenopausal women (in whom it is often transient) and in pregnancy, and > 20% in community-dwelling women > 80 years of age. It is rarely present in healthy males, but occurs at elevated frequency in elderly community-dwelling men. In general, antibiotic treatment of asymptomatic bacteriuria is contraindicated because the personal and societal risks of this approach are real and the benefit is nonexistent. The authors of a recent study of 68,265 veterans concluded that “receipt of antimicrobial therapy with activity against asymptomatic bacteria organisms identified in preoperative cultures was not associated with reductions in the risk for postoperative infections, including urinary tract infections and surgical site infections.”1 In a 2018 systematic review and meta-analysis, the authors found no benefit from screening and treatment of asymptomatic bacteriuria in patients undergoing joint arthroplasty.2
Prevention of inappropriate screening and treatment of asymptomatic bacteriuria is an important antimicrobial stewardship activity and, frequently, a frustrating one. Adherence to this guideline will be associated with decreased occurrence of adverse reactions to unnecessarily administered antibiotics, the decreased occurrence of Clostridioides difficile infection, and reduced selective pressure that leads to antimicrobial resistance. However, altering clinician behavior in this domain often is difficult and frustrating — but increasingly important.
Financial Disclosure: Internal Medicine Alert’s Physician Editor Stephen Brunton, MD, is a retained consultant for Abbott, Acadia, Allergan, AstraZeneca, Avadel, Boehringer Ingelheim, GlaxoSmithKline, Janssen, Mylan, and Salix; he serves on the speakers bureau of AstraZeneca, Boehringer Ingelheim, Janssen, Lilly, and Novo Nordisk. Peer Reviewer Gerald Roberts, MD; Editor Jonathan Springston; Editorial Group Manager Leslie Coplin; and Accreditations Manager Amy M. Johnson, MSN, RN, CPN, report no financial relationships relevant to this field of study.