Approach to the adult with asymptomatic bacteriuria

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Authors
Thomas Fekete, MD
Thomas M Hooton, MD
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Allyson Bloom, MD
Approach to the adult with asymptomatic bacteriuria
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2015. | This topic last updated: Aug 12, 2015.
INTRODUCTION — Asymptomatic bacteriuria is defined as isolation of a specified quantitative count of bacteria in
an appropriately collected urine specimen from an individual without symptoms or signs of urinary tract infection.
This topic will outline the epidemiology, pathophysiology, clinical definitions, and approach to management in specific
clinical circumstances.
CLINICAL DEFINITIONS — Urine is normally sterile but can be a good growth medium for bacteria that enter the
bladder and are not eliminated. Because of the difficulty in obtaining uncontaminated voided midstream urine
specimens, quantitative thresholds have been established to distinguish bladder bacteriuria from urethral
contamination. Asymptomatic bacteriuria is defined as isolation of a specified quantitative count of bacteria in an
appropriately collected urine specimen from an individual without symptoms or signs of urinary tract infection. The
quantitative thresholds are different for voided clean catch specimens and catheterized specimens.
The presence of pyuria (≥10 leukocytes/mm of uncentrifuged urine) is not sufficient for diagnosis of bacteriuria [1-3].
This was illustrated in a study of urine samples from asymptomatic elderly women; 60 percent of samples with pyuria
had no bacteriuria [2].
Voided clean catch specimens — Diagnostic criteria for clean catch specimens including number of specimens
and minimum quantitative bacteria counts are outlined for women and men below. The definition of a positive urine
culture in the setting of symptoms of cystitis is distinct and discussed in detail elsewhere. (See "Sampling and
evaluation of voided urine in the diagnosis of urinary tract infection in adults", section on 'Definition of a positive
culture'.)
Women — Asymptomatic bacteriuria in women is defined by the 2005 Infectious Diseases Society of America
(IDSA) guidelines as two consecutive clean-catch voided urine specimens with isolation of the same organism in
quantitative counts of ≥10 cfu/mL [4].
This definition is based upon studies of voided and catheterized urine specimens from asymptomatic patients [5-9]. A
bacterial count of ≥10 cfu/mL in a catheterized specimen was confirmed by a repeat catheterized specimen in >95
percent of cases. On the other hand, ≥10 cfu/mL documented in an initial voided urine specimen was confirmed in a
second voided specimen in 80 percent of cases. Two consecutive positive cultures predicted a third positive culture
with 95 percent confidence. Therefore, two consecutive voided specimens were needed to predict bladder
bacteriuria with the same degree of accuracy as a single urine specimen obtained through a catheter.
Other studies have used a more permissive definition of a single positive urine specimen with ≥10 cfu/mL [1].
Because transient bacteriuria is common among young healthy women, the prevalence of asymptomatic bacteriuria
will be lower if >1 specimen is required for diagnosis.
Men — Asymptomatic bacteriuria in men is defined by the 2005 IDSA guidelines as a single clean-catch voided
urine specimen with isolation of a single organism in quantitative counts of ≥10 cfu/mL in the absence of symptoms
[4]. In general, external contamination during voiding among men is an extremely unlikely cause of significant
bacteriuria. (See "Acute uncomplicated cystitis and pyelonephritis in men".)
There are fewer data on microbiologic criteria for diagnosis of asymptomatic bacteriuria in men. The most rigorous
report is a study of 59 asymptomatic men with the incidental finding of ≥10 cfu/mL of an Enterobacteriaceae that
was reproducible with repeat culture one week later in 98 percent of cases [10].
Catheterized specimens — In asymptomatic catheterized men or women, bacteriuria is defined by the IDSA
guidelines as a single catheterized specimen with isolation of a single organism in quantitative counts of ≥10 cfu/mL
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5
5
5
5
5
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[4].
Catheterized specimens are less likely to be contaminated than voided specimens; therefore, positive cultures of
catheterized specimens are more likely to reflect true bladder bacteriuria even with low colony counts. There have
been no comparisons of culture yields from urethral catheterized specimens and suprapubic aspiration specimens.
EPIDEMIOLOGY
Women — The prevalence of asymptomatic bacteriuria among healthy women increases with advancing age, from
about 1 percent among schoolgirls to >20 percent among women over 80 years residing in the community [1,11,12].
It correlates with sexual activity; as an example, prevalence is greater among premenopausal married women than
nuns of the same age (4.6 versus 0.7 percent, respectively) [13]. Pregnant and non-pregnant women have a similar
prevalence (2 to 7 percent) [12]. In young healthy women, asymptomatic bacteriuria is transient; it rarely lasts longer
than a few weeks.
Prevalence among diabetic women is 8 to 14 percent and is usually correlated with duration and presence of long
term complications of diabetes, rather than with metabolic parameters of diabetes control [14]. Asymptomatic
bacteriuria in diabetic patients is discussed separately. (See "Asymptomatic bacteriuria in patients with diabetes
mellitus".)
Men — Asymptomatic bacteriuria is rare among healthy young men [15]. Among men older than 75 years residing in
the community, prevalence is 6 to 15 percent [12]. Diabetic men do not appear to have a higher prevalence of
bacteriuria than nondiabetic men [16]. (See "Acute uncomplicated cystitis and pyelonephritis in men".)
PATHOPHYSIOLOGY — The absence of symptoms in patients with asymptomatic bacteriuria could reflect
characteristics specific to the pathogen, the host or both.
The microbiology of asymptomatic bacteriuria is similar to that of cystitis and pyelonephritis, although some strains
capable of producing asymptomatic bacteriuria may have subtle adaptations that facilitate pathogenesis. For
example, attachment of bacteria via fimbrial adhesins is thought to be important for the establishment and
persistence of symptomatic infection. Some bacterial strains with reduced capability for fimbriae expression appear
to have the capacity for relatively rapid growth that thus allows them to cause asymptomatic bacteriuria [17].
Alternatively, strains implicated in asymptomatic bacteriuria may be less virulent and therefore may not necessarily
be true pathogens [18-22]. For example, Escherichia coli strains recovered from spinal cord injury patients with
asymptomatic bacteriuria demonstrate diminished capacity for red blood cell hemagglutination and hemolysis than
strains implicated in symptomatic urinary tract infections [20,21]. Even if they persist, such strains are unlikely to
progress to serious infection. Based on this notion, some investigators have suggested that colonization with
"uroprotective" strains of E. coli may be protective against infection with more invasive uropathogens [23]. (See
"Bacterial adherence and other virulence factors for urinary tract infection".)
The absence of symptoms in patients with asymptomatic bacteriuria could also reflect differences in the host
response [24,25]. A study of children with asymptomatic bacteriuria demonstrated lower levels of neutrophil Toll-like
receptor 4 (TLR4) expression compared to age-matched controls [24]. In mice, TLR4 controls the mucosal response
to E. coli and inactivation of TLR4 can lead to a carrier state that resembles asymptomaticbacteriuria [25]. (See
"Toll-like receptors: Roles in disease and therapy".)
WHOM TO TREAT — Screening for and treatment of asymptomatic bacteriuria is appropriate for pregnant women
and for patients undergoing urologic procedures in which mucosal bleeding is anticipated [4,26,27].
Pregnancy — Screening for and treatment of asymptomatic bacteriuria is warranted for pregnant women [4]. This
topic is discussed separately. (See "Urinary tract infections and asymptomatic bacteriuria in pregnancy".)
Urologic intervention — Screening for and treatment of asymptomatic bacteriuria is warranted for patients
undergoing transurethral resection of the prostate and other urologic procedures in which mucosal bleeding is
anticipated [4]. This topic is discussed separately. (See "Antimicrobial prophylaxis for prevention of surgical site
infection in adults", section on 'Genitourinary surgery'.)
WHOM NOT TO TREAT — There is no role for screening for or treating asymptomatic bacteriuria in populations
other than pregnant women or patients undergoing urologic procedures expected to cause mucosal bleeding [28,29].
In a meta-analysis of nine trials that included women and men from outpatient, geriatric, and nursing home settings,
treatment of asymptomatic bacteriuria did not reduce the incidence of symptomatic UTI (RR 1.11, 95% CI 0.51-2.43),
complications (RR 0.78, 95% CI 0.35-1.74), or death (RR 0.99, 95% CI 0.70-1.41) compared with no treatment or
placebo [29]. However, antibiotics did increase the incidence of any adverse event. Avoiding treatment of
asymptomatic bacteriuria is also important for reducing development of antibiotic resistance [30].
The following sections discuss the data supporting not treating asymptomatic bacteriuria in the following populations:
nonpregnant premenopausal women, men, diabetic patients, the elderly, or patients with spinal cord injury or
indwelling urethral catheters, and patients undergoing joint arthroplasty.
Nonpregnant premenopausal women — There is no role for screening for or treatment of asymptomatic
bacteriuria in premenopausal, nonpregnant women [4,31,32]. Although women with asymptomatic bacteriuria are at
increased risk for symptomatic urinary tract infection (UTI) [1], treatment does not reduce the frequency of
symptomatic infection or recurrent asymptomatic bacteriuria [11,31]. Although antibiotics initially sterilize the urine in
almost all patients, bacteriuria recurs in approximately one-half by one year such that the prevalence is similar to that
in untreated women at one year [31]. In addition, asymptomatic bacteriuria is not associated with long-term adverse
outcomes such as chronic kidney disease or mortality [11,33].
In fact, in healthy premenopausal, nonpregnant women who experience frequent recurrent symptomatic UTIs,
antibiotic therapy for episodes of asymptomatic bacteriuria not only is unnecessary but may also be harmful. In a trial
of such women who were found to have asymptomatic bacteriuria with a uropathogen, a greater proportion of the
361 participants randomly assigned to receive antibiotic treatment for the bacteriuria experienced a subsequent
symptomatic UTI over the following year compared with the 312 women who did not receive antibiotics (83 versus 24
percent) [34]. Interpretation of these dramatic results may be limited by the lack of blinding and a placebo control, the
unexpected pathogen profile, with E. coli accounting for only a third of cases, and the unusually low rate of study
dropout in either group. Nevertheless, if these findings are confirmed by additional studies, they support the concept
that asymptomatic bacterial colonization can protect against superinfection with more virulent strains and should not
be treated [35]. (See 'Pathophysiology' above.)
Even women on immunosuppressive agents do not appear to be at greater risk of adverse outcomes from untreated
asymptomatic bacteriuria. In a study of 260 women with rheumatologic disease, of whom 94 percent were taking an
immunosuppressive agent, asymptomatic bacteriuria was identified in 9 percent [36]. After a median of 12 months of
follow-up, the rates of symptomatic UTI among those with and without asymptomatic bacteriuria at baseline were not
statistically different (17 versus 12 percent), and no woman with asymptomatic bacteriuria developed sepsis or
pyelonephritis requiring hospitalization.
Men — In general, men should not be screened for and/or treated for asymptomatic bacteriuria. However, there are
a few circumstances in which screening may be reasonable. Screening for asymptomatic bacteriuria is warranted
prior to transurethral resection of the prostate or other urologic procedures for which mucosal bleeding is anticipated
because of the risk of post-procedure bacteremia and sepsis [4]. (See 'Urologic intervention' above and "Acute
bacterial prostatitis", section on 'Risk factors'.)
There is less apparent benefit to screening for asymptomatic bacteriuria prior to other surgical procedures. In a
retrospective study of 489 men who had urine cultures performed prior to undergoing orthopedic, cardiothoracic, and
vascular procedures, bacteriuria was uncommon (11 percent of patients) [37]. Preoperative bacteriuria was not
associated with an increased risk of surgical site infection. Furthermore, the incidence of subsequent urinary tract
infection was not decreased with antibiotic therapy for bacteriuria (3 of 43 untreated versus 2 of 11 treated patients).
A detailed discussion on the evaluation for asymptomatic bacteriuria prior to joint arthroplasty, specifically, is found
elsewhere. (See 'Patients undergoing joint arthroplasty' below.)
Diabetic patients — Asymptomatic bacteriuria in diabetic patients is discussed separately. (See "Asymptomatic
bacteriuria in patients with diabetes mellitus".)
Spinal cord injury — There is no role for screening for or treatment of asymptomatic bacteriuria among patients
with spinal cord injury [4]. Although these patients have a high prevalence of asymptomatic bacteriuria, they also
have a high rate of urinary infection with signs or symptoms (such as fever or elevated white blood cell count). In a
study of 64 spinal cord injury patients with urine quantitative bacteria counts ≥10 cfu/mL, 27 percent of patients5
were asymptomatic during the bacteriuric episode [38]. Bacteriuria tends to recur early after therapy or prophylaxis,
with emergence of antibiotic resistance [39,40].
Indwelling urethral catheters — Asymptomatic bacteriuria in patients with indwelling bladder catheters is discussed
separately. (See "Catheter-associated urinary tract infection in adults".)
Elderly in the community — There is no role for screening for or treatment of asymptomatic bacteriuria among
older persons in the community [4]. These patients are not at increased risk for adverse outcomes related to
asymptomatic bacteriuria [41-46]. This was illustrated in a randomized controlled trial of antibiotic therapy for 124
elderly ambulatory women with asymptomatic bacteriuria [41]. There was no significant difference in the number of
symptomatic episodes during the six-month follow-up period. In addition, bacteriuria is transient and tends to recur
after therapy, with emergence of antibiotic resistance [4].
Elderly in health care facilities — There is no role for screening for or treatment of asymptomatic bacteriuria
among the elderly in health care facilities [4]. Although half of women and 15 to 40 percent of men have
asymptomatic bacteriuria [42], antimicrobial treatment has not been shown to be of benefit [47,48]. This was
illustrated in a study of 191 nursing home residents with incontinence and bacteriuria who were randomly assigned
to immediate or delayed treatment [47]. Eradicating bacteriuria had no short-term effects on the severity of chronic
urinary incontinence.In addition, bacteriuria tends to recur after therapy, with emergence of antibiotic resistance [48].
(See "Medical care in skilled nursing facilities (SNFs) in the United States", section on 'Asymptomatic bacteriuria'.)
Patients undergoing joint arthroplasty — The optimal approach to the evaluation of asymptomatic bacteriuria
prior to hip or knee arthroplasty is uncertain, and there are no data from large trials to inform this issue [49]. Given
the lack of a clear association between joint infections and bacteriuria in multiple studies and the difference in the
typical pathogen profiles of these infections, we favor not routinely performing urinalysis or culture in patients without
urinary symptoms prior to or following joint arthroplasty. If a patient is found to have perioperative bacteriuria in the
confirmed absence of urinary symptoms, we favor not treating with antibiotics for the same reasons.
Most observational studies do not demonstrate a clear association between perioperative bacteriuria and
subsequent development of prosthetic joint infection, and most studies do not clearly distinguish whether
asymptomatic bacteriuria was screened for or treated [50-54]. In a prospective, multicenter study of nearly 2500
patients undergoing total hip or knee arthroplasty, screening identified asymptomatic bacteriuria (≥10 colony-
forming units/mL in the absence of signs or symptoms of UTI) in 12 percent [55]. In the year following surgery, there
were 43 prosthetic joint infections (1.7 percent). Although patients with preoperative asymptomatic bacteriuria were
more likely to have a prosthetic joint infection than those without (4.3 versus 1.4 percent infection rate, odds ratio
3.23, 95% CI 1.67-6.27), treatment of the bacteriuria, which was at the discretion of the clinician, was not associated
with a decreased risk of infection. Moreover, the organisms isolated from the urine were not the same as those from
the surgical site infection in any patient with asymptomatic bacteriuria. These results complement those of a prior
large retrospective review that did not demonstrate an association between symptomatic UTI and prosthetic joint
infection and also noted that organisms isolated from the urine and the surgical site infection in a given patient were
not the same [50]. Other small studies evaluating patients with asymptomatic preoperative bacteriuria who
proceeded to surgery (with preoperative or postoperative antibiotic therapy) failed to find any instances of
subsequent joint infections attributable to the urinary pathogens [51,52].
Other studies have suggested an association between postoperative UTI and prosthetic joint infections, but these
are mainly limited to small case reports [56-58]. In one large retrospective study, post-arthroplasty UTI was
independently associated with a subsequent surgical site infection [59]. However, the criteria for UTI diagnosis used
in the study were not specified, and there was no evaluation of a microbiological link between the uropathogens and
those causing the joint infections [59].
Some experts have advocated screening and treatment for asymptomatic bacteriuria in patients undergoing joint
arthroplasty because of the biological plausibility of subsequent surgical site infection and the relative ease of
treatment [60]. We believe that further data are warranted before such a recommendation can be made. The very
low infection risk of total joint arthroplasty, the disparity of flora between bacteriuria and surgical site infection, and
the delays as well as the small but real risks related to screening and treating bacteriuria do not support universal
screening.
5
In contrast, evaluation and treatment is indicated in pre- and postoperative patients who have symptomatic UTI. (See
"Acute uncomplicated cystitis and pyelonephritis in women", section on 'Treatment' and "Acute uncomplicated cystitis
and pyelonephritis in men", section on 'Treatment' and "Acute complicated cystitis and pyelonephritis", section on
'Treatment'.)
SUMMARY AND RECOMMENDATIONS
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Asymptomatic bacteriuria is defined as isolation of a specified quantitative count of bacteria in an appropriately
collected urine specimen from an individual without symptoms or signs of urinary tract infection. (See 'Clinical
definitions' above.)
●
In asymptomatic women, bacteriuria is defined as two consecutive clean-catch voided urine specimens with
isolation of the same organism in quantitative counts of ≥10 cfu/mL. (See 'Women' above.)
●
5
In asymptomatic men, bacteriuria is defined as a single clean-catch voided urine specimen with isolation of a
single organism in quantitative counts of ≥10 cfu/mL. (See 'Men' above.)
●
5
In asymptomatic catheterized men or women, bacteriuria is defined as a single catheterized specimen with
isolation of a single organism in quantitative counts of ≥10 cfu/mL. (See 'Catheterized specimens' above.)
●
2
Treatment of asymptomatic bacteriuria is appropriate for pregnant women and for patients undergoing urologic
procedures in which mucosal bleeding is anticipated. (See 'Whom to treat' above.)
●
Treatment of asymptomatic bacteriuria is not appropriate in other populations, including: nonpregnant
premenopausal women, diabetics, the elderly, nursing home residents, patients with spinal cord injury or
indwelling urethral catheters, and those undergoing joint arthroplasty. (See 'Whom not to treat' above.)
●
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Disclosures: Thomas Fekete, MD Nothing to disclose. Thomas M Hooton, MD Consultant/Advisory Boards: Cubist [Complicated UTI
(Ceftolozane/tazobactam)]; Vifor Pharma [Uncomplicated UTI (Immunostimulant uro-vaxom)]. Equity Ownership/Stock Options: Fimbrion
Therapeutics [Prevention of UTI (Developing mannosides that may eventually be useful in prevention of UTI)]. Stephen B Calderwood,
MD Patent Holder: Vaccine Technologies Inc. [Vaccines (Cholera vaccines)]. Equity Ownership/Stock Options: Pulmatrix [Inhaled
antimicrobials]; PharmAthene [Anthrax (Anti-protective antigen monoclonal antibody)]. Allyson Bloom, MD Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a
multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced
content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
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Disclosures