Asymptomatic bacteriuria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Abdurahman Khalil, M.D. [2], Usama Talib, BSc, MD [3]

Overview

Urine is normally sterile. Asymptomatic bacteriuria is a condition in which a significant number of bacteria appear in the urine, without the presence of typical symptoms of a urinary tract infection. Examples of such symptoms include burning during urination, frequent urination (frequency) and urgency. Presence of >10 leukocytes/mm³ is considered as pyuria but not asymptomatic bacteriuria unless the number exceeds ≥105 colony forming units(cfu)/mL.[1][2]

Definitions

According to the Infectious Disease Society of America (IDSA), asymptomatic bacteriuria is defined as the presence of ≥105 cfu/mL of bacteria in clean catch urine specimen of an asymptomatic person with respect to symptoms urinary tract infection. By definition, one positive sample is enough to confirm asymptomatic bacteriuria in men, whereas in women two consecutive samples with same organism are required to diagnose asymptomatic bacteriuria. In men or women who are catheterized and are asymptomatic, identification of ≥102 cfu/mL of a single organism in the catheterized specimen is defined as asymptomatic bacteriuria.[3][4]

Historical Perspective

Pathophysiology

Microbial Virulence

  • Asymptomatic bacteriuria may also be due to the decreased virulence of some strains that gather in the bladder but do not cause a symptomatic appearance. Some strains isolated from patients with asymptomatic bacteriuria in the setting of spinal cord injury have decreased capability of causing hemolysis.[9][10]

Host Factors

Causes

Most common organism

Escherichia coli is the single most common cause of asymptomatic bacteriuria.[13][14][15][16]

Other common causes of asymptomatic bacteriuria include:

Common

Causes

Less Common

Causes

GU abnormalities

& Hospitalization

Long Term Catheterisation[17][18]
Enterococcus[19] Chromobacterium violaceum[20] E.Coli[17][21] Pseudomonas aeruginosa
Enterobacteriaceae[22] Staphylococci[23] P. mirabilis
Klebsiella[24] Gardnerella vaginalis[25][26] Proteus mirabilis[17][27] Providencia stuartii
Pseudomonas aeruginosa[28] Elizabethkingia meningoseptica[29] Morganella morganii
Group B Streptococcus[30][31]

Differentiating Asymptomatic Bacteriuria From Other Diseases

UTI

As the name signifies, asymptomatic bacteriuria has no symptomatic presentation. It can be easily differentiated from other urinary tract infections in that they are identified by the presence of urinary symptoms including dysuria, hematuria, urgency, frequency and flank pain. Fever is also an important finding accompanying other urinary tract infections.

Pyuria

Asymptomatic bacteriuria should be differentiated from pyuria, which also signifies presence of an inflammatory response. Pyuria is the presence of excessive leukocytes in the urine. Less than 5 leukocytes are a normal finding in the urine whereas >15 leukocytes per 400x microscopic field in the urine sample are considered to be pyuria. Pyuria is not defined on the basis of colony forming units of the organism but exclusive on the number of leukocytes. Pyuria usually accompanies asymptomatic bacteriuria.[32]

Epidemiology

Prevalance

Age

  • Asymptomatic bacteriuria is more common in elderly and its prevalence increase with age.[35]
  • The prevalence of asymptomatic bacteriuria in women greater than 80 years old is >20%.[36][37]
  • The prevalence of asymptomatic bacteriuria in men greater than 75 year old is 6 to 15%.[38]
  • Asymptomatic bacteriuria is present in 3-5% of the women population between 38-60 years of age. It was identified in 5% of women in universities and 6% of women in groups related to health maintenance organisations.[39][40]

Gender

Race

  • Asymptomatic bacteriuria has been slightly more common in black population.[44]

Risk Factors

Asymptomatic bacteriuria has risk factors similar to symptomatic bacteriuria. Some of these include:[45][46]

General Risk Factors

Disease Conditions

Natural History, Complications and Prognosis

Natural History

Complications

Asymptomatic bacteriuria rarely leads to complications. These may include

Complications in Pregnancy

Prognosis

Asymptomatic bacteriuria has a good prognosis and completely resolves with treatment.[61]

Screening

Screening for asymptomatic subjects is considered if bacteriuria is associated with preventable adverse outcomes such as symptomatic urinary infection, progression to chronic kidney disease or hypertension, development of urinary tract cancer, and decreased duration of survival.[4]

Individuals requiring screening

The following should be screened for asymptomatic bacteriuria[62][54]

Catheter Associated Asymptomatic Bacteriuria

It is not recommended to screen for or treat asymptomatic bacteriuria or fungiuria for short or long term catheters,[63] exceptions are catheterized pregnant women and women with persistent bacteriuria 48 hours after removal of the urethral catheter. Prophylaxis can also be used also with patients undergoing urological procedures.[64]

Diagnosis

Diagnostic Criteria

The diagnosis of bacteriuria in an asymptomatic individual is based on the culture results of urine collected in a manner that minimizes the possibility of contamination and limits the period between sampling and testing the specimen to avoid false positivity due to bacterial growth.

The quantitative definition for significant bacteriuria is:[68]

  • For asymptomatic women, bacteriuria is defined as 2 consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts of ≥105 CFU/mL.

Laboratory Findings

Pyuria

Pyuria is defined as increased numbers of polymorphonuclear leukocytes in the uirne and is evidence of an inflammatory response in the urinary tract.[32] An operational definition of pyuria is the presence of ≥10 leukocytes per 400x microscopic field in the sediment of first-void urine. Although pyuria is prevalent among people with asympatomatic bacteriuria,[49][71][72][73][74] its presence or degree has not been shown to correlate with the prognosis and should not affect clinical decisions about antibiotics.[75][76][77] Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment.[4]

Click here for more details about pyuria.

X-ray

Xray is not required to diagnose asymptomatic bacteriuria.

CT

CT is not required to diagnose asymptomatic bacteriuria.

MRI

MRI is not required to diagnose asymptomatic bacteriuria.

Treatment

Treatment is not required in otherwise healthy individuals unless it is associated with a urinary tract infection. Some other conditions that might require the asymptomatic bacteriuria to be treated are: [78][79][80]

Antimicrobial Regimen

  • Asymptomatic bacteriuria treatment[81][82]
  • 1. Empiric antimicrobial therapy
  • Treatment of asymptomatic bacteriuria is not recommended for the following persons:
  • 2. Specific considerations[54]
  • 2.1 Women, pregnant[83]
  • Preferred regimen (1): Nitrofurantoin 100 mg PO bid for 3–5 days (avoid in glucose-6-phosphate dehydrogenase deficiency)
  • Preferred regimen (2): Amoxicillin 500 mg PO tid for 3–5 days
  • Preferred regimen (3): Amoxicillin-Clavulanate 500 mg PO bid for 3–5 days
  • Preferred regimen (4): Cephalexin 500 mg PO tid for 3–5 days
  • Preferred regimen (5): Fosfomycin 3 g PO single dose
  • Preferred regimen (6): Trimethoprim 200 mg PO bid for 3–5 days (only after first trimester)
  • Note (1): Pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy, and they should be treated if the results are positive.
  • Note (2): Periodic screening for recurrent bacteriuria should be undertaken after therapy.
  • Note (3): Infectious Disease Society of America (IDSA) guidelines recommend 3–7 days of antimicrobial therapy.
  • 2.2 Patients with indwelling urethral catheters
  • Screening for or treatment of asymptomatic bacteriuria in patients with indwelling urethral catheters is not recommended.
  • Note: Antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria that persists 48 hours after catheter removal may be considered.
  • 2.3 Urologic interventions[84]
  • Screening for or treatment of asymptomatic bacteriuria before transurethral resection of the prostate is recommended
  • Preferred regimen: Trimethoprim-Sulfamethoxazole DS 1 tab PO bid for 3 days after obtaining urine cultures
  • 2.5 Catheter Associated Asymptomatic Bacteriuria
  • Regimen : TMP-SMX DS 1 tab bid x 3 days

Followup

  • A large proportion of women with asymptomatic bacteriuria in pregnancy have a recurrence after a short duration of therapy and for this reason a followup is done one week after completing the therapy and then monthly until the birth due to a higher chance of recurrence.[88]

Primary Prevention

Primary preventive measure for asymptomatic bacteriuria include[89][90]

Secondary Prevention

Secondary preventive measures for asymptomatic bacteriuria include

References

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  3. Rubin, RH.; Shapiro, ED.; Andriole, VT.; Davis, RJ.; Stamm, WE. (1992). "Evaluation of new anti-infective drugs for the treatment of urinary tract infection. Infectious Diseases Society of America and the Food and Drug Administration". Clin Infect Dis. 15 Suppl 1: S216–27. PMID 1477233. Unknown parameter |month= ignored (help)
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  38. Lindsay E. Nicolle (2003). "Asymptomatic bacteriuria: when to screen and when to treat". Infectious disease clinics of North America. 17 (2): 367–394. PMID 12848475. Unknown parameter |month= ignored (help)
  39. C. Bengtsson, U. Bengtsson, C. Bjorkelund, K. Lincoln & J. A. Sigurdsson (1998). "Bacteriuria in a population sample of women: 24-year follow-up study. Results from the prospective population-based study of women in Gothenburg, Sweden". Scandinavian journal of urology and nephrology. 32 (4): 284–289. PMID 9764457. Unknown parameter |month= ignored (help)
  40. T. M. Hooton, D. Scholes, A. E. Stapleton, P. L. Roberts, C. Winter, K. Gupta, M. Samadpour & W. E. Stamm (2000). "A prospective study of asymptomatic bacteriuria in sexually active young women". The New England journal of medicine. 343 (14): 992–997. doi:10.1056/NEJM200010053431402. PMID 11018165. Unknown parameter |month= ignored (help)
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