Asymptomatic bacteriuria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2], Abdurahman Khalil, M.D. [3], Sadaf Sharfaei M.D.[4]

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. Presence of >10 leukocytes/mm³ is considered as pyuria but not asymptomatic bacteriuria unless the number exceeds ≥105 colony forming units(cfu)/mL. There are two main pathogenesis that might be responsible for asymptomatic bacteriuria which include microbial virulence and host factors. Escherichia coli is the single most common cause of asymptomatic bacteriuria. Asymptomatic bacteriuria is more common in elderly and its prevalence increase with age. Asymptomatic bacteriuria has been slightly more common in black population. Asymptomatic bacteriuria has risk factors similar to symptomatic bacteriuria such as pregnancy, aging, diabetes mellitus, sexual intercourse, using diaphragm plus spermicide, BPH, renal stones, or patients with spinal cord injuries, hemodialysis, indwelling urethral catheters, genitourinary abnormalities. 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. If left untreated asymptomatic bacteriuria normally cures on its own and active treatment is not required except in those who are pregnant, require renal transplantation or are supposed to undergo a urinary tract procedure. In patients who acquire asymptomatic bacteriuria early in their pregnancy, there is a minute chance of issues related to pregnancy like low birth weight etc or pyelonephritis. Most cases resolve postpartum. 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. Treatment is not required in otherwise healthy individuals unless it is associated with a urinary tract infection. Conditions that might require the asymptomatic bacteriuria to be treated are pregnancy, before transurethral prostatic resection, and renal transplant follow-up.

Historical Perspective

Classification

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. The prevalence of bacteriuria is more in sexually active women (4.6%) as compared to sexually inactive women (0.7%) or men.

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.[5][6]

Host Factors

Causes

Most common organism

Common Causes Less Common Causes GU abnormalities & Hospitalization Long Term Catheterisation[13][14]
Enterococcus[15] Chromobacterium violaceum[16] E.coli[13][17] Pseudomonas aeruginosa
Enterobacteriaceae[18] Staphylococci[19] Proteus mirabilis[13][20] P. mirabilis
Klebsiella[21] Gardnerella vaginalis[22][23] Providencia stuartii
Pseudomonas aeruginosa[24] Elizabethkingia meningoseptica[25] Morganella morganii
Group B Streptococcus[26][27]

Differentiating Asymptomatic Bacteriuria From Other Diseases

Asymptomatic Bacteriuria must be differentiated from other diseases that might cause bacteriuria.[28][29][30][31]

To review differential diagnosis of pyuria, click here.

To review differential diagnosis of sterile pyuria, click here.

Category Disease Clinical manifestations Para−clinical findings Gold standard for diagnosis Associated findings
Symptoms Physical examination
Lab Findings Imaging
Pain Fever N/V Urinary symptoms BP Other CBC Electrolytes Urinalysis
Dysuria Frequency Urgency Gross hematuria Cell Cast Bacteriuria Culture Other
Infectious diseases UTI[32] Bacterial Asymptomatic bacteriuria[33][34] Nl Nl Nl ± + NA NA Urinalysis
  • Increased risk in pregnancy
  • Must be treated prior to an invasive urologic procedure
Cystitis[35] + + + Nl Nl Nl + + + NA Urinalysis NA
Pyelonephritis[36] + + + + + + Nl Nl + WBC cast + + NA Clinical manifestation + urinalysis NA
Prostatitis[37]  Pelvic or perineal pain + + + + + Nl or ↑
  • Dribbling of urine
  • Firm and tender prostate
Nl + ± + NA Clinical manifestation + urinalysis
  • Increased risk of bacteremia, prostatic abscess, and metastatic infection
  • Might be acute or chronic infection
Balanitis[38] Penile pain + + + + Nl
  • Pruritus
  • Erythematous lesions on the glans and/or the foreskin
Nl Nl + ± NA NA Clinical manifestation
Non−infectious diseases Urinary tract disorders Urinary catheterization[39] + + Nl Nl + + + Clinical manifestation + urinalysis
Disease Pain Fever N/V Dysuria Frequency Urgency Gross hematuria BP Other PE CBC Electrolytes Cell Cast Bacteriuria Culture Other UA findings Imaging Gold standard for diagnosis Associated findings

Epidemiology and Demographics

Prevalance

Age

  • Asymptomatic bacteriuria is more common in elderly and its prevalence increase with age.[42][43]
  • The prevalence of asymptomatic bacteriuria in women greater than 80 years old is >20%.[44][45]
  • The prevalence of asymptomatic bacteriuria in men greater than 75 year old is 6-15%.[46]
  • 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.[47][48]

Gender

  • Asymptomatic bacteriuria is more prevalent in females as compared to males.
  • Asymptomatic bacteriuria is rare among healthy men.[49][50]

Race

  • Asymptomatic bacteriuria has been slightly more common in black population.[51]

Risk Factors

Asymptomatic bacteriuria has risk factors similar to symptomatic bacteriuria. Some of these include:[52][53]

General Risk Factors

Disease Conditions

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.[61]

Individuals requiring screening

The following should be screened for asymptomatic bacteriuria:[62][63]

Catheter Associated Asymptomatic Bacteriuria

It is not recommended to screen for or treat asymptomatic bacteriuria or fungiuria for short or long term catheters, 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][65]

Natural History, Complications, and Prognosis

Natural History

Complications

Asymptomatic bacteriuria rarely leads to complications. These may include:

Prognosis

Asymptomatic bacteriuria has a good prognosis and completely resolves with treatment.[75]

Diagnosis

Diagnostic Study of Choice

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:[76]

  • 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.

History and Symptoms

Patients with asymptomatic bacteriuria are asymptomatic.

Physical Examination

Patients with asymptomatic bacteriuria appear completely normal.

Laboratory Findings

Electrocardiogram

There are no ECG findings associated with asymptomatic bacteriuria.

X-ray

There are no x-ray findings associated with asymptomatic bacteriuria.

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with asymptomatic bacteriuria.

CT scan

There are no CT scan findings associated with asymptomatic bacteriuria.

MRI

There are no MRI findings associated with asymptomatic bacteriuria.

Other Imaging Findings

There are no other imaging findings associated with asymptomatic bacteriuria.

Other Diagnostic Studies

There are no other diagnostic studies associated with asymptomatic bacteriuria.

Treatment

Medical Therapy

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:[87][88][89][63][90][91]

Asymptomatic bacteriuria treatment

  • 1. Empiric antimicrobial therapy
  • Treatment of asymptomatic bacteriuria is not recommended for the following persons:
  • 2. Specific considerations
  • 2.1 Women, pregnant
  • 2.2 Patients with indwelling urethral catheters
  • Screening for or treatment of asymptomatic bacteriuria in patients with indwelling urethral catheters is not recommended.
  • Note (1): Antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria that persists 48 hours after catheter removal may be considered.
  • 2.3 Urologic interventions
  • 2.4 Renal transplant
  • 2.5 Catheter Associated Asymptomatic Bacteriuria

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.[97]

Surgery

Surgical intervention is not recommended for the management of asymptomatic bacteriuria.

Primary Prevention

Primary preventive measure for asymptomatic bacteriuria include:[98][99]

Secondary Prevention

Secondary preventive measures for asymptomatic bacteriuria include:

References

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