Asymptomatic bacteriuria does not cause any symptoms. Diagnosis Your doctor will ask you to provide a clean-catch urine sample. You will be given a sterile container and instructions on how to clean the area around the urethra. Do not touch inside the container. The urine sample will be sent to the laboratory where a urine culture is performed. The urine culture will determine if there are bacteria in your urine.
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Nicolle, Kalpana Gupta, Suzanne F. Bradley, Richard Colgan, Gregory P. Eckert, Suzanne E. Knight, Sanjay Saint, Anthony J.
PDF Abstract Asymptomatic bacteriuria ASB is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures.
Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available.
In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance.
The current guideline updates the recommendations of the guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.
ASB is a common finding in some healthy female populations and in many women or men with abnormalities of the genitourinary tract that impair voiding. The current guideline reviews and updates the guideline, incorporating new evidence that has become available.
The recommendations also consider populations not addressed in the guidelines, such as children and patients with solid organ transplants or neutropenia. Since the previous guideline was published, antimicrobial stewardship programs have identified nontreatment of ASB as an important opportunity for decreasing inappropriate antimicrobial use.
Nonlocalizing signs and symptoms are common in individuals in some populations with a high prevalence of ASB and may lead to clinical uncertainty in the diagnosis of symptomatic infection. This may compromise the implementation of nontreatment recommendations. Candiduria is not addressed, as recommendations for management of this syndrome were included in the recent update of the IDSA Clinical Practice Guidelines for the Management of Candidiasis.
The panel followed a process used in the development of other IDSA guidelines, which included a systematic weighting of the strength of recommendation and quality of evidence using Grading of Recommendations Assessment, Development and Evaluation GRADE Figure 1 [1—5]. Summarized below are the revised recommendations for the management of ASB in adults and children.
The guidelines are not intended to replace clinical judgment in the management of individual patients. A detailed description of the methods, background, and evidence summaries that support each recommendation can be found in the full text of the guideline. Keywords: asymptomatic bacteriuria, bacteriuria, urinary tract infection, pyelonephritis, cystitis, diabetes, pregnancy, renal transplant, endourologic surgery, urologic devices, urinary catheter, older adults, nursing home, long-term care, spinal cord injury, neurogenic bladder Recommendations Abridged I.
Should asymptomatic bacteriuria be screened for and treated in pediatric patients? In infants and children, we recommend against screening for or treating asymptomatic bacteriuria ASB strong recommendation, low-quality evidence.
Should ASB be screened for or treated in healthy nonpregnant women? In healthy premenopausal, nonpregnant women or healthy postmenopausal women, we recommend against screening for or treating ASB strong recommendation, moderate-quality evidence. Should ASB be screened for and treated in pregnant women? In pregnant women, we recommend screening for and treating ASB strong recommendation, moderate-quality evidence.
Remarks: A recent study in the Netherlands suggested that nontreatment of ASB may be an acceptable option for selected low-risk women. However, the committee felt that further evaluation in other populations was necessary to confirm the generalizability of this observation. We suggest a urine culture collected at 1 of the initial visits early in pregnancy. There is insufficient evidence to inform a recommendation for or against repeat screening during the pregnancy for a woman with an initial negative screening culture or following treatment of an initial episode of ASB.
In pregnant women with ASB, we suggest 4—7 days of antimicrobial treatment rather than a shorter duration weak recommendation, low-quality evidence. Remarks: The optimal duration of therapy will vary depending on the antimicrobial given; the shortest effective course should be used. Should ASB be screened for and treatred in functionally impaired older women or men residing in the community, or in older residents of long-term care facilities?
In older, community-dwelling persons who are functionally impaired, we recommend against screening for or treating ASB strong recommendation, low-quality evidence. In older persons resident in long-term care facilities, we recommend against screening for or treating ASB strong recommendation, moderate-quality evidence.
In an older, functionally or cognitively impaired patient, which nonlocalizing symptoms distinguish ASB from symptomatic UTI? Values and preferences: This recommendation places a high value on avoiding adverse outcomes of antimicrobial therapy such as Clostridioides difficile infection, increased antimicrobial resistance, or adverse drug effects, in the absence of evidence that such treatment is beneficial for this vulnerable population.
Should patients with diabetes be screened or treated for ASB? In patients with diabetes, we recommend against screening for or treating ASB strong recommendation, moderate-quality evidence. Remarks: The recommendation for nontreatment of men is inferred from observations in studies that have primarily enrolled women. Should patients who have received a kidney transplant be screened or treated for ASB?
Remarks: There is insufficient evidence to inform a recommendation for or against screening or treatment of ASB within the first month following renal transplantation.
Should patients who have received a solid organ tranpslant other than a renal transplant be screened or treated for ASB? In patients with nonrenal solid organ transplant SOT , we recommend against screening for or treating ASB strong recommendation, moderate-quality evidence.
Values and preferences: This recommendation places a high value on avoidance of antimicrobial use so as to limit the acquisition of antimicrobial-resistant organisms or Clostridioides difficile infection in SOT patients, who are at increased risk for these adverse outcomes. Should patients with neutropenia be screened or treated for ASB? Remarks: For patients with high-risk neutropenia managed with current standards of care, including prophylactic antimicrobial therapy and prompt initiation of antimicrobial therapy when febrile illness occurs, it is unclear how frequently ASB occurs and how often it progresses to symptomatic UTI.
Should ASB be screened for or treated in individuals with impaired voiding following spinal cord injury? In patients with spinal cord injury SCI , we recommend against screening for or treating ASB strong recommendation, low-quality evidence. Remarks: Clinical signs and symptoms of UTI experienced by patients with SCI may differ from the classic genitourinary symptoms experienced by patients with normal sensation. The atypical presentation of UTI in these patients should be considered in making decisions with respect to treatment or nontreatment of bacteriuria.
Should patients with an indwelling urethral catheter be screened or treated for ASB? Remarks: Considerations are likely to be similar for patients with indwelling suprapubic catheters, and it is reasonable to manage these patients similar to patients with indwelling urethral catheters, for both short-term and long-term suprapubic catheterization. In patients with indwelling catheters, we make no recommendation for or against screening for and treating ASB at the time of catheter removal knowledge gap.
Remarks: Antimicrobial prophylaxis given at the time of catheter removal may confer a benefit for prevention of symptomatic UTI for some patients. The evidence to support this observation is largely from studies enrolling surgical patients who receive prophylactic antimicrobials at the time of short-term catheter removal, generally without screening to determine if ASB is present.
It is unclear whether or not the benefit is greater in patients with ASB. In patients with long-term indwelling catheters, we recommend against screening for or treating ASB strong recommendation, low-quality evidence.
Should patients undergoing elective nonurologic surgery be screened and treated for ASB? In patients undergoing elective nonurologic surgery, we recommend against screening for or treating ASB strong recommendation, low-quality evidence. Should patients undergoing endourological procedures be screened or treated for ASB? In patients who will undergo endoscopic urologic procedures associated with mucosal trauma, we recommend screening for and treating ASB prior to surgery strong recommendation, moderate-quality evidence.
Values and preferences: This recommendation places a high value on the avoidance of the serious postoperative complication of sepsis, which is a substantial risk for patients undergoing invasive endourologic procedures in the presence of bacteriuria.
Remarks: In individuals with bacteriuria, these are procedures in a heavily contaminated surgical field. High-quality evidence from other surgical procedures shows that perioperative antimicrobial treatment or prophylaxis for contaminated or clean-contaminated procedures confers important benefits.
In patients who will undergo endoscopic urologic procedures, we suggest that a urine culture be obtained prior to the procedure and targeted antimicrobial therapy prescribed rather than empiric therapy weak recommendation, very low-quality evidence.
In patients with ASB who will undergo a urologic procedure, we suggest a short course 1 or 2 doses rather than more prolonged antimicrobial therapy weak recommendation, low-quality evidence.
Remarks: Antimicrobial therapy should be initiated 30—60 minutes before the procedure. Should patients undergoing implanatation of urologic devices or living with urologic devices be screened or treated for ASB?
In patients planning to undergo surgery for an artificial urine sphincter or penile prosthesis implantation, we suggest not screening for or treating ASB weak recommendation, very low-quality evidence.
Remarks: All patients should receive standard perioperative antimicrobial prophylaxis prior to device implantation. In patients living with implanted urologic devices, we suggest not screening for or treating ASB weak recommendation, very low-quality evidence.
Introduction ASB is common in healthy women and in adults and children with urologic abnormalities associated with impaired voiding [6—19] Table 1. ASB was first described when early studies validating the use of the quantitative urine culture for urinary infection reported a high prevalence of positive urine cultures, with or without pyuria, in some populations of women, without accompanying genitourinary symptoms attributable to infection .
In addition, early studies consistently observed that a high proportion of women with persistent ASB initially identified in early pregnancy developed pyelonephritis and potential negative fetal outcomes later in the pregnancy.
Thus, ASB was interpreted as an ominous finding that warranted screening and treatment. Subsequent observational and intervention studies evaluating long-term screening and treatment in schoolchildren, pregnant women, and healthy women suggested that ASB was benign in children and in women who were not pregnant . In addition, efforts to maintain sterile urine were often futile. Prospective, randomized studies of antimicrobials or no antimicrobials for bacteriuria in children, healthy women, older populations, patients with chronic indwelling or intermittent catheters, and patients with diabetes suggested that antimicrobial treatment did not confer any benefits.
At the same time, antimicrobials increased the risk of outcomes such as antimicrobial resistance and Clostridioides difficile infection CDI and, in some cases, increased the risk of urinary tract infection UTI shortly after therapy [21, 22]. For some populations with a high prevalence of ASB, such as patients with chronic indwelling catheters , older institutionalized populations [24, 25], patients with spinal cord injury SCI [15, 26], and some persons with diabetes , a sterile urine cannot be maintained, despite intense antimicrobial use.
The Infectious Diseases Society of America IDSA guidelines published in summarized this evidence for adults, and made recommendations for treatment or nontreatment of ASB in relevant populations . Additional evidence that has become available since for some of the populations addressed in the previous guideline has been reviewed for this guideline update. These updated guidelines also include populations not considered in the previous guideline, including children, solid organ transplant SOT recipients, patients with neutropenia, and those undergoing nonurologic surgery.
Difficulty in clinical distinction between UTI and ASB in some populations with a high prevalence of bacteriuria has been increasingly recognized. Thus, this update also addresses the assessment of potential nonlocalizing symptoms for subjects in populations with a high prevalence of bacteriuria, where diagnostic uncertainty may compromise implementation of nontreatment recommendations.
There are important considerations unique to the use of antimicrobials. Antimicrobial use drives antimicrobial resistance in the community, as well as in the individual treated. Antimicrobial stewardship programs have identified the treatment of ASB as an important contributor to inappropriate antimicrobial use, which promotes resistance [30—34].
A positive urine culture often encourages antimicrobial use, irrespective of symptoms [34—37]. Thus, obtaining urine cultures when not clinically indicated, including for routine screening, promotes inappropriate antimicrobial use. Given the potential negative societal consequence of antimicrobial resistance, the guideline committee felt that screening for bacteriuria and treatment of ASB should be discouraged unless there is evidence to support a benefit of treatment for a given population.
This guideline is most applicable to those who similarly place a high value on addressing the problem of increasing antimicrobial resistance and other harms of antimicrobial exposure, and a lower value on very small or uncertain benefits to individuals.
Scope and Purpose The purpose of this document is to provide evidence-based guidance on the screening and treatment of ASB in populations where ASB has been identified as common or potentially detrimental. The target audience for this guideline includes all healthcare professionals who care for patients who may have ASB. These include general internists, internal medicine subspecialists infectious diseases, nephrology, endocrinology, and others , surgeons, urologists, pediatricians, obstetricians and gynecologists, geriatricians, physical medicine specialists, family practitioners, hospitalists, pharmacists, nurse practitioners, and physician assistants.
Infections in Pregnancy: Asymptomatic Bacteriuria
Especialistas em Bacteriúria assintomática