Indications for Treating Asymptomatic UTI
Definition and Treatment
- Asymptomatic bacteriuria is defined as bacterial growth >10^5 CFU/mL in two consecutive urine samples in women or a single sample in men, without any urinary tract symptoms, and represents commensal colonization rather than infection, according to the European Urology guidelines 3, 4
- The American College of Physicians and European Urology recommend treating asymptomatic bacteriuria only in pregnant women and patients undergoing urological procedures that breach the mucosa, with a strength of evidence rated as strong 1, 2
Recommended Indications for Treatment
- The European Urology guidelines recommend screening for and treating asymptomatic bacteriuria in pregnant women, preferably in the first trimester, to reduce the risk of pyelonephritis during pregnancy, with a strength of evidence rated as moderate 1, 3
- The Clinical Infectious Diseases guidelines suggest using standard short-course treatment (4-7 days) or single-dose fosfomycin trometamol for treating asymptomatic bacteriuria in pregnant women, with a strength of evidence rated as low 1, 2
Populations Where ASB Should NOT Be Treated
- The European Urology guidelines recommend not screening for or treating asymptomatic bacteriuria in women without risk factors, patients with well-regulated diabetes mellitus, postmenopausal women, elderly institutionalized patients, patients with dysfunctional and/or reconstructed lower urinary tract, patients with renal transplant (>1 month post-transplant), patients with non-renal solid organ transplant, patients before arthroplasty surgery, patients with recurrent UTIs, and older patients with functional/cognitive impairment who experience delirium or falls, due to the lack of evidence showing a benefit, with a strength of evidence rated as moderate 1, 2, 3
Special Considerations
- The European Urology guidelines recommend not screening or treating asymptomatic bacteriuria in patients before cardiovascular surgeries, with a weak recommendation and a strength of evidence rated as low 2, 3
- The Clinical Infectious Diseases guidelines state that insufficient evidence exists regarding management of asymptomatic bacteriuria within the first month following renal transplantation, with a strength of evidence rated as very low 1
Rationale for Not Treating ASB in Most Populations
- The Clinical Infectious Diseases guidelines note that treatment of asymptomatic bacteriuria has not been shown to improve clinical outcomes in most populations, and may lead to increased antimicrobial resistance, risk of Clostridioides difficile infection, adverse drug effects, eradication of potentially protective bacterial strains, and higher healthcare costs, with a strength of evidence rated as moderate 1, 5