Treatment of Coagulase-Negative Staphylococcus in Urine

Determining Clinical Significance

Coagulase-negative staphylococci (CoNS) isolated from urine are not considered clinically relevant in the majority of cases, particularly in asymptomatic patients 1
True urinary tract infection (UTI) requires both positive culture and clinical symptoms, such as dysuria, frequency, urgency, suprapubic pain, fever, or flank pain 1

The American College of Physicians recommends treatment for symptomatic CoNS infections, which may present with lower tract symptoms, such as dysuria, frequency, urgency, and suprapubic pain 1
The Infectious Diseases Society of America recommends treatment for upper tract symptoms, such as fever, flank pain, and costovertebral angle tenderness 2
Treatment is warranted in patients with high-risk clinical contexts, including indwelling urinary catheter, recent urological procedure, immunocompromised status, and pregnancy 1

For uncomplicated cystitis, the first-line treatment is nitrofurantoin for 5 days or TMP/SMX for 3 days 1
For pyelonephritis, the recommended treatment is a first-generation cephalosporin for 7 days 1
For catheter-associated UTI (CAUTI), the management differs significantly, and the catheter should be replaced before starting antibiotics if it has been in place for 2 weeks or more 2

Asymptomatic bacteriuria should not be treated, except in pregnancy, as treatment promotes antibiotic resistance without clinical benefit 1
Antimicrobial susceptibility testing should be obtained when treatment is pursued, as methicillin resistance is common among CoNS 2
Fluoroquinolones should be avoided unless local resistance is less than 10%, the patient has not used them in 6 months, and has beta-lactam anaphylaxis 2

In neutropenic patients, CoNS bacteremia rarely causes rapid deterioration, and vancomycin is not routinely needed at fever onset, according to the Infectious Diseases Society of America 3