Treatment of Asymptomatic Bacteriuria in Older Adults

Introduction to Asymptomatic Bacteriuria Guidelines

• The Infectious Diseases Society of America recommends against screening for or treatment of asymptomatic bacteriuria in older adults, whether they live in the community or in long-term care facilities, regardless of underlying medical conditions 1

Clear Recommendations Against Treatment

• The Infectious Diseases Society of America provides guidance that asymptomatic bacteriuria is not recommended for treatment in older persons living in the community (Grade A-II recommendation) 1
• The Infectious Diseases Society of America recommends against treatment of asymptomatic bacteriuria in elderly institutionalized residents of long-term care facilities (Grade A-I recommendation) 1, 2
• The Infectious Diseases Society of America recommends against treatment of asymptomatic bacteriuria in diabetic women (Grade A-I recommendation) 1
• The Infectious Diseases Society of America recommends against treatment of asymptomatic bacteriuria in catheterized patients while the catheter remains in place (Grade A-I recommendation) 1

Evidence Supporting No Treatment

• Multiple randomized controlled trials demonstrate that treating asymptomatic bacteriuria in elderly populations provides no clinical benefit, with no reduction in symptomatic UTI rates 3, 2
• Studies show no mortality benefit from treating asymptomatic bacteriuria in elderly patients 3, 2
• There is no improvement in chronic genitourinary symptoms in long-term care residents with asymptomatic bacteriuria 3

Harms of Treatment

• Treating asymptomatic bacteriuria causes significant harm without benefit, including increased adverse drug effects (RR 5.62, 95% CI 1.07-29.55) 3
• Treatment of asymptomatic bacteriuria leads to the development of resistant organisms 3, 2
• Treated patients have 5 times as many days of antimicrobial use 2

Critical Diagnostic Pitfall to Avoid

• Pyuria accompanying asymptomatic bacteriuria is not an indication for treatment (Grade A-II recommendation) 4, 5, 1
• Cloudy or smelly urine alone should not be interpreted as symptomatic infection in elderly patients 4, 5, 7

High Prevalence in Elderly Populations

• 25-50% of elderly women in long-term care facilities have bacteriuria 4, 5, 7
• 15-40% of elderly men in long-term care facilities have bacteriuria 4, 5, 7
• 10.8-16% of community-dwelling elderly women are bacteriuric 4, 5
• 3.6-19% of community-dwelling elderly men are bacteriuric 4, 5

Only Two Exceptions Where Treatment IS Indicated

• The Infectious Diseases Society of America recommends treating asymptomatic bacteriuria in pregnant women, with 3-7 days of therapy (Grade A-I) 1
• The Infectious Diseases Society of America recommends treating asymptomatic bacteriuria before urologic procedures with anticipated mucosal bleeding (Grade A-I for TURP, Grade A-III for other procedures) 1

Special Consideration for Catheter-Acquired Bacteriuria

• Antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria that persists 48 hours after catheter removal may be considered (Grade B-I recommendation) 1

Quality of Life and Antimicrobial Stewardship

• There is no improvement in quality of life from treating asymptomatic bacteriuria 3, 2
• Treatment of asymptomatic bacteriuria can lead to prevention of antibiotic-related adverse effects and reduction of antimicrobial resistance 3, 2
• Avoidance of unnecessary healthcare costs without clinical benefit is recommended 6