11/11/2017 Approach to the adult with asymptomatic bacteriuria

19.3

Approach to the adult with asymptomatic bacteriuria

Approach to the adult with asymptomatic bacteriuria Find Print

TOPIC OUTLINE
Approach to the adult with asymptomatic bacteriuria
INTRODUCTION
Authors Section Editor Deputy Editor
CLINICAL DEFINITIONS
Thomas Fekete, MD Stephen B Elinor L Baron, MD,
Voided clean catch specimens
Thomas M Hooton, Calderwood, MD DTMH
- Women MD
- Men
Catheterized specimens Disclosures

EPIDEMIOLOGY
Women Last literature review version 19.3: Fri Sep 30 00:00:00
Men GMT 2011 | This topic last updated: Tue Apr 20 00:00:00
GMT 2010 (More)
PATHOPHYSIOLOGY
INTRODUCTION Asymptomatic bacteriuria is defined as
WHOM TO TREAT
isolation of a specified quantitative count of bacteria in an
Pregnancy
appropriately collected urine specimen from an individual
Urologic intervention
without symptoms or signs of urinary tract infection. This topic
Hip arthroplasty
will outline the epidemiology, pathophysiology, clinical
WHOM NOT TO TREAT definitions, and approach to management in specific clinical
Women (premenopausal, circumstances.
nonpregnant)
Diabetic patients CLINICAL DEFINITIONS Urine is normally sterile but can
be a good growth medium for bacteria that enter the bladder
Spinal cord injury
and are not eliminated. Because of the difficulty in obtaining
Indwelling urethral catheters
uncontaminated voided midstream urine specimens,
Elderly in the community
quantitative thresholds have been established to distinguish
Elderly in health care facilities
bladder bacteriuria from urethral contamination.
SUMMARY AND Asymptomatic bacteriuria is defined as isolation of a specified
RECOMMENDATIONS quantitative count of bacteria in an appropriately collected
REFERENCES urine specimen from an individual without symptoms or signs
of urinary tract infection. The quantitative thresholds are
RELATED TOPICS
different for voided clean catch specimens and catheterized
Acute uncomplicated cystitis, specimens.
pyelonephritis, and asymptomatic
bacteriuria in men The presence of pyuria (10 leukocytes/mm3 of
uncentrifuged urine) is not sufficient for diagnosis of
Asymptomatic bacteriuria in
patients with diabetes mellitus bacteriuria [1-3]. This was illustrated in a study of urine
samples from asymptomatic elderly women; 60 percent of
Bacterial adherence and other
samples with pyuria had no bacteriuria [2].
virulence factors for urinary tract
infection Voided clean catch specimens Diagnostic criteria for
Medical care of the nursing home clean catch specimens including number of specimens and
patient in the United States minimum quantitative bacteria counts are outlined for women
Overview of control measures to and men below.
prevent surgical site infection Women Asymptomatic bacteriuria in women is defined
Toll-like receptors: Roles in disease by the 2005 Infectious Diseases Society of America (IDSA)
and therapy guidelines as two consecutive clean-catch voided urine
Urinary tract infection associated specimens with isolation of the same organism in quantitative
with urethral catheters counts of 10(5) cfu/mL [4].
Urinary tract infections and This definition is based upon studies of voided and
asymptomatic bacteriuria in
catheterized urine specimens from asymptomatic patients [5-
pregnancy
9]. A bacterial count of 10(5) cfu/mL in a catheterized
Help improve UpToDate. Did UpToDate answer your question? Yes
http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?9/1/9247?view=print 1/9
11/11/2017 Approach to the adult with asymptomatic bacteriuria

specimen was confirmed by a repeat catheterized specimen in

>95 percent of cases. On the other hand, 10(5) cfu/mL
documented in an initial voided urine specimen was confirmed
in a second voided specimen in 80 percent of cases. Two
consecutive positive cultures predicted a third positive culture
with 95 percent confidence. Therefore, two consecutive voided
specimens were needed to predict bladder bacteriuria with the
same degree of accuracy as a single urine specimen obtained
through a catheter.

Other studies have used a more permissive definition of a

single positive urine specimen with 10(5) cfu/mL [1].
Because transient bacteriuria is common among young
healthy women, the prevalence of asymptomatic bacteriuria
will be lower if >1 specimen is required for diagnosis.

Men Asymptomatic bacteriuria in men is defined by the

2005 IDSA guidelines as a single clean-catch voided urine
specimen with isolation of a single organism in quantitative
counts of 10(5) cfu/mL [4]. In general, external
contamination during voiding among men is an extremely
unlikely cause of significant bacteriuria. (See "Acute
uncomplicated cystitis, pyelonephritis, and asymptomatic
bacteriuria in men".)

There are fewer data on microbiologic criteria for diagnosis of

asymptomatic bacteriuria in men. The most rigorous report is
a study of 59 asymptomatic men with the incidental finding of
10(5) cfu/mL of an Enterobacteriaceae that was reproducible
with repeat culture one week later in 98 percent of cases [10].

Catheterized specimens In asymptomatic catheterized

men or women, bacteriuria is defined by the IDSA guidelines
as a single catheterized specimen with isolation of a single
organism in quantitative counts of 10(2) cfu/mL [4].

Catheterized specimens are less likely to be contaminated

than voided specimens; therefore, positive cultures of
catheterized specimens are more likely to reflect true bladder
bacteriuria even with low colony counts. There have been no
comparisons of culture yields from urethral catheterized
specimens and suprapubic aspiration specimens.

EPIDEMIOLOGY

Women The prevalence of asymptomatic bacteriuria

among healthy women increases with advancing age, from
about 1 percent among schoolgirls to >20 percent among
women over 80 years residing in the community [1,11,12]. It
correlates with sexual activity; as an example, prevalence is
greater among premenopausal married women than nuns of
the same age (4.6 versus 0.7 percent, respectively) [13].
Pregnant and non-pregnant women have a similar prevalence
(2 to 7 percent) [12]. In young healthy women, asymptomatic
bacteriuria is transient; it rarely lasts longer than a few
weeks.

Prevalence among diabetic women is 8 to 14 percent and is

usually correlated with duration and presence of long term
complications of diabetes, rather than with metabolic
parameters of diabetes control [14]. Asymptomatic bacteriuria

http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?9/1/9247?view=print 2/9
11/11/2017 Approach to the adult with asymptomatic bacteriuria

in diabetic patients is discussed separately. (See

"Asymptomatic bacteriuria in patients with diabetes mellitus".)

Men Asymptomatic bacteriuria is rare among healthy

young men [15]. Among men over 75 years residing in the
community prevalence is 6 to 15 percent [12]. Diabetic men
do not appear to have a higher prevalence of bacteriuria than
nondiabetic men [16]. (See "Acute uncomplicated cystitis,
pyelonephritis, and asymptomatic bacteriuria in men".)

PATHOPHYSIOLOGY The absence of symptoms in

patients with asymptomatic bacteriuria could reflect
characteristics specific to the pathogen, the host or both.

The microbiology of asymptomatic bacteriuria is similar to that

of cystitis and pyelonephritis, although some strains capable
of producing asymptomatic bacteriuria may have subtle
adaptations that facilitate pathogenesis. For example,
attachment of bacteria via fimbrial adhesins is thought to be
important for the establishment and persistence of
symptomatic infection. Some bacterial strains with reduced
capability for fimbriae expression appear to have the capacity
for relatively rapid growth that thus allows them to cause
asymptomatic bacteriuria [17].

Alternatively, strains implicated in asymptomatic bacteriuria

may be less virulent and therefore may not necessarily be
true pathogens [18-22]. For example, E. coli strains recovered
from spinal cord injury patients with asymptomatic bacteriuria
demonstrate diminished capacity for red blood cell
hemagglutination and hemolysis than strains implicated in
symptomatic urinary tract infections [20,21]. Even if they
persist, such strains are unlikely to progress to serious
infection. Based on this notion, some investigators have
suggested that colonization with "uroprotective" strains of E.
coli may be protective against infection with more invasive
uropathogens [23]. (See "Bacterial adherence and other
virulence factors for urinary tract infection".)

The absence of symptoms in patients with asymptomatic

bacteriuria could also reflect differences in the host response
[24,25]. A study of children with asymptomatic bacteriuria
demonstrated lower levels of neutrophil Toll-like receptor 4
(TLR4) expression compared to age-matched controls [24]. In
mice, TLR4 controls the mucosal response to E. coli and
inactivation of TLR4 can lead to a carrier state that resembles
asymptomatic bacteriuria [25]. (See "Toll-like receptors: Roles
in disease and therapy".)

WHOM TO TREAT Screening for and treatment of

asymptomatic bacteriuria is appropriate for pregnant women
and for patients undergoing urologic procedures in which
mucosal bleeding is anticipated [4,26,27].

Pregnancy Screening for and treatment of asymptomatic

bacteriuria is warranted for pregnant women [4]. This topic is

http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?9/1/9247?view=print 3/9
11/11/2017 Approach to the adult with asymptomatic bacteriuria

discussed separately. (See "Urinary tract infections and

asymptomatic bacteriuria in pregnancy".)

Urologic intervention Screening for and treatment of

asymptomatic bacteriuria is warranted for patients undergoing
transurethral resection of the prostate and other urologic
procedures in which mucosal bleeding is anticipated [4]. This
topic is discussed separately. (See "Overview of control
measures to prevent surgical site infection", section on
'Genitourinary surgery'.)

Hip arthroplasty The optimal approach to evaluating for

asymptomatic bacteriuria prior to hip arthroplasty is uncertain
and there are no data from large trials to evaluate this issue
[28]. In general, it is appropriate to perform urinalysis prior to
hip arthroplasty if a urinary catheter is expected to be in place
postoperatively. An abnormal urinalysis should prompt urine
culture, and the presence of urinary tract infection (eg,
10(5) CFU/mL) warrants treatment with three days of
antibiotic therapy prior to surgery.

WHOM NOT TO TREAT There is no role for screening for

or treatment of asymptomatic bacteriuria in the following
populations: women (premenopausal, nonpregnant), diabetic
patients, the elderly, or patients with spinal cord injury or
indwelling urethral catheters. Avoiding treatment of
asymptomatic bacteriuria is important for reducing
development of antibiotic resistance, and a hospital and
ambulatory performance measure for not treating
asymptomatic bacteriuria in adults has been proposed [29].

Women (premenopausal, nonpregnant) There is no

role for screening for or treatment of asymptomatic
bacteriuria in premenopausal, nonpregnant women [4,30,31].
Although women with asymptomatic bacteriuria are at
increased risk for symptomatic urinary tract infection [1],
treatment does not reduce the frequency of symptomatic
infection or recurrent asymptomatic bacteriuria [11,30].
Although antibiotics initially sterilize the urine in almost all
patients, bacteriuria recurs in approximately one-half by one
year such that the prevalence is similar to that in untreated
women at one year [30]. In addition, asymptomatic
bacteriuria is not associated with long-term adverse outcomes
such as chronic kidney disease or mortality [11,32].

Diabetic patients Asymptomatic bacteriuria in diabetic

patients is discussed separately. (See "Asymptomatic
bacteriuria in patients with diabetes mellitus".)

Spinal cord injury There is no role for screening for or

treatment of asymptomatic bacteriuria among patients with
spinal cord injury [4]. Although these patients have a high
prevalence of asymptomatic bacteriuria, they also have a high
rate of urinary infection with signs or symptoms (such as fever
or elevated white blood cell count). In a study of 64 spinal
cord injury patients with urine quantitative bacteria counts
10(5) cfu/mL, 27 percent of patients were asymptomatic
http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?9/1/9247?view=print 4/9
11/11/2017 Approach to the adult with asymptomatic bacteriuria

during the bacteriuric episode [33]. Bacteriuria tends to recur

early after therapy or prophylaxis, with emergence of
antibiotic resistance [34,35].

Indwelling urethral catheters Asymptomatic bacteriuria

in patients with indwelling bladder catheters is discussed
separately. (See "Urinary tract infection associated with
urethral catheters".)

Elderly in the community There is no role for screening

for or treatment of asymptomatic bacteriuria among older
persons in the community [4]. These patients are not at
increased risk for adverse outcomes related to asymptomatic
bacteriuria [36-41]. This was illustrated in a randomized
controlled trial of antibiotic therapy for 124 elderly ambulatory
women with asymptomatic bacteriuria [36]. There was no
significant difference in the number of symptomatic episodes
during the six-month follow-up period. In addition, bacteriuria
is transient and tends to recur after therapy, with emergence
of antibiotic resistance [4].

Elderly in health care facilities There is no role for

screening for or treatment of asymptomatic bacteriuria among
the elderly in health care facilities [4]. Although half of women
and 15 to 40 percent of men have asymptomatic bacteriuria
[37], antimicrobial treatment has not been shown to be of
benefit [42,43]. This was illustrated in a study of 191 nursing
home residents with incontinence and bacteriuria who were
randomly assigned to immediate or delayed treatment [42].
Eradicating bacteriuria had no short-term effects on the
severity of chronic urinary incontinence. In addition,
bacteriuria tends to recur after therapy, with emergence of
antibiotic resistance [43]. (See "Medical care of the nursing
home patient in the United States", section on 'Asymptomatic
bacteriuria'.)

SUMMARY AND RECOMMENDATIONS

Asymptomatic bacteriuria is defined as isolation of a

specified quantitative count of bacteria in an
appropriately collected urine specimen from an
individual without symptoms or signs of urinary tract
infection. (See 'Clinical definitions' above.)

In asymptomatic women, bacteriuria is defined as two

consecutive clean-catch voided urine specimens with
isolation of the same organism in quantitative counts of
10(5) cfu/mL. (See 'Women' above.)

In asymptomatic men, bacteriuria is defined as a single

clean-catch voided urine specimen with isolation of a
single organism in quantitative counts of 10(5) cfu/mL.
(See 'Men' above.)

In asymptomatic catheterized men or women,

bacteriuria is defined as a single catheterized specimen
with isolation of a single organism in quantitative counts

http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?9/1/9247?view=print 5/9
11/11/2017 Approach to the adult with asymptomatic bacteriuria

of 10(2) cfu/mL. (See 'Catheterized

specimens' above.)

Treatment of asymptomatic bacteriuria is appropriate for

pregnant women and for patients undergoing urologic
procedures in which mucosal bleeding is anticipated.
(See 'Whom to treat' above.)

Treatment of asymptomatic bacteriuria is not

appropriate for the following populations: women
(premenopausal, nonpregnant), diabetics, the elderly,
nursing home residents, or patients with spinal cord
injury or indwelling urethral catheters. (See 'Whom not
to treat' above.)

Use of UpToDate is subject to the Subscription and License

Agreement.

REFERENCES

1. Hooton TM, Scholes D, Stapleton AE, et al. A prospective

study of asymptomatic bacteriuria in sexually active
young women. N Engl J Med 2000; 343:992.
2. Boscia JA, Abrutyn E, Levison ME, et al. Pyuria and
asymptomatic bacteriuria in elderly ambulatory women.
Ann Intern Med 1989; 110:404.
3. Stamm WE. Measurement of pyuria and its relation to
bacteriuria. Am J Med 1983; 75:53.
4. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases
Society of America guidelines for the diagnosis and
treatment of asymptomatic bacteriuria in adults. Clin
Infect Dis 2005; 40:643.
5. KASS EH. Asymptomatic infections of the urinary tract.
Trans Assoc Am Physicians 1956; 69:56.
6. Kass EH. The role of asymptomatic bacteriuria in the
pathogenesis of pyelonephritis. In: Quinn EL, Kass EH,
eds. Biology of pyelonephritis. Boston; Little, Brown,
1960:399.
7. Norden CW, Kass EH. Bacteriuria of pregnancy--a critical
appraisal. Annu Rev Med 1968; 19:431.
8. KASS EH. Bacteriuria and the diagnosis of infections of
the urinary tract; with observations on the use of
methionine as a urinary antiseptic. AMA Arch Intern Med
1957; 100:709.
9. MONZON OT, ORY EM, DOBSON HL, et al. A comparison
of bacterial counts of the urine obtained by needle
aspiration of the bladder, catheterization and midstream-
voided methods. N Engl J Med 1958; 259:764.
10. Gleckman R, Esposito A, Crowley M, Natsios GA.
Reliability of a single urine culture in establishing
diagnosis of asymptomatic bacteriuria in adult males. J
Clin Microbiol 1979; 9:596.
11. Bengtsson C, Bengtsson U, Bjrkelund C, et al.
Bacteriuria in a population sample of women: 24-year
follow-up study. Results from the prospective population-

http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?9/1/9247?view=print 6/9
11/11/2017 Approach to the adult with asymptomatic bacteriuria

based study of women in Gothenburg, Sweden. Scand J

Urol Nephrol 1998; 32:284.
12. Nicolle LE. Asymptomatic bacteriuria: when to screen
and when to treat. Infect Dis Clin North Am 2003;
17:367.
13. Kunin CM, McCormack RC. An epidemiologic study of
bacteriuria and blood pressure among nuns and working
women. N Engl J Med 1968; 278:635.
14. Zhanel GG, Nicolle LE, Harding GK. Prevalence of
asymptomatic bacteriuria and associated host factors in
women with diabetes mellitus. The Manitoba Diabetic
Urinary Infection Study Group. Clin Infect Dis 1995;
21:316.
15. Lipsky BA. Urinary tract infections in men. Epidemiology,
pathophysiology, diagnosis, and treatment. Ann Intern
Med 1989; 110:138.
16. Zhanel GG, Harding GK, Nicolle LE. Asymptomatic
bacteriuria in patients with diabetes mellitus. Rev Infect
Dis 1991; 13:150.
17. Roos V, Nielsen EM, Klemm P. Asymptomatic bacteriuria
Escherichia coli strains: adhesins, growth and
competition. FEMS Microbiol Lett 2006; 262:22.
18. Hanson LA. Prognostic indicators in childhood urinary
infections. Kidney Int 1982; 21:659.
19. Roos V, Schembri MA, Ulett GC, Klemm P. Asymptomatic
bacteriuria Escherichia coli strain 83972 carries
mutations in the foc locus and is unable to express F1C
fimbriae. Microbiology 2006; 152:1799.
20. Hull RA, Rudy DC, Wieser IE, Donovan WH. Virulence
factors of Escherichia coli isolates from patients with
symptomatic and asymptomatic bacteriuria and
neuropathic bladders due to spinal cord and brain
injuries. J Clin Microbiol 1998; 36:115.
21. Hull RA, Rudy DC, Donovan WH, et al. Virulence
properties of Escherichia coli 83972, a prototype strain
associated with asymptomatic bacteriuria. Infect Immun
1999; 67:429.
22. Plos K, Carter T, Hull S, et al. Frequency and organization
of pap homologous DNA in relation to clinical origin of
uropathogenic Escherichia coli. J Infect Dis 1990;
161:518.
23. Klemm P, Hancock V, Schembri MA. Mellowing out:
adaptation to commensalism by Escherichia coli
asymptomatic bacteriuria strain 83972. Infect Immun
2007; 75:3688.
24. Ragnarsdttir B, Samuelsson M, Gustafsson MC, et al.
Reduced toll-like receptor 4 expression in children with
asymptomatic bacteriuria. J Infect Dis 2007; 196:475.
25. Fischer H, Yamamoto M, Akira S, et al. Mechanism of
pathogen-specific TLR4 activation in the mucosa:
fimbriae, recognition receptors and adaptor protein
selection. Eur J Immunol 2006; 36:267.
26. Lin K, Fajardo K, U.S. Preventive Services Task Force.
Screening for asymptomatic bacteriuria in adults:
evidence for the U.S. Preventive Services Task Force

http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?9/1/9247?view=print 7/9
11/11/2017 Approach to the adult with asymptomatic bacteriuria

reaffirmation recommendation statement. Ann Intern

Med 2008; 149:W20.
27. U.S. Preventive Services Task Force. Screening for
asymptomatic bacteriuria in adults: U.S. Preventive
Services Task Force reaffirmation recommendation
statement. Ann Intern Med 2008; 149:43.
28. Rajamanickam A, Noor S, Usmani A. Should an
asymptomatic patient with an abnormal urinalysis
(bacteriuria or pyuria) be treated with antibiotics prior to
major joint replacement surgery? Cleve Clin J Med 2007;
74 Suppl 1:S17.
29. Gross PA, Patel B. Reducing antibiotic overuse: a call for
a national performance measure for not treating
asymptomatic bacteriuria. Clin Infect Dis 2007; 45:1335.
30. Asscher AW, Sussman M, Waters WE, et al.
Asymptomatic significant bacteriuria in the non-pregnant
woman. II. Response to treatment and follow-up. Br Med
J 1969; 1:804.
31. Harding GK, Zhanel GG, Nicolle LE, et al. Antimicrobial
treatment in diabetic women with asymptomatic
bacteriuria. N Engl J Med 2002; 347:1576.
32. Tencer J. Asymptomatic bacteriuria--a long-term study.
Scand J Urol Nephrol 1988; 22:31.
33. Waites KB, Canupp KC, DeVivo MJ. Epidemiology and risk
factors for urinary tract infection following spinal cord
injury. Arch Phys Med Rehabil 1993; 74:691.
34. Waites KB, Canupp KC, DeVivo MJ. Eradication of urinary
tract infection following spinal cord injury. Paraplegia
1993; 31:645.
35. Kuhlemeier KV, Stover SL, Lloyd LK. Prophylactic
antibacterial therapy for preventing urinary tract
infections in spinal cord injury patients. J Urol 1985;
134:514.
36. Boscia JA, Kobasa WD, Knight RA, et al. Therapy vs no
therapy for bacteriuria in elderly ambulatory
nonhospitalized women. JAMA 1987; 257:1067.
37. Nicolle LE. Asymptomatic bacteriuria in the elderly. Infect
Dis Clin North Am 1997; 11:647.
38. Nordenstam GR, Brandberg CA, Odn AS, et al.
Bacteriuria and mortality in an elderly population. N Engl
J Med 1986; 314:1152.
39. Wood CA, Abrutyn E. Urinary tract infection in older
adults. Clin Geriatr Med 1998; 14:267.
40. Abrutyn E, Mossey J, Berlin JA, et al. Does asymptomatic
bacteriuria predict mortality and does antimicrobial
treatment reduce mortality in elderly ambulatory
women? Ann Intern Med 1994; 120:827.
41. Abrutyn E, Berlin J, Mossey J, et al. Does treatment of
asymptomatic bacteriuria in older ambulatory women
reduce subsequent symptoms of urinary tract infection? J
Am Geriatr Soc 1996; 44:293.
42. Ouslander JG, Schapira M, Schnelle JF, et al. Does
eradicating bacteriuria affect the severity of chronic
urinary incontinence in nursing home residents? Ann
Intern Med 1995; 122:749.

http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?9/1/9247?view=print 8/9
11/11/2017 Approach to the adult with asymptomatic bacteriuria

43. Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized

comparison of therapy and no therapy for asymptomatic
bacteriuria in institutionalized elderly women. Am J Med
1987; 83:27.

http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?9/1/9247?view=print 9/9