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.

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Data are mean age, unless otherwise indicated. Median age. These studies uniformly report no excess adverse outcomes in women with asymptomatic bacteriuria. A prospective, randomized study of nitrofurantoin or placebo also enrolled women aged years, with a median age between years [50].

Thus, these studies report that outcomes of bacteriuria and treatment of bacteriuria in healthy postmenopausal women are similar to those observed in premenopausal, nonpregnant women. A prospective, randomized clinical trial of antimicrobial treatment versus placebo for bacteriuria enrolled ambulatory women who resided in a geriatric apartment facility and reported a decrease in the prevalence of asymptomatic bacteriuria at 6 months, but there was no significant difference in the number of symptomatic episodes [73].

A prospective cohort study of ambulatory male veterans years of age observed for Population-based cohort studies report no association between bacteriuria and survival for Swedish men and women at 5 years of follow-up [74] or Finnish men and women aged years during 5 years of follow-up [75].

Routine screening for and treatment of asymptomatic bacteriuria in older persons resident in the community is not recommended A-II. A prospective, randomized, placebo-controlled trial of antimicrobial treatment of asymptomatic bacteriuria persisting 48 h after removal of short-term catheters in women with catheteracquired bacteriuria reported significantly improved microbiologic and clinical outcomes at 14 days in treated women [95].

No women in the treatment group became symptomatic. This study enrolled a selected group of hospitalized women characterized by being relatively young median age, 50 years and experiencing a short period of catheterization median duration, 3 days.

Long-term catheters. A prospective, randomized trial of cephalexin therapy versus no antibiotic therapy for bacteriuric patients with long-term indwelling urethral catheters in place and drug-susceptible organisms isolated reported a similar incidence of fever among both treated and untreated patients observed for weeks [96]. A prospective, noncomparative study of consecutive courses of antimicrobial treatment to eradicate bacteriuria in elderly patients with long-term catheters reported no decrease in the number of episodes of fever with treatment, compared with the pretreatment period, and there was immediate recurrence of bacteriuria after therapy, often with organisms of increasing resistance [97].

Asymptomatic bacteriuria or funguria should not screened for or treated in patients with an indwelling urethral catheter A-I. Patients with Indwelling Urethral Catheters Short-term catheters. This high frequency of concurrent antimicrobial use makes assessment of outcomes unique to treatment of asymptomatic bacteriuria problematic.

A casecontrol study reported that acquisition of bacteriuria with indwelling urethral catheterization increased mortality 3-fold, but the explanation for this association was not clear, and multivariate analysis found that antimicrobial therapy did not alter the association with mortality [93]. A prospective, randomized, placebo-controlled trial of treatment of funguria in patients, more than one-half of whom had indwelling urethral catheters in place, showed no differences in eradication of fun CID 1 March Nicolle et al.

Antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria that persists 48 h after catheter removal may be considered. B-I Urologic Interventions Patients with asymptomatic bacteriuria who undergo traumatic genitourinary procedures associated with mucosal bleeding have a high rate of postprocedure bacteremia and sepsis.

Retrospective analysis [99] and prospective, randomized clinical trials [] support the effectiveness of antimicrobial treatment in preventing these complications in bacteriuric men undergoing transurethral resection of the prostate. In one comparative trial, the efficacy of cefotaxime was superior to that of methenamine mandelate [].

When asymptomatic bacteriuria was uniformly treated in a cohort of catheter-free, primarily male, spinal cordinjured subjects, early recurrence of bacteriuria after therapy was the usual outcome. Reinfecting strains showed increased antimicrobial resistance. In a small, randomized, placebo-controlled trial, rates of symptomatic urinary infection and recurrence of bacteriuria were similar among recipients of either antimicrobial or placebo for patients with bladder emptying managed by intermittent catheterization [85].

A prospective, randomized trial of antimicrobial treatment or no treatment of asymptomatic bacteriuria enrolled 50 patients who were treated with intermittent catheterization and reported a similar frequency of symptomatic urinary infection during an average of 50 days of follow-up, irrespective of whether prophylactic antimicrobials were given [86].

Although there have been a limited number of clinical trials, and although interpretation of results is compromised by relatively short durations of follow-up and small study numbers, review articles [87, 88] and consensus guidelines [89] uniformly recommend treatment only of symptomatic urinary tract infection in patients with spinal cord injuries.

Asymptomatic bacteriuria should not be screened for or treated in spinal cordinjured patients A-II. An assessment for the presence of bacteriuria should be obtained, so results will be available to direct antimicrobial therapy prior to the procedure A-III. Antimicrobial therapy should be initiated shortly before the procedure A-II.

Antimicrobial therapy should not be continued beyond the procedure, unless an indwelling catheter remains in place B-II. Screening for and treatment of asymptomatic bacteriuria is recommended before other urologic procedures in which mucosal bleeding is anticipated A-III. Immunocompromised Patients and Other Patients Cohort studies performed early in the transplantation era reported a high prevalence of asymptomatic bacteriuria among renal transplant recipients, especially in the first 6 months after transplantation [, ].

Evolution in management of transplantation has introduced routine perioperative prophylaxis, minimization of use of indwelling urethral catheters, and longterm antimicrobial prophylaxis to prevent pneumonia and other infections.

These interventions also prevent both asymptomatic bacteriuria and symptomatic urinary infection [, ]. Recent studies, including a retrospective chart review [] and a prospective cohort study [], have not reported an association between asymptomatic bacteriuria and graft survival. Transplant recipients with urinary infection and poor graft outcome are also characterized by urologic abnormalities and are identified by episodes of symptomatic urinary infection, rather than bacteriuria [].

Thus, with current management strategies, screening for bacteriuria is unlikely to provide a benefit. Some experts do recommend screening for bacteriuria, at least for the first 6 months after renal transplantation []. Recent guidelines for outpatient surveillance of renal transplant recipients, however, make no recommendation for screening for bacteriuria [, ]. Screening for or treatment of bacteriuria has not been evaluated for other solid organ transplant recipients.

Guidelines for infection prevention in bone marrow transplant recipients make no recommendation for screening for bacteriuria []. A small study of women with primary biliary cirrhosis and bacteriuria randomized to receive either antimicrobial therapy or no antimicrobial therapy reported no differences in the time to reinfection or the number of reinfections in the 2 groups [].

Adverse clinical outcomes associated with bacteriuria in these populations have not been reported. No recommendation can be made for screening for or treatment of asymptomatic bacteriuria in renal transplant or other solid organ transplant recipients C-III. Pregnant women with asymptomatic bacteriuria are at an increased risk for adverse outcomes, and these can be prevented with antimicrobial treatment of asymptomatic bacteriuria.

Thus, pregnant women should be screened for bacteriuria and treated if test results are positive. Asymptomatic bacteriuria is also a risk for patients who undergo traumatic urologic interventions with mucosal bleeding, and such patients should be treated prior to such interventions. For all other adult populations, asymptomatic bacteriuria has not been shown to be harmful. Although persons with bacteriuria are at an increased risk of symptomatic urinary infection, treatment of asymptomatic bacteriuria does not decrease the frequency of symptomatic infection or improve other outcomes.

Thus, in populations other than those for whom treatment has been documented to be beneficial, screening for or treatment of asymptomatic bacteriuria is not appropriate and should be discouraged. Pretreatment of asymptomatic bacteriuria is not beneficial for all invasive procedures. For instance, replacement of a longterm indwelling foley catheter is associated with a low risk of bacteremia, and antimicrobial treatment is not beneficial [, ].

The appropriate timing for initiation of antimicrobial therapy is not well defined. Although 72 h before the intervention has been suggested [], this is likely to be excessive and allows the opportunity for superinfection before the procedure. Initiation of therapy the night before or immediately before the procedure is effective [99, ]. The optimal time to obtain a sample for culture before the procedure and the duration of antimicrobial therapy are also not addressed in clinical trials.

In the absence of an indwelling catheter, antimicrobial therapy can likely be discontinued immediately after the procedure [99, , ]. When an indwelling catheter remains in place after a prostatic resection, it has been recommended by some investigators that antimicrobial therapy be continued until the catheter is removed [98, 99]. Screening for and treatment of asymptomatic bacteriuria before transurethral resection of the prostate is recommended A-I.


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