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Asymptomatic bacteriuria in patients with diabetes mellitus

Authors: Amy C Weintrob, MD, Daniel J Sexton, MD


Section Editor: Stephen B Calderwood, MD
Deputy Editor: Allyson Bloom, MD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2017. | This topic last updated: May 09, 2017.

INTRODUCTION The term asymptomatic bacteriuria refers to the presence of a positive urine culture in an
asymptomatic person. Most patients with asymptomatic bacteriuria have no adverse consequences and derive
no benefit from antibiotic therapy. As a result, most episodes of asymptomatic bacteriuria are not detected since
general screening is not recommended. (See "Approach to the adult with asymptomatic bacteriuria".)

Issues related to asymptomatic bacteriuria in patients with diabetes mellitus will be reviewed here. Diabetic
patients have an increased risk of certain symptomatic urinary tract infections such as acute cystitis,
emphysematous infections, renal and perinephric abscess, and Candida infections. (See "Acute uncomplicated
cystitis and pyelonephritis in women" and "Emphysematous urinary tract infections" and "Renal and perinephric
abscess" and "Candida infections of the bladder and kidneys" and "Acute complicated cystitis and
pyelonephritis".)

The discussion in this topic refers only to non-pregnant women. Asymptomatic bacteriuria in pregnancy is
discussed in detail elsewhere. (See "Urinary tract infections and asymptomatic bacteriuria in pregnancy".)

DEFINITION AND DIAGNOSIS The term asymptomatic bacteriuria refers to the presence of high quantities of
an uropathogen in the urine of an asymptomatic person. Initial studies showed that colony counts 105 cfu/mL
more often predicted persistently high levels of bacteriuria compared with lower colony counts [1].

Guidelines from the Infectious Diseases Society of America (IDSA) on asymptomatic bacteriuria in adults and
catheter-associated urinary tract infections recommend the following criteria for the diagnosis of asymptomatic
bacteriuria [2,3]:

For asymptomatic women, bacteriuria is defined as two consecutive clean-catch voided urine specimens
with isolation of the same bacterial strain in counts 105cfu/mL.

For asymptomatic men, bacteriuria is defined as a single, clean-catch, voided urine specimen with one
bacterial species isolated in a quantitative count of 105 cfu/mL.

For any asymptomatic patient, bacteriuria is defined as a single catheterized urine specimen with one
bacterial species isolated in counts 105 cfu/mL.

INCIDENCE Since screening for the presence of microalbuminuria is recommended in diabetic patients, these
routine evaluations often lead to the incidental discovery of asymptomatic bacteriuria. The overall approach to
this generally benign disorder is discussed separately. (See "Approach to the adult with asymptomatic
bacteriuria".)

Concern about asymptomatic bacteriuria in diabetic patients derives in part from three observations:

There is a roughly five-fold greater propensity toward UTI in diabetic women [4].
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Asymptomatic bacteriuria often precedes symptomatic UTI in type 2 diabetes (relative risk [RR] 1.65, 95
percent confidence interval [CI] 1.02-2.67) [5].

UTIs are likely to be more severe in diabetic than nondiabetic women [6].

The best estimate is an approximately three- to fourfold increase in risk of bacteriuria in diabetic women (eg, 18
versus 6 percent [7], 26 versus 6 percent [8]). The incidence is even higher in diabetic patients with advanced or
severe disease as determined by end-organ damage or elevated levels of glycosylated hemoglobin [7].

RISK FACTORS A prospective cohort study of 218 diabetic and 799 nondiabetic postmenopausal women
examined risk factors for asymptomatic bacteriuria and UTI [9]. Increased risk occurred mainly in women taking
insulin (relative risk 3.7) and those with a longer diabetes duration (>10 years, relative risk 2.6), but there was no
association between asymptomatic bacteriuria and glucose control.

Genetic factors may also be involved. One Canadian study, for example, showed a higher rate of asymptomatic
UTI in aboriginal diabetic women than in diabetic women of European heritage [7].

ASSOCIATION WITH URINARY TRACT INFECTIONS A large cohort of diabetic women in the Netherlands
was studied to determine the incidence of symptomatic UTIs [10]. In women with type 2 diabetes (but not with
type 1), the presence of asymptomatic bacteriuria at baseline increased the risk of subsequent symptomatic UTI
in the 18 month follow-up period from 19 to 34 percent. The rate of asymptomatic bacteriuria in this population
was approximately 28 percent. By contrast, incidence of asymptomatic UTI was 6 percent in women who were
not diabetic but attended other clinics in the same institution [8]. Even in this cohort of diabetic women, there
were more symptomatic UTIs in the women who had negative baseline urine cultures than in those with positive
ones. Thus, screening for later UTI risk would not be very cost effective even in this high-risk population.

A prospective study of 496 adult diabetics assessed the relationship between asymptomatic bacteriuria and
subsequent hospitalization for urosepsis [11]. The prevalence of asymptomatic bacteriuria was 7.3 percent (14
percent females and 1 percent males). Twenty-nine patients were subsequently hospitalized with urosepsis.
Asymptomatic bacteriuria was significantly associated with an increased risk of hospitalization for urosepsis
(hazard ratio, 4.4; 95% CI 1.2-16.5). Further large scale studies are needed.

MICROBIOLOGY The bacteriology of UTIs is similar in diabetic and nondiabetic women with the
preponderance being caused by E. coli and other gram-negative organisms. However, as in the subgroups
described above, antibiotic therapy for asymptomatic bacteriuria does not affect the frequency of or time to
symptomatic infection (including pyelonephritis), reinfection is common, and long-term prognosis is not improved
[12,13]. (See "Acute uncomplicated cystitis and pyelonephritis in women", section on 'Microbiology'.)

SHOULD YOU TREAT? We suggest not treating asymptomatic bacteriuria in women with diabetes mellitus,
regardless of the presence of pyuria. This recommendation is based upon multiple studies which have shown
that antibiotic therapy is associated with no reduction in symptomatic infection and a high rate of recurrent
bacteriuria once antibiotics are discontinued [12,14]. In addition, persistent asymptomatic bacteriuria is not
associated with an adverse effect on renal function [15].

The best data come from a prospective trial in which 105 diabetic women over the age of 16 years with
asymptomatic bacteriuria were randomly assigned to 14 days of antibiotics or placebo [12]. At four weeks after
the end of therapy, a significantly greater proportion of patients in the antibiotic group cleared the bacteriuria (80
versus 22 percent with placebo).

After this six week period, the group assignment was revealed, and patients were followed for a mean of 27
months; bacteriuria was assessed at three month intervals and patients who originally received antibiotics were
treated during subsequent episodes. Patients were also evaluated for symptomatic UTI, pyelonephritis, and

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hospitalization for UTI. There were no significant differences between the groups in the development of a
symptomatic UTI, the timing of onset of such an infection, or any of the other parameters. Patients in the
antibiotic treatment group had nearly five times the number of days on antibiotics compared to the placebo
group.

In a second report, 333 diabetic patients attending a clinic were screened for bacteriuria and followed for one
year [14]. Forty-five of these patients were found to have bacteriuria; despite effective treatment, more than one-
half had positive cultures within the year of the study. A similar study by the same authors tracked 45 diabetic
women with bacteriuria [16]. Despite six weeks of therapy for women with positive tests for antibody-coated
bacteria (suggestive of parenchymal infection), there was a high rate (80 percent) of recurrent bacteriuria during
a follow-up of up to several years.

In addition, the presence of pyuria, which is a reflection of inflammation of the genitourinary tract and is
frequently observed among patients with asymptomatic bacteriuria, is not an indication that antibiotics should be
given. Pyuria is also common in diabetic patients with bacteriuria and does not have prognostic significance. As
an example, the prevalence of pyuria in diabetic patients with asymptomatic bacteriuria is almost 80 percent [7].
The presence or degree of pyuria has not been shown to be associated with an increased risk of symptomatic
infection [12].

These data in women with diabetes mellitus are similar to those in other nonpregnant populations, which suggest
that treatment of asymptomatic bacteriuria has no clinical benefit, is associated with a higher rate of recurrent
bacteriuria, and increases the risk of increased resistance in bacterial isolates that cause subsequent UTI
[17,18]. (See "Approach to the adult with asymptomatic bacteriuria", section on 'Whom not to treat'.)

SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries
and regions around the world are provided separately. (See "Society guideline links: Urinary tract infections in
adults" and "Society guideline links: Asymptomatic bacteriuria in adults".)

SUMMARY AND RECOMMENDATIONS

The term asymptomatic bacteriuria refers to the presence of high quantities of an uropathogen in the urine of
an asymptomatic person. (See 'Definition and diagnosis' above.)

The discussion in this topic refers only to non-pregnant women. Asymptomatic bacteriuria in pregnancy is
discussed in detail elsewhere. (See "Urinary tract infections and asymptomatic bacteriuria in pregnancy".)

There is an approximately three- to fourfold increase in risk of bacteriuria in diabetic women (eg, 18 versus 6
percent). (See 'Incidence' above.)

Risk factors for UTI in diabetics includes those who take insulin (relative risk 3.7) and those with a longer
diabetes duration (>10 years, relative risk 2.6) but not glucose control. (See 'Risk factors' above.)

We suggest not treating asymptomatic bacteriuria in diabetic women, regardless of the presence of pyuria.
Screening for bacteriuria is not necessary. (See 'Should you treat?' above.)

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