Professional Documents
Culture Documents
2019 Asymptomatic Bacteriuria PDF
2019 Asymptomatic Bacteriuria PDF
I D S A F E AT U R E S
Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underly-
ing urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be
screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment
was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury.
The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and
nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In
addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which
promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes
new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing
clinical symptoms in populations with a high prevalence of ASB.
Keywords. asymptomatic bacteriuria; bacteriuria; urinary tract infection; pyelonephritis; cystitis; diabetes; pregnancy; renal
transplant; endourologic surgery; urologic devices; urinary catheter; older adults; nursing home; long-term care; spinal cord injury;
neurogenic bladder.
EXECUTIVE SUMMARY
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 1
individuals in some populations with a high prevalence of ASB the methods, background, and evidence summaries that sup-
and may lead to clinical uncertainty in the diagnosis of symptom- port each recommendation can be found in the full text of the
atic infection. This may compromise the implementation of non- guideline.
treatment recommendations. Thus, this updated guideline also
addresses the clinical presentation of symptomatic UTI in popu- RECOMMENDATIONS FOR ASYMPTOMATIC
lations where there is a high prevalence of ASB, such as patients BACTERIURIA
with spinal cord injury or older adults (≥65 years). Candiduria is
I. Should Asymptomatic Bacteriuria Be Screened for and Treated in
not addressed, as recommendations for management of this syn- Pediatric Patients?
drome were included in the recent update of the IDSA Clinical Recommendation
Figure 1. Approach and implications to rating the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development
and Evaluation (GRADE) methodology (unrestricted use of the figure granted by the US GRADE Network).
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 3
is no evidence to suggest that, in this population, ASB has moderate-quality evidence). Values and preferences: This
greater risk than for nonneutropenic populations. recommendation places a high value on the avoidance of
the serious postoperative complication of sepsis, which is a
X. Should ASB Be Screened for or Treated in Individuals With Impaired substantial risk for patients undergoing invasive endouro-
Voiding Following Spinal Cord Injury?
logic procedures in the presence of bacteriuria. Remarks:
Recommendation
In individuals with bacteriuria, these are procedures in a
1. In patients with spinal cord injury (SCI), we recommend
heavily contaminated surgical field. High-quality evidence
against screening for or treating ASB (strong recommendation,
from other surgical procedures shows that perioperative
low-quality evidence). Remarks: Clinical signs and symptoms
antimicrobial treatment or prophylaxis for contaminated or
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 5
data that might change the recommendations from the last METHODOLOGY
IDSA guideline for ASB [6]. The panel also reviewed guidelines Panel Composition
from other organizations relevant to the management of ASB. The IDSA Guidelines for the Management of Asymptomatic
Bacteriuria in Adults were published in 2005 [6]. For this up-
Values and Preferences
date, the IDSA Standards and Practice Guideline Committee
Values and preferences were considered from the viewpoint of
(SPGC) convened a multidisciplinary panel of 15 individuals
the patient and from the societal perspective. We believe that
with expertise relevant to ASB encompassing different patient
most patients would wish to receive antimicrobial therapy for
groups, including infectious diseases as well as representation
ASB if the potential benefits of treatment outweigh possible
from family practice, pediatrics, geriatrics, obstetrics and gyne-
Patients All or almost all individuals in this situation would want Most individuals in this situation would probably want the suggested course of ac-
the recommended course of action, and only a small tion, but many would not.
proportion would not.
Clinicians All or almost all individuals should receive the intervention. Recognize that fully informed individuals might reasonably choose different courses
of action. A shared decision-making process is typically useful in helping individu-
als to make decisions consistent with their values and preferences.
Policy The recommendation can be adopted as policy in most sit- Policymaking will require substantial debate and involvement of various stakeholders.
makers uations. Adherence to this recommendation according
to the guideline can be used as a quality criterion or
performance indicator.
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 7
outcomes relevant to children with ASB for whom antimicro- a noncomparative study of a cohort of girls with ASB and radio-
bial therapy is being considered include not only symptomatic graphic evidence of renal scarring, initially aged 4–14 years
infection, but also the development of long-term renal scarring. and followed until 16 years of age, acute pyelonephritis was not
Most of the evidence describing prognosis and treatment of observed in girls with persistent bacteriuria or those who spon-
ASB in children was performed in the 1970s and 1980s. Based taneously cleared bacteriuria [54]. The duration of bacteriuria
on current evaluations of the quality of clinical trials, these early did not influence renal growth or the glomerular filtration rate.
studies have substantial methodological limitations, including It is not clear why the rates of renal sequelae were substantially
poor case definitions, small sample size, lack of randomization, higher in this study compared with other reports. The long-
no placebo group, inconsistent outcome measures, inconsistent term consequences of ASB were also reported for a cohort of
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 9
attributable to the ASB. Moreover, treatment of ASB may not 53 per 1000 [69]; antibiotics may reduce the risk to approxi-
decrease the frequency of symptomatic UTI, including pyelone- mately 14 per 1000 (RD, –39 [95% CI, –47 to –20]; low quality).
phritis (moderate quality). Antibiotics may increase rather than Antibiotics probably lower the chance of very low birth weight
decrease the risk of subsequent UTI (moderate quality). There from approximately 137 per 1000 to 88 per 1000 (RD, –49 [95%
is high-quality evidence that antibiotics have an increased risk CI, –75 to –10]; moderate quality).
of adverse effects, that screening and treating ASB is extremely In the Netherlands, screening for ASB in pregnancy has not
costly, and that the use of antibiotics promotes emergence of been instituted as a routine practice for prenatal care. A 2015
antimicrobial resistance. prospective study undertaken in that country, which included
an underpowered nested RCT of treatment of ASB, reported
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 11
effects are particularly common following the use of antimicro- Mental Status Changes
bials in this population, including CDI and isolation of organ- Observational evidence suggests that patients with delirium are
isms with increased antimicrobial resistance. more likely to have bacteriuria than patients without delirium
[94, 95]. However, confounding factors such as age, comor-
Research Needs bidities, and reduced mobility were not fully adjusted for in
Evaluation of potential biomarkers to differentiate symp- these observational studies, and there is a high probability of
tomatic UTI and ASB in older functionally impaired persons residual confounding. Therefore, a causal relationship between
should be pursued. Identifying objective criteria to diagnose bacteriuria and delirium has not been established. One small
symptomatic UTI is essential to facilitate optimal management cohort study found a higher rate of bacteriuria in patients who
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 13
Evidence Summary and outcomes of ASB and efficacy of antimicrobial treatment
In the 2005 IDSA ASB guideline [6], there was a recommenda- would be warranted. Randomized trials of treatment or non-
tion against screening for or treatment of ASB in people with treatment of ASB in diabetic men are needed.
diabetes. The updated literature review looked for RCTs that
compared antimicrobial therapy to no antimicrobial therapy in VII. Should Patients Who Have Received a Kidney Transplant Be Screened
patients with ASB and diabetes. We did not identify any new or Treated for ASB?
Recommendation
studies to inform this recommendation.
1. In renal transplant recipients who had the renal transplant
The previous recommendation against treating women with
surgery >1 month prior, we recommend against screening
diabetes who had ASB was based on 1 RCT [22] and 2 prospec-
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 15
effectively treated with oral therapy. Treatment of ASB probably kidney 0.05, kidney-pancreas 0.11, liver 0.03, heart 0, and lung
promotes reinfection with organisms increasingly resistant to 0.04 [130].
antimicrobials, potentially compromising treatment of sympto-
matic UTI, which is also frequent in these patients. There is also Rationale
high-quality evidence that antimicrobial therapy has an impor- UTIs are uncommon in nonkidney SOT, and the evidence
tant risk of adverse effects. suggests that serious harms resulting from symptomatic UTIs
are extremely rare. Any serious adverse consequences of ASB
Research Needs in nonrenal transplant recipients would be even more un-
There may be subgroups of transplant recipients at higher risk common than symptomatic UTIs and are, therefore, almost
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 17
Rationale catheter remains in situ. Acquisition of bacteriuria is 3%–5%
The efficacy of antimicrobial therapy for patients with ASB and per catheter day; antimicrobial therapy may delay but not pre-
SCI is uncertain (low-quality evidence). Some preliminary ev- vent onset [6]. Once bacteriuria is established in a catheterized
idence suggests that ASB may be protective in people with SCI urinary tract, antimicrobials can temporarily suppress the bac-
and impaired voiding. There is also high-quality evidence that teriuria, but recurrence with the same or different species, often
antimicrobials cause harm through adverse effects and costs, as with organisms of increased antimicrobial resistance, occurs
well as increasing the risk for antimicrobial-resistant infections universally. Many individuals with short-term catheters (in place
in the individual and the community. for <30 days) do not develop bacteriuria because the catheter is
removed prior to acquisition of bacteriuria. In addition, 60%–
ulations were heterogeneous. In 5 of 6 studies, the outcome mea- We make a strong recommendation because there is very low
sured was ASB, and 4 of these studies were in surgical patients. certainty of any benefit and high-quality evidence of harm.
There are no studies generalizable to current practice specifi-
Rationale cally addressing the question of whether screening for or treat-
Most patients with short-term indwelling catheters do not ing ASB at the time of catheter removal confers benefits or
acquire bacteriuria, and short-term catheter-associated bacte- results in adverse outcomes. While selected patient groups, such
riuria does not appear to increase the risk for sepsis or death. as patients with recent surgery for urinary tract reconstruc-
When bacteriuria occurs, it infrequently results in symptomatic tion, may possibly benefit from treatment of ASB at catheter
infection or bacteremia. Whether or not antimicrobials for ASB removal, the extent of benefit, association with bacteriuria, and
are effective in preventing symptomatic UTI, sepsis, or death is specific patient groups who may benefit is uncertain. While the
uncertain. In the acute care hospital setting, the risk of CDI is benefits of antimicrobial therapy at catheter removal are uncer-
high; thus, avoiding antimicrobials is particularly important in tain, there is high-quality evidence that antimicrobials cause
hospitalized patients. Patients with short-term catheters are also harm including adverse effects and increasing costs, as well as
at high risk for nosocomial infections with antimicrobial-resis- increasing the risk of antimicrobial-resistant infections in the
tant organisms, so avoiding antimicrobials is important to the individual and the community.
individual and the community.
Chronic Indwelling Catheters
Bacteriuria at Catheter Removal Individuals with chronic indwelling catheters are, generally,
No additional clinical trials that screened for ASB at the time of always bacteriuric, usually with a polymicrobial flora [19].
catheter removal and, if present, randomized patients to treat- Residents of long-term care facilities who have chronic indwell-
ment or no treatment, were published since 2005. One RCT in ing catheters have an increased frequency of febrile UTI com-
women, published in 1991 [163], addressed this topic and was pared with bacteriuric residents without catheters [165, 166].
included in prior guidelines [6, 18]. Seven of 42 (17%) women CAUTI is the source of more than half of all episodes of bac-
randomized to no treatment developed symptomatic UTI teremia in long-term care residents, while only 5%–10% of
within 14 days, while 15 (36%) had spontaneous clearance of residents have indwelling catheters [167]. Kunin et al [168]
bacteriuria during this period. Thus, selected women in whom reported increased mortality in residents with chronic indwell-
bacteriuria persists after catheter removal may be at increased ing catheters, but when adjusted for other differences between
short-term risk for symptomatic UTI. However, the generaliz- catheterized and noncatheterized long-term care facility resi-
ability of these observations to the current cohort of women dents, the CI included no effect. In a subsequent larger prospec-
with short-term indwelling catheters is unclear, as women in tive study among 1540 residents [166], he reported a significant
this study were enrolled only if there was a negative urine cul- independent association of chronic urinary catheter use with
ture at catheter insertion, no antimicrobial therapy while the mortality, and a stepwise increase in mortality with duration of
catheter remained in situ, and bacteriuria documented at cath- catheterization. However, we did not identify any evidence that
eter removal and persisting 48 hours after catheter removal. antimicrobial treatment of bacteriuria in persons with long-
Many of these women were also catheterized for gynecologic term indwelling catheters can reduce the risk of death.
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 19
A prospective cohort study of prophylaxis to prevent ASB and Evidence Summary
UTI in patients with long-term indwelling catheters reported Antimicrobial therapy for patients with ASB undergoing
no benefits [169]. Studies also consistently report that treat- nonurologic surgery was not addressed in the previous IDSA
ment of subjects with ASB and chronic catheters is followed by ASB guideline. Preoperative ASB has been identified as a risk
rapid emergence of antimicrobial resistance in urinary strains factor for postoperative complications, including deep and
[169, 170]. A prospective, randomized comparative trial [23] in superficial surgical-site infections [171–173], and preoperative
residents of long-term care facilities compared 17 patients who testing for pyuria and bacteriuria has been a relatively com-
received a 10-day course of cephalexin monohydrate, repeated mon practice in some settings for at least 30 years [174]. One
whenever susceptible bacteria were isolated (160 courses), and major clinical concern is prosthetic infection developing in
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 21
ureteric stents) are considered low risk for infectious complica- appropriate antimicrobials, and 10 of 87 (11.5%) patients who
tions. Studies comparing different approaches to reduce post- received appropriate antimicrobials. No patient developed post-
surgical infection rates, including antimicrobial prophylaxis, operative septicemia.
often need to enroll subjects undergoing “high-volume” proce-
dures to facilitate adequate participant recruitment numbers. Antimicrobial Regimens Prior to Traumatic Endourological Surgery
In urology, TURP is a high-volume procedure and has been the Six studies [185–190] compared different perioperative ASB
“model” for randomized trials; indirect evidence from TURP treatment regimens and durations. Two of these [189, 190] were
must then be applied to procedures performed less frequently. published after the previous guideline. Two early RCTs com-
For diagnostic, nontraumatic procedures, randomized studies pared the efficacy of perioperative antimicrobial treatment to
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 23
associated with an increased risk for device infection following for Paratek, Ocean Spray, Iterum, and Tetraphase and has received other
remuneration from UpToDate. S. G. has served as a consultant for Nordic
surgery. The universal use of perioperative antimicrobials for
Pharma, T. M. H. has served as a consultant for Damone, Melnata, Melinta
prophylaxis of surgical infection is effective for resolution of OM Pharma, GlaxoSmithline (GSK), Ocean Spray, Paratek, Shionogi,
most episodes of ASB [199]. Therefore, any additional benefit Achaogen, and Cubist; has ownership interest in Fimbrion Therapeutics;
from screening and treating ASB would be negligible. Bacterial and has received other remuneration from Fimbrion Therapeutics and
UpToDate. M. J. M. has received research grants from NIH and has served
species isolated from device infections are usually distinct from as a consultant to Iterum Therapeutics. B. K. has received research grants
organisms isolated from ASB. We also did not identify any evi- from the European Association of Urology and served as a consultant for
dence that ASB in patients with a urological device in situ is a F. Hoffmann-La Roche Ltd. L. N. has served as a consultant for Paratek,
Tetraphase, Utility, and GSK. R. S. is a member of the GRADE Working
risk factor for urological device infection. Similar to other rec-
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 25
nitrofurantoin for asymptomatic bacteriuria in pregnancy: a randomized con- 95. Balogun SA, Philbrick JT. Delirium, a symptom of UTI in the elderly: fact or
trolled trial. Obstet Gynecol 2009; 113:339–45. fable? A systematic review. Can Geriatr J 2014; 17:22–6.
72. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guide- 96. Bhattacharya B, Maung A, Barre K, et al. Postoperative delirium is associated with
lines for the treatment of acute uncomplicated cystitis and pyelonephritis in increased intensive care unit and hospital length of stays after liver transplanta-
women: a 2010 update by the Infectious Diseases Society of America and the tion. J Surg Res 2017; 207:223–8.
European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 97. Sundvall PD, Ulleryd P, Gunnarsson PK. Urine culture doubtful in determining
52:e103–20. etiology of diffuse symptoms among elderly individuals: a cross sectional study of
73. Reeves DS. Treatment of bacteriuria in pregnancy with single dose fosfomycin 32 nursing homes. BMC Fam Pract 2011; 12:36. doi:10.1186/1471-2296-12-36.
trometamol: a review. Infection 1992; 20(Suppl 4):S313–6. 98. Potts L, Cross S, MacLennan WJ, Watt B. A double-blind comparative study of
74. Keating GM. Fosfomycin trometamol: a review of its use as a single-dose oral norfloxacin versus placebo in hospitalised elderly patients with asymptomatic
treatment for patients with acute lower urinary tract infections and pregnant bacteriuria. Arch Gerontol Geriatr 1996; 23:153–61.
women with asymptomatic bacteriuria. Drugs 2013; 73:1951–66. 99. Silver SA, Baillie L, Simor AE. Positive urine cultures: a major cause of inap-
IDSA 2019 Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria • cid 2019:XX (XX XXXX) • 27
172. David TS, Vrahas MS. Perioperative lower urinary tract infections and deep sep- prostatic resection. A controlled comparison with methenamine. Scand J Urol
sis in patients undergoing total joint arthroplasty. J Am Acad Orthop Surg 2000; Nephrol 1983; 17:299–301.
8:66–74. 187. Holmquist B, Lundgren R. Pivmecillinam plus pivampicillin versus co-trimoxaz-
173. Ollivere BJ, Ellahee N, Logan K, Miller-Jones JC, Allen PW. Asymptomatic uri- ole in patients undergoing transurethral prostate resection. Pharmatherapeutica
nary tract colonisation predisposes to superficial wound infection in elective 1984; 3:686–91.
orthopaedic surgery. Int Orthop 2009; 33:847–50. 188. Adolfsson J, Köhler C, Falck L. Norfloxacin versus trimethoprim-sulfamethoxaz-
174. Lawrence VA, Kroenke K. The unproven utility of preoperative urinalysis. ole. A study in patients with known bacteriuria undergoing transurethral resec-
Clinical use. Arch Intern Med 1988; 148:1370–3. tion of the prostate. Scand J Urol Nephrol 1989; 23:255–9.
175. Sousa R, Muñoz-Mahamud E, Quayle J, et al. Is asymptomatic bacteriuria a risk 189. Sayin Kutlu S, Aybek Z, Tekin K, et al. Is short course of antimicrobial therapy for
factor for prosthetic joint infection? Clin Infect Dis 2014; 59:41–7. asymptomatic bacteriuria before urologic surgical procedures sufficient? J Infect
176. Drekonja DM, Zarmbinski B, Johnson JR. Preoperative urine cultures at a Dev Ctries 2012; 6:143–7.
Veterans Affairs medical center. JAMA Intern Med 2013; 173:71–2. 190. Chong JT, Klausner AP, Petrossian A, et al. Pre-procedural antibiotics for endo-