IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Clinical Practice Guideline for the Management of Asymptomatic

Bacteriuria: 2019 Update by the Infectious Diseases Society of
America
Supplemental Materials

Contents
Literature Search and Systematic Review Methodology ................................................................ 2
Appendix. PRISMA flow diagrams and GRADE Evidence Profiles ............................................. 2
1. Children................................................................................................................................ 3
2. Healthy, non-pregnant, premenopausal women................................................................... 6
3. Pregnant women .................................................................................................................. 9
4. Elderly people with asymptomatic bacteriuria .................................................................. 11
5. Elderly people .................................................................................................................... 14
5a. Delirium ................................................................................................................... 14
5b. Falls ......................................................................................................................... 17
6. Persons with diabetes ......................................................................................................... 18
7-8. Solid organ transplant recipients ........................................................................................ 20
9. Patients with neutropenia ................................................................................................... 23
10. Impaired voiding following spinal cord injury ................................................................. 24
11. Indwelling urethral or supra-pubic catheter ...................................................................... 26
12. Patients undergoing elective, non-urologic surgery .......................................................... 31
Endourologic procedures ................................................................................................ 35
Urologic devices ............................................................................................................. 38

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Literature Search and Systematic Review Methodology

The health sciences librarian (S.K.) designed search strategies for asymptomatic
bacteriuria PICOs (population, intervention, comparison, outcome) using medical subject
headings and text words (see tables in the online supplement), limited to human studies or non-
indexed citations, and articles in English or in any language with English abstracts. The Ovid
platform was used to search MEDLINE, EMBASE and Cochrane Registry of Controlled Trials.
Years of coverage varied, with all searches updated through July 7, 2017. Reviewers hand-
searched reference lists and contacted experts for additional articles.
Librarians used the following peer-reviewed search strategy to search MEDLINE with
minor revisions for other databases.
Results were distributed to reviewers as EndNote files. Reviewers used a two-step
screening process with predefined inclusion and exclusion criteria. First, two reviewers
independently screened titles and abstracts. If either reviewer thought a title and abstract was
potentially relevant, two reviewers independently reviewed the full text for inclusion. Two
reviewers then independently reviewed the full texts of all potentially relevant studies.
Discrepancies were resolved through discussion.
Two reviewers extracted individual study data independently; they also assessed risk of
bias. The data and risk of bias assessments were finalized following a discussion with the panel
members.

Appendix. PRISMA flow diagrams and GRADE Evidence Profiles

See below.

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

1. Children

Records identified through Additional records identified

database searching through other sources
(n = 7727) (n = 4)

Records after duplicates removed

(n = 147)

Records screened Records excluded

(n = 147) (n = 126)

Full-text articles excluded,

Full-text articles assessed
for eligibility (n = 6)
1 not population
(n = 21)
1 not relevant to question
4 duplicate populations in
other studies

Studies included
(n=15)

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table A. GRADE Evidence Profile, PICO 1

Population: Children with asymptomatic bacteriuria
Intervention: Antibiotics
Comparator: No antibiotics

Absolute effect estimates Certainty in effect

Outcome Study results and
estimates Plain text summary
Timeframe measurements
No antibiotics Antibiotics (Quality of evidence)

Odds Ratio: 0.54 32 17

(CI 95% 0.06 - 5.25) per 1000 per 1000 Low Antibiotics may not
Pyelonephritis Based on data from
Due to serious risk of bias reduce the risk of
122 patients in 2 Difference: 15 fewer per 1000 and imprecision1 pyelonephritis.
studies (CI 95% 78 fewer - 47 more)
Follow up 44 months
One RCT found that there was no
difference in renal function
(concentrating ability) with 2
years of intermittent antibiotic
Based on data from
Renal therapy for asymptomatic Low Antibiotics may not
122 patients in 2
insufficiency bacteriuria. No children in the Due to serious risk of bias prevent renal
studies
two RCTs developed renal and imprecision2 insufficiency.
Follow up 2 years
insufficiency over approximately
2 years of follow-up. Neither
RCT found any differences in
renal scarring.
Abbreviations: CI = confidence interval, RCT = randomized controlled trial.
1. Risk of bias: Serious. Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Imprecision:
Serious.
2. Risk of bias: Serious. Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias, Inadequate
sequence generation/ generation of comparable groups, resulting in potential for selection bias; Imprecision: Serious. Low number of
patients.

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table B. Study characteristics, children with asymptomatic bacteriuria

Author, year Study Location Number of Intervention Control Notable
design patients limitations
Kunin, 1970 Single United States 156 Not defined No Not a
group control comparative
cohort study. Used to
study define baseline
risk in the no
treatment group.
Lindberg, RCT Sweden 61 Nitrofurantoin for 6 Not Not blinded;
1975 months. defined very long
treatment course.
Savage, 1975 RCT Scotland 61 3 months of antibiotics Not Not blinded.
initially and after their defined Very long
first relapse; 6 months of treatment
antibiotics on later courses.
relapses. Antibiotic
options: ampicillin,
nitrofurantoin, or
trimethoprim and
sulfamethoxazole,
according to sensitivity.
Abbreviations: RCT = randomized controlled study.
1. Kunin CM. N Engl J Med. 1970 Jun 25;282(26):1443-8. DOI: 10.1056/NEJM197006252822601
2. Lindberg U. Acta Paediatr Scand. 1975 Sep;64(5):718-24.
3. Savage DC, Howie G, Adler K, Wilson MI. Lancet. 1975 Feb 15;1(7903):358-61.

Figure C. Forest plot of pyelonephritis, children with asymptomatic bacteriuria.

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

2. Healthy, non-pregnant, premenopausal women

Records identified through database Additional records identified

searching through other sources
(n = 111) (n = 7)

Records after duplicates removed

(n = 118)

Records screened Records excluded

(n = 118) (n = 105)

Full-text articles assessed Full-text articles excluded,

for eligibility with reasons
(n = 13) (n = 10)
6 reviews
1 no UTI outcome
3 no interventions
Studies included
(n=3)

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table D. GRADE Evidence Profile, PICO 2

Population: Non-pregnant women with asymptomatic bacteriuria
Intervention: Antibiotics
Comparator: No antibiotics

Absolute effect estimates

Outcome Study results and Certainty in effect estimates
Plain text summary
Timeframe measurements (Quality of evidence)
No antibiotics Antibiotics

Relative risk: 0.87 444 388

Based on data from per 1000 per 1000 Very low The effect on UTI in
UTI
673 patients in 1 Due to observational study, the long-term is
Long-term
studies Difference: 56 fewer imprecision unclear.
Follow up 3-4 years
Relative risk: 1.69 154 260
(CI 95% 0.17 - 16.41) per 10001 per 1000 Very low
The effect on UTI in
UTI Based on data from Due to serious risk of bias,
the short-term is
Short-term 673 patients in 1 serious imprecision,
Difference: 106 more unclear.
studies observational study
Follow up 1 week
Relative risk: 1.69 3 5
(CI 95% 0.17 - 16.41) per 1000 per 1000 Antibiotics may not
Pyelonephritis Based on data from Moderate
reduce the risk of
673 patients in 1 Difference: 2 more per 1000 Due to serious risk of bias2
pyelonephritis.
studies (CI 95% 8 fewer - 12 more)
Follow up 1 year
Abbreviations: UTI = urinary tract infection, CI = confidence interval.
1. Baseline risk from Hooten et. Al., N Engl J Med. 2000 Oct 5;343(14):992-7. DOI: 10.1056/NEJM200010053431402
2. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Imprecision: Serious. Only data
from one study.

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table E. Study characteristics, non-pregnant women with asymptomatic bacteriuria (PICO

2)

Author, year Study design Location Number of Intervention Control Notable

patients limitations
Asscher, 1969 RCT United 94 Nitrofurantoin Placebo Possibly
Kingdom for 7 days and inadequate
ampicillin for 7 allocation
days if failed concealment.
treatment
Cai, 2012 RCT Italy 673 Antibiotic Usual care Not blinded
therapy
according to
antibiogram.
Abbreviations: RCT = randomized controlled trial.
1. Asscher AW, Sussman M, Waters WE, Evans JA, Campbell H, Evans KT, Williams JE. Br Med J. 1969 Mar 29;1(5647):804-6.
2. Cai T, Mazzoli S, Mondaini N, Meacci F, Nesi G, D'Elia C, Malossini G, Boddi V, Bartoletti R. Clin Infect Dis. 2012 Sep;55(6):771-7.
doi: 10.1093/cid/cis534.

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

3. Pregnant women

Records identified through database Additional records identified

searching through other sources
(n = 5162) (n = 3)

Records after duplicates removed

(n = 5165)

Records screened Records excluded

(n = 5165) (n = 5096)

Full-text articles assessed Full-text articles excluded, with

for eligibility reasons
(n = 69) (n =49)
31 not a randomized controlled trial
3 not English
12 not relevant outcome
Studies included in 3 not relevant population
qualitative synthesis
(n = 20)

Studies included in
quantitative synthesis
(meta-analysis)
(n = 0)

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table F. GRADE Evidence Profile, PICO 3

Population: Pregnant women with asymptomatic bacteriuria
Intervention: Antibiotics
Comparator: No antibiotics

Absolute effect estimates

Outcome Study results and Certainty in effect estimates
Plain text summary
Timeframe measurements (Quality of evidence)
No antibiotics Antibiotics

Relative risk: 0.23 24b 6

(CI 95% 0.13 - 0.41)a per 1000 per 1000
Based on data from Antibiotics probably
Pyelonephritis Moderate
1932 patients in 11 reduce the risk of
Difference: 18 fewer per 1000 Due to serious risk of bias1
studies pyelonephritis.
Follow up Duration of (CI 95% 21 fewer - 14 fewer)
pregnancy
Relative risk: 0.27 53b 14
a
(CI 95% 0.11 - 0.62) per 1000 per 1000
Preterm birth Based on data from Low Antibiotics may
(<37 weeks) 242 patients in 2 Due to serious risk of bias and reduce the risk of
studies Difference: 39 fewer per 1000 imprecision2 preterm birth.
Follow up Duration of (CI 95% 47 fewer - 20 fewer)
pregnancy
Relative risk: 0.64 137b 88
(CI 95% 0.45 - 0.93)a per 1000 per 1000
Very low
Based on data from Antibiotics probably
birthweight Moderate
1437 patients in 6 reduce the risk of
(<2500g) Difference: 49 fewer per 1000 Due to serious risk of bias3
studies very low birthweight.
Follow up Duration of (CI 95% 75 fewer - 10 fewer)
pregnancy
Abbreviations: CI = confidence interval.
a. Relative effects obtained from Smaill FM, Vazquez JC. Cochrane Database Syst Rev. 2015 Aug 7;(8):CD000490. doi:
10.1002/14651858.CD000490.pub3.
b. Baseline risk without antibiotics obtained from Kazemier BM, Koningstein FN, Schneeberger C, et al. Lancet Infect Dis. 2015
Nov;15(11):1324-33. doi: 10.1016/S1473-3099(15)00070-5.

1. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Inconsistency: No serious.
I2=64%. However, point estimates almost all of the RCTs favored antibiotics over no antibiotics.
2. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Imprecision: Serious. Low
number of patients.
3. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias.

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

4. Elderly people with asymptomatic bacteriuria

Records identified through Additional records identified

database searching through other sources
(n = 9038) (n = 0)

Records after duplicates removed

(n = 9038)

Records screened Records excluded

(n = 9038) (n = 8969)

Full-text articles assessed Full-text articles excluded,

for eligibility (n = 59)
(n = 69) 23 wrong population (not
aged, not ASB)
20 wrong outcome (not
UTI, death, sepsis)
Studies included in 13 reviews
qualitative synthesis 3 wrong intervention (no
(n = 4) antibiotic use)

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table G. GRADE Evidence Profile, PICO (4.1)

Population: Elderly people with asymptomatic bacteriuria
Intervention: Antibiotics
Comparator: No antibiotics

Absolute effect estimates

Outcome Study results and Certainty in effect estimates
Plain text summary
Timeframe measurements (Quality of evidence)
No antibiotics Antibiotics

Antibiotics do not
No relative effect
UTI substantially reduce
161 patients 0a 0 High
1-2 weeks the short-term risk of
Follow-up 1-2 weeks
UTI.
Relative risk: 1.19 68 81
(CI 95% 0.63 - 2.25) per 1000 per 1000
Based on data from Low Antibiotics may not
Mortality
566 patients in 4 Due to serious risk of bias and reduce the risk of
studies Difference: 13 more per 1000 imprecision1 death.
Follow up 6 months to (CI 95% 25 fewer - 85 more)
3 years

Relative risk: 0.25 100 0

per 1000 per 1000 Whether antibiotics
(CI 95% 0.01 - 4.81) Very Low
Sepsis reduce the risk of
Based on data from 36 Difference: 100 fewer per Due to serious risk of bias and
sepsis or not is
patients in 1 studies 1000 very serious imprecision2
uncertain.
Follow up 1 year (CI 95% 260 fewer - 60 more)
Abbreviations: UTI = urinary tract infection, CI = confidence interval.
a. Baseline/comparator: obtained from Abrutyn E, et al. Ann Intern Med. 1994 May 15;120(10):827-33. None of 161 patients with
asymptomatic bacteriuria had symptomatic UTI within 2 weeks.

1. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Imprecision: Serious. Wide
confidence intervals.
2. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Imprecision: Very Serious. Wide
confidence intervals, Only data from one study

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table H. Study characteristics, elderly adults with asymptomatic bacteriuria

Author, year Study design Location Number of Intervention Control Notable
patients limitations
Abrutyn, 19941 Cohort study United 318 None in the Placebo RCT reports
and nested States cohort study; results for
RCT some patients mortality
randomized to only
receive
antibiotics after 2
weeks
Boscia, 19872 RCT United 124 200-mg dose of No Not blinded
States trimethoprim antibiotics
administered or
500 mg of
cefaclor three
times a
day administered
orally for three
days
Nicolle, 19833 Cohort study Canada 36 Trimethoprim No Not blinded
and nested and antibiotics
RCT sulfamethoxazole
or tobramycin
Nicolle, 19874 RCT Canada 50 Monthly No Not blinded
screening for antibiotics
asymptomatic unless
bacteriuria and symptomatic
targeted
antibiotics
Abbreviations: RCT = randomized controlled trial.
1. Abrutyn E, Mossey J, Berlin JA, Boscia J, Levison M, Pitsakis P, Kaye D. Does asymptomatic bacteriuria predict mortality and does
antimicrobial treatment reduce mortality in elderly ambulatory women? Ann Intern Med. 1994 May 15;120(10):827-33.
2. Boscia JA, Kobasa WD, Knight RA, Abrutyn E, Levison ME, Kaye D. Therapy vs no therapy for bacteriuria in elderly ambulatory
nonhospitalized women. JAMA. 1987 Feb 27;257(8):1067-71.
3. Nicolle LE, Bjornson J, Harding GK, MacDonell JA. Bacteriuria in elderly institutionalized men. N Engl J Med. 1983 Dec
8;309(23):1420-5.
4. 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 Jul;83(1):27-33.

Figure I. Forest plot, impact of antibiotics on mortality in elderly patients with IAI

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5. Elderly people
5a. Delirium

Records identified through database Additional records identified

searching through other sources
(n = 1634) (n = 15)

Records after duplicates removed

(n = 1649)

Records screened Records excluded

(n = 1649) (n = 1629)

Full-text articles assessed Full-text articles excluded,

for eligibility (n = 10)
(n = 20) 8 missing exposure or
outcome data
2 not ASB

Studies included in
qualitative synthesis
(n = 10)

Studies included in
quantitative synthesis
(meta-analysis)
(n = 2)

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table J. GRADE Evidence Profile, PICO (5a)

Population: Elderly patients with delirium and bacteriuria
Intervention: Antibiotics
Comparator: No antibiotics

Absolute effect estimates

Outcome Study results and Certainty in effect estimates
Plain text summary
Timeframe measurements (Quality of evidence)
No antibiotics Antibiotics

Relative risk: 0.19 42 8

(CI 95% 0.01 - 4.48) per 1000 per 1000 Very Low The impact on
Mortality
Based on data from 67 Due to serious risk of bias and mortality is
patients in 1 studies Difference: 34 fewer per 1000 very serious imprecision1 uncertain.
Follow up in hospital (CI 95% 42 fewer - 146 more)
One randomized controlled
trial of 58 patients with
delirium and ASB assessed
delirium with a behavioral
scale. The mean scores were
higher (worse) in the treatment
group but not statistically
different at any of the time
Based on data from periods measured, and
Delirium Low
148 patients in 2 worsened in both groups (18.1 Antibiotics may not
resolution Due to serious risk of bias and
studies to 19.1 in norfloxacin group 2 improve delirium.
imprecision
Follow up in hospital and 15.7 to 16.6 in the placebo
group). In an observational
study, there was no difference
chance of recovery for
delirious patients with ASB
who received antibiotics (n=68)
and those who did not (n=22;
unadjusted RR 1.10, 95% CI
0.86 – 1.41).
Abbreviations: CI = confidence interval, ASB = asymptomatic bacteriuria, RR = relative risk.
1. Risk of bias: Serious. Not adjusted.; Imprecision: Very Serious. Low number of patients, Only data from one study.
2. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Imprecision: Serious.

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table K. Study characteristics, elderly adults with delirium and bacteriuria without
urinary or infectious symptoms
Author, year Study Location Number of Intervention Comparator Notable
design patients limitations
Dasgupta, Cohort Canada 343 Antibiotics for Did not Did not adjust
20171 bacteriuria receive for most key
antibiotics for confounders.
bacteriuria Many patients
were lost to
follow-up.
Potts, 19962 Randomized United 58 Antibiotics Placebo It isn’t clear
controlled Kingdom what exactly
trial the symptoms
were that the
patients were
experiencing,
although many
were confused.
Silver, 20093 Cohort study Canada 137 Antibiotics No antibiotics Did not adjust
for most key
confounders.
1. Dasgupta M, Brymer C, Elsayed S. Treatment of asymptomatic UTI in older delirious medical in-patients: A prospective cohort study.
Arch Gerontol Geriatr. 2017 Sep;72:127-134. doi: 10.1016/j.archger.2017.05.010.
2. Potts L, Cross S, MacLennan WJ, Watt B. A double-blind comparative study of norfloxacin versus placebo in hospitalised elderly
patients with asymptomatic bacteriuria. Arch Gerontol Geriatr. 1996 Sep-Oct;23(2):153-61.
3. Silver SA, Baillie L, Simor AE. Positive urine cultures: A major cause of inappropriate antimicrobial use in hospitals? Can J Infect Dis
Med Microbiol. 2009 Winter;20(4):107-11

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5b. Falls

Note: no studies were identified that matched this population directly. We considered indirect evidence
from studies of elderly patients with bacteriuria, non-specific symptoms, but no urinary or infectious
symptoms.

Records identified through database Additional records identified

searching through other sources
(n = 1424) (n = 1)

Records after duplicates removed

(n = 1425)

Records screened Records excluded

(n = 1425) (n = 1419)

Full-text articles assessed Full-text articles excluded

for eligibility n=4
(n = 6) 3 missing exposure or
outcome data
1 not ASB

Studies included in
qualitative synthesis
(n = 2)

Studies included in
quantitative synthesis
(meta-analysis)
(n = 0)

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials
6. Persons with diabetes
Records identified through database
searching
(n = 4043 + 393 update = 4436)
Records after duplicates removed
(n = 3558 + 393 update = 3951)
Records screened
(n = 3558 + update = 3951)
Full-text articles assessed
for eligibility
(n = 66 + update 2 = 68)
Studies included in
qualitative synthesis
(n = 0)
Studies included in
quantitative synthesis
(meta-analysis)
(n = 0)
Records excluded
(n = 3492 + update 391 = 3883)
Full-text articles excluded, with
reasons
(n = 66 + 2 update = 68)
 No asymptomatic
bacteriuria: 25
 No antimicrobial therapy:
24 + 1 update = 25
 Not included study type:
14 + 1 update = 15
 Not involving patients with
diabetes: 2
 Included in previous
guideline: 1
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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table L. GRADE Evidence Profile, PICO 7

Population: People with diabetes and asymptomatic bacteriuria
Intervention: Antibiotics
Comparator: No antibiotics

Absolute effect estimates

Outcome Study results and Certainty in effect estimates
Plain text summary
Timeframe measurements (Quality of evidence)
No antibiotics Antibiotics

Relative risk: 0.24 80 20

(CI 95% 0.03 - 2.22) per 1000 per 1000 Low Antibiotics may not
Pyelonephritis
Based on data from 99 Due to very serious reduce the risk of
patients in 1 studies Difference: 60 fewer per 1000 imprecision1 pyelonephritis.
Follow up 6 weeks (CI 95% 145 fewer - 25 more)
Abbreviation: CI = confidence interval.
1. Imprecision: Very Serious.

Table M. Study characteristics, patients with diabetes and asymptomatic bacteriuria

Author, year Study Location Number of Intervention Comparator Notable
design patients limitations
Harding, RCT Canada 105 Antimicrobial Placebo Imbalances in
20021 therapy baseline
characteristics,
may be due to
small sample
size.
1. Harding GK, Zhanel GG, Nicolle LE, Cheang M; Manitoba Diabetes Urinary Tract Infection Study Group. Antimicrobial treatment in
diabetic women with asymptomatic bacteriuria. N Engl J Med. 2002 Nov 14; 347(20):1576-83.

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

7-8. Solid organ transplant recipients

Records identified through database Additional records identified

searching through other sources
(n = 5290) (n = 4)

Records after duplicates removed

(n = 5294)

Records screened Records excluded

(n = 5294) (n = 5254)

Full-text articles assessed

for eligibility
(n = 40) Full-text articles excluded
(n = 38)
24 not ASB
12 no interventions
Studies included in 2 consensus
qualitative synthesis
(n = 2)

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table N. GRADE Evidence Profile, PICO 8

Population: Renal transplant recipients more than one month after transplant receipt with
asymptomatic bacteriuria
Intervention: Antibiotics
Comparator: No antibiotics

Absolute effect estimates Certainty in effect

Outcome Study results and
estimates* Plain text summary
Timeframe measurements
No antibiotics Antibiotics (Quality of evidence)

Relative risk: 0.78 212 165

(CI 95% 0.44 - 1.38) per 1000 per 1000 Antibiotics may not
Urinary tract Low
Based on data from reduce the risk of
infection Due to serious risk of bias and
200 patients in 2 urinary tract
Difference: 47 fewer per 1000 imprecision1
studies (CI 95% 119 fewer - 81 more) infection.
Follow up 2 years
Relative risk: 0.89 85 76 It is uncertain
(CI 95% 0.25 - 3.14) per 1000 per 1000 Low whether or not
Pyelonephritis Based on data from
Due to serious risk of bias and antibiotics reduce the
112 patients in 1 Difference: 9 fewer per 1000 imprecision2 risk of
studies (CI 95% 64 fewer - 182 more) pyelonephritis.
Follow up 2 years
Relative risk: 0.93 203 189 It is uncertain
(CI 95% 0.44 - 1.97) per 1000 per 1000 Very Low whether or not
Graft rejection Based on data from
Due to serious risk of bias and antibiotics reduce the
112 patients in 1 Difference: 14 fewer per 1000 very serious imprecision3 risk of
studies (CI 95% 114 fewer - 197 more) pyelonephritis.
Follow up 2 years
In one RCT with 112 patients,
antibiotics did not improve
creatinine clearance at 12
months (mean difference = -2.4
Based on data from mL/min/1.73m2; p=0.50) or at
Antibiotics probably
Renal function 200 patients in 2 24 months (mean difference - Moderate
do not improve renal
studies 3.6 mL/min/1.73 m2; p=0.34). Due to serious risk of bias4
function.
Follow up 2 years In another RCT with 88
patients, there was no
difference in mean serum
creatinine levels or in change in
creatinine levels.
Abbreviations: CI = confidence interval, RCT = randomized controlled trial.

*This evidence applies to renal transplant recipients. The certainty is lower for all outcomes for non-renal transplant recipients because of
indirectness.
1. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Imprecision: Serious.
2. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Imprecision: Serious. Wide
confidence intervals, Only data from one study.
3. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Imprecision: Very Serious. Wide
confidence intervals, Only data from one study.
4. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias.

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table O. Study characteristics, patients with solid organ transplants*

Author, year Study Location Number of Intervention Comparator Notable
design patients limitations
Moradi, 20051 RCT Iran 88 Antimicrobial No treatment Not blinded
therapy
Origen, 20162 RCT Spain 112 Antimicrobial No treatment Not blinded
therapy
Abbreviation: RCT = randomized controlled trial.
*Both studies enrolled renal transplant recipients only

1. Moradi M, Abbasi M, Moradi A, Boskabadi A, Jalali A. Effect of antibiotic therapy on asymptomatic bacteriuria in kidney transplant
recipients. Urol J. 2005 Winter;2(1):32-5.
2. Origüen J, López-Medrano F, Fernández-Ruiz M, Polanco N, Gutiérrez E, González E, Mérida E, Ruiz-Merlo T, Morales-Cartagena
A, Pérez-Jacoiste Asín MA, García-Reyne A, San Juan R, Orellana MÁ, Andrés A, Aguado JM. Should Asymptomatic Bacteriuria Be
Systematically Treated in Kidney Transplant Recipients? Results From a Randomized Controlled Trial. Am J Transplant. 2016
Oct;16(10):2943-2953. doi: 10.1111/ajt.13829

Figure P. Forest plot, impact of antibiotics on urinary tract infections in renal transplant
recipients

Figure Q. Forest plot, impact of antibiotics on pyelonephritis in renal transplant recipients

Figure R. Forest plot, impact of antibiotics on graft rejection in renal transplant recipients

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

9. Patients with neutropenia

Records identified through database Additional records identified

searching through other sources
(n = 2091) (n = 3)

Records after duplicates removed

(n = 2094)

Records screened Records excluded

(n = 2094) 2086

Full-text articles excluded,

Full-text articles assessed with reasons
for eligibility (n = 8)
(n = 8) 4 not ASB
3 review
1 not neutropenia

Studies included in
qualitative synthesis
(n = 0)

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

10.Impaired voiding following spinal cord injury

Record identified through Additional records identified

database searching through other sources
(n = 1146) (n = 15)

Records after duplicates removed

(n = 1104)

Records screened Records excluded

(n = 1104) (n = 1080)

Full-text articles assessed Full-text articles excluded,

for eligibility with reasons
(n = 24) (n = 16)
▫ not RCT
▫ not relevant outcome
▫ not relevant population
Studies included
(n = 8)

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table S. GRADE Evidence Profile, PICO 10

Population: People with spinal cord injury and asymptomatic bacteriuria
Intervention: Antibiotics
Comparator: No antibiotics

Absolute effect estimates

Outcome Study results and Certainty in effect estimates
Plain text summary
Timeframe measurements (Quality of evidence)
No antibiotics Antibiotics

Relative risk: 0.93 400 372

Urinary tract (CI 95% 0.54 - 1.58) per 1000 per 1000 Very Low The effect of
infection Based on data from 85 Due to serious risk of bias and antibiotics for ASB
patients in 2 studies Difference: 28 fewer per 1000 very serious imprecision1 is uncertain.
Follow up 50 days (CI 95% 184 fewer - 232 more)
1. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection
bias, Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Imprecision: Very
Serious. Wide confidence intervals, Low number of patients.

Table T. Study characteristics, patients with spinal cord injury

Author, year Study Location Number of Intervention Comparator Notable
design patients limitations
Maynard, RCT United States 50 Antibiotic No antibiotics Not blinded.
19841 prophylaxis Used
prophylactic
antibiotics
rather than
targeted
treatment.
Mohler, 19872 RCT United States 46 Antibiotic No antibiotics Not blinded.
prophylaxis Used
prophylactic
antibiotics
rather than
targeted
treatment.
Abbreviation: RCT = randomized controlled trial.
1. Maynard FM, Diokno AC. Urinary infection and complications during clean intermittent catheterization following spinal cord injury. J
Urol. 1984 Nov;132(5):943-6.
2. Mohler JL, Cowen DL, Flanigan RC. Suppression and treatment of urinary tract infection in patients with an intermittently catheterized
neurogenic bladder. J Urol. 1987 Aug;138(2):336-40.

Figure U. Forest plot, impact of prophylactic antibiotics on urinary tract infection in patients
with neurogenic bladder from a spinal cord injury

25
IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

11.Indwelling urethral or supra-pubic catheter

Records identified through database Additional records identified

searching through other sources
(n = 1271) (n = 12)

Records after duplicates removed

(n = 1282)

Records screened Records excluded

(n = 1282) (n = 1248)

Full-text articles assessed Full-text articles excluded, with

for eligibility reasons
(n = 34) (n =30)
 17 not a randomized
controlled trial
 9 studies of antibiotic
Studies included in prophylaxis
qualitative synthesis  2 patients did not have
(n = 4) indwelling catheters
 2 studies belonged in other
section
 4 included
Studies included in
quantitative synthesis
(meta-analysis)
(n = 1)

26
IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table V. GRADE Evidence Profile, PICO 11a

Population: People with short-term indwelling urinary catheter (<30 days) and asymptomatic
bacteriuria
Intervention: Antibiotics
Comparator: No antibiotics

Absolute effect estimates

Outcome Study results and Certainty in effect estimates
Plain text summary
Timeframe measurements (Quality of evidence)
No antibiotics Antibiotics

Relative risk: 1.25 133 166

(CI 95% 0.37 - 4.21) per 1000 per 1000 Very Low
Sepsis Based on data from 60 The impact on sepsis
Due to serious risk of bias and
patients in 1 studies is uncertain.
Difference: 33 more per 1000 very serious imprecision1
Follow up during ICU (CI 95% 84 fewer - 427 more)
stay
Relative risk: 1.52 167 254
(CI 95% 0.42 - 5.47) per 1000 per 1000 Very Low
Death Based on data from 60 The impact on death
Due to serious risk of bias and
patients in 1 studies Difference: 87 more per 1000 2 is uncertain.
very serious imprecision
Follow up during ICU (CI 95% 97 fewer - 746 more)
stay
Abbreviation: CI = confidence interval, ICU = intensive care unit.
1. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Imprecision: Very Serious. Wide
confidence intervals, Only data from one study, Low number of patients.
2. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Inadequate/lack of blinding of participants and personnel, resulting in potential for performance bias; Imprecision: Very Serious. Wide
confidence intervals, Only data from one study, Low number of patients.

Table W. GRADE Evidence Profile, PICO 11b

Population: People with short-term indwelling catheters and asymptomatic bacteriuria at the time
of catheter removal
Intervention: Antibiotics
Comparator: No antibiotics

Absolute effect estimates

Outcome Study results and Certainty in effect estimates
Plain text summary
Timeframe measurements (Quality of evidence)
No antibiotics Antibiotics

Relative risk: 0.45 119 54

(CI 95% 0.28 - 0.72) per 1000 per 1000 Low Antibiotics may
UTI Based on data from
Due to serious risk of bias and prevent symptomatic
1520 patients in 7 Difference: 65 fewer per 1000 inconsistency1 UTIs.
studies (CI 95% 86 fewer - 33 fewer)
Abbreviations: UTI = urinary tract infection, CI = confidence interval.
1. Risk of bias: Serious. Inadequate concealment of allocation during randomization process, resulting in potential for selection bias,
Incomplete data and/or large loss to follow up; Inconsistency: Serious. Study designs were very different. Indirectness: Not serious.
Differences between the population of interest and those studied (most patients were treated regardless of whether or not they had
bacteriuria).

27
IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table X. Table. Study characteristics, patients with short-term urinary catheters

Author, year Study Location Number of Intervention Comparator Notable
design patients limitations
Leone, 2007 RCT France 60 Antibiotics and No Effect of
replacement of antibiotics, no antibiotics is
urinary catheter catheter confounded
replacement by removal of
catheter. Not
blinded.
Marschall, Meta- NA Antibiotics at No antibiotics Two of six
2013 analysis of 7 the time of at the time of studies were
RCTs catheter catheter judged to be
removal removal at low risk of
bias.
Abbreviations: RCT = randomized controlled trial, NA = not applicable.
1. Leone M, Perrin AS, Granier I, Visintini P, Blasco V, Antonini F, Albanèse J, Martin C. A randomized trial of catheter change and short
course of antibiotics for asymptomatic bacteriuria in catheterized ICU patients. Intensive Care Med. 2007 Apr;33(4):726-9.
2. Marschall J, Carpenter CR, Fowler S, Trautner BW; CDC Prevention Epicenters Program. Antibiotic prophylaxis for urinary tract
infections after removal of urinary catheter: meta-analysis. BMJ. 2013 Jun 11;346:f3147. doi: 10.1136/bmj.f3147.

28
IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table Y. GRADE Evidence Profile, PICO 12a

Population: Adults with long-term indwelling urinary catheters and asymptomatic bacteriuria
Intervention: Antibiotic therapy
Comparator: No treatment

Absolute effect estimates

Outcome Study results and Certainty in effect estimates
Plain text summary
Timeframe measurements (Quality of evidence)
No antibiotics Antibiotics

Odds Ratio: 0.66 33 22 We are uncertain

(CI 95% 0.44 - 0.97)
Sepsis/
Based on data from
bacteremia
965 patients in 1
studies
Follow up in hospital
per 1000 per 1000
whether antibiotics
Very Low
increase or decrease
Difference: 11 fewer per 1000 Due to serious imprecision1
risk of
(CI 95% 18 fewer - 1 fewer) sepsis/bacteremia.

Antibiotic 250 640 High Antibiotics probably

resistant Based on data from 35 per 1000 per 1000 Due to serious risk of bias, increase the risk of
bacteriuria patients in 1 studies Difference: 390 more per 1000 Upgraded due to large antibiotic resistant
Follow up 36 weeks magnitude of effect2 bacteriuria

Odds Ratio: 3.55 5 18 Antibiotics may

Clostridium per 1000 per 1000 Moderate
(CI 95% 2.56 - 4.94) increase the risk of
difficile infection Upgraded due to clear dose-
clostridium difficile
Difference: 13 more per 1000 response gradient3
(CI 95% 8 more - 19 more) infection.

One observational study did

Based on data from We are uncertain
not find a significant
Mortality 1474 patients in 1 Very Low whether antibiotics
association between antibiotics
studies Due to serious imprecision4 increase or decrease
and mortality after controlling
Follow up in hospital risk of mortality.
for key confounders.
Abbreviation: CI = confidence interval.
1. Imprecision: Serious. Only data from one study, with wide confidence intervals.
2. Risk of bias: Serious. Not blinded: probable differential outcome assessments and co-interventions; Indirectness: No serious.
Differences between the outcomes of interest and those reported (e.g., short-term/surrogate, not patient-important) -- bacteriuria was not
quantified nor qualified; Upgrade: Large magnitude of effect.
3. Inconsistency: No serious. Point estimates vary widely, but all suggest harm.; Upgrade: Clear dose-response gradient.
4. Imprecision: Serious. Only data from one study, confidence intervals not reported. Few events.

Table Z. Study characteristics, patients with short-term urinary catheters

Author, year Study Location Number of Intervention Comparator Notable
design patients limitations
Warren, Randomized United States 35 Cephalexin No antibiotics Not blinded.
19821 controlled each time Allocation
trial bacteriuria was may not have
detected been
adequately
concealed.
1. Warren JW, Anthony WC, Hoopes JM, Muncie HL Jr. Cephalexin for susceptible bacteriuria in afebrile, long-term catheterized patients.
JAMA. 1982 Jul 23;248(4):454-8.

29
IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table AA. GRADE Evidence Profile, PICO 12b

Population: Patients with persistent asymptomatic bacteriuria after catheter removal
Intervention: Antibiotic therapy
Comparator: No antibiotic therapy

Absolute effect estimates

Outcome Study results and Certainty in effect estimates
Plain text summary
Timeframe measurements (Quality of evidence)
No antibiotics Antibiotics

Relative risk: 0.45 73 33

(CI 95% 0.23 - 0.86) per 1000 per 1000 Antibiotics reduce
UTI Based on data from Moderate
the risk of
807 patients in 1 Difference: 40 fewer per 1000 Due to serious risk of bias1
symptomatic UTI.
studies (CI 95% 56 fewer - 10 fewer)

0 69 We are uncertain
per 1000 per 1000 whether one course
Antibiotic
Based on data from Very Low of antibiotics
resistance
334 patients in 1 Due to very serious risk of increase or decrease
After removal of
studies Difference: 69 more per 1000 bias and serious imprecision2 the risk of bacteriuria
catheter
with antibiotic
resistance.
No studies reported
sepsis/bacteremia. In the
experience of the guideline We are uncertain
Sepsis/ Based on data from panel, ASB leading to sepsis Very Low whether antibiotics
bacteremia patients in 0 studies and bacteremia is extremely Due to very serious risk of decrease the risk of
rare and therefore even if bias3 sepsis and
antibiotics are effective, the bacteremia.
benefit is likely to be extremely
small.
No studies reported mortality.
In the experience of the
guideline panel members, ASB
Based on data from Very Low We are uncertain
Mortality leading to death is extremely
patients in 0 studies Due to very serious risk of whether antibiotics
rare and therefore even if
bias4 reduce mortality.
antibiotics are effective, the
benefit is likely to be extremely
small.
Abbreviations: UTI = urinary tract infection, CI = confidence interval, ASB = asymptomatic bacteriuria.
1. Risk of bias: Serious. Attrition bias and selection bias.; Indirectness: No serious. All patients, whether or not they had asymptomatic
bacteriuria were included. If anything, we expect the effect size to be higher in patients with asymptomatic bacteriuria and therefore did
not rate down for indirectness.
2. Risk of bias: Very Serious. No control group; Imprecision: Serious.
3. Risk of bias: Very Serious. Clinical observation only.
4. Risk of bias: Very Serious. Based on clinical observations only.

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

12.Patients undergoing elective, non-urologic surgery

Records identified through database Additional records identified

searching through other sources
(n = 538) (n = 2)

Records after duplicates removed

(n = 9527)

Records screened Records excluded

(n = 9527) (n = 9499)

Full-text articles assessed Full-text articles excluded,

for eligibility with reasons
(n = 28) (n = 25)
 Non-English: 2
 Subjects without
asymptomatic bacteriuria:
Studies included in 11
qualitative synthesis  No bacteriuria at time of
(n = 3) surgery: 2
 Not relevant article type:
3
 Subjects not treated: 6
Studies included in  Incomplete reporting of
quantitative synthesis bacteriuria: 1
(meta-analysis)
(n = 0)

31
IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table AB. GRADE Evidence Profile, PICO 12b

Population: Patients with asymptomatic bacteriuria undergoing non-urologic surgery
Intervention: Targeted antibiotic therapy
Comparator: Usual care with usual prophylactic antibiotics

Absolute effect estimates

Outcome Study results and Certainty in effect estimates
Summary
Timeframe measurements (Quality of evidence)
No antibiotics Antibiotics

140 456 We are uncertain

Relative risk: 3.26
per 1000 per 1000
Surgical site (CI 95% 1.22 - 8.07)
infection Based on data from 54 Difference: 316 more per
30 days patients in 1 studies 1000
Follow up 30 days (CI 95% 31 more - 990 more)
Relative risk: 0.92 27 25
(CI 95% 0.34 - 2.53) per 1000 per 1000
Prosthetic joint Based on data from
infection 351 patients in 3 Due to serious risk of bias and
Difference: 2 fewer per 1000
1 year studies very serious imprecision
(CI 95% 18 fewer - 41 more)
Follow up 3 months to
1 year
Relative risk: 0.88 36 32
(CI 95% 0.08 - 9.79) per 1000 per 1000
Based on data from
UTI
357 patients in 2
30 days Difference: 4 fewer per 1000
studies
(CI 95% 33 fewer - 316 more)
Follow up Immediate
post-operative period
No studies examined the risk of
pyelonephritis. The risk of
pyelonephritis in patients with
untreated ASB undergoing
surgery is probably very low,
especially considering that the
Sepsis and Based on expert risk of symptomatic UTI is less
pyelonephritis experiences than 5%. The related outcome, Inferences based on informal
symptomatic UTI, might
provide indirect evidence on
the relative effect of antibiotic
therapy, however evidence for
that outcome is also very
uncertain and thus does not
provide any useful information.
No studies examined the risk of
AAD, including CDI in this
patient population. Antibiotics
AAD including Based on expert
almost certainly carry some
CDI experiences
risk AAD and CDI, which
varies by antibiotic type and
other risk factors including
severity of illness. The risk of
whether antibiotics
Very Low
for ASB increase or
Due to very serious risk of
decrease the risk of
bias and serious imprecision1
surgical site
infection.
We are uncertain
whether antibiotics
Very Low
for ASB increase or
2 decrease the risk of
prosthetic joint
infection.
We are uncertain
whether antibiotics
Very Low
for ASB increase or
Due to very serious risk of
decrease the risk of
bias and very serious
post-operative
imprecision3
symptomatic urinary
tract infection.
We are uncertain
whether antibiotics
Very Low
for ASB increase or
decrease the risk of
expert experience.4
post-operative sepsis
and pyelonephritis.
We are uncertain
Very Low whether antibiotics
Inferences based on informal for ASB increase or
expert experiences.5 decrease the risk of
AAD and CDI.

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

AAD and CDI is probably low

for most patients undergoing
surgical procedures, especially
in patients healthy enough for
an elective procedure. Almost
all surgical patients receive
antibiotic prophylaxis during
surgery, and we are unsure of
the magnitude of incremental
risk of AAD and CDI with
additional antibiotics for ASB.
No studies examined duration We are uncertain
Based on expert of hospitalization. We are Very Low whether antibiotics
Duration of
experiences unsure what the effect on Inferences based on informal for ASB prolong or
hospitalization
duration of hospitalization expert experiences.6 decrease the duration
would be. of hospitalization.
Abbreviations: CI = confidence interval, ASB = asymptomatic bacteriuria, UTI = urinary tract infection, AAD = antibiotic-associated diarrhea,
CDI = Clostridium difficile infection.
1. Risk of bias: Very Serious. Serious confounding bias, probable detection bias.; Imprecision: Serious. Very few events.
2. Risk of bias: Serious. Not blinded, serious confounding; Imprecision: Very Serious. Confidence interval includes important harm and
important benefit.
3. Risk of bias: Very Serious. Not blinded, serious detection bias; Imprecision: Very Serious. Confidence interval include important
benefit and important harm.
4. Risk of bias: Very Serious. Expert experience; Imprecision: Very Serious. Expert experience.
5. Risk of bias: Very Serious. Expert experiences.; Imprecision: Very Serious. Expert experiences.
6. Risk of bias: Very Serious. Expert experience only; Imprecision: Very Serious. Expert experience only.

33
IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table AC. Study characteristics for patients undergoing non-urologic surgery

Study author, Study Type Total N N (% of total) N (% of those with N (% of those with
year with ASB ASB) treated ASB) not treated
Drekonja, 2012 Cohort 1,688 54 11 43
Cordero- Randomized 471 46 26 20
Ampuero, 2013 controlled
trial
Sousa, 2014 Cohort 2,497 303 154 149
Abbreviation: ASB = asymptomatic bacteriuria.

Table AD. Risk of bias and outcomes in patients treated vs. not treated for asymptomatic
bacteriuria
Study author, Study Type Risk of bias Surgical site Urinary tract Prosthetic joint
year infection* infection* infection*
Drekonja, 2012 Cohort Serious 5/11 vs. 6/43 2/11 vs. 3/43 0/1 vs. 0/1
confounding, (45% vs. 14%) (18% vs. 7%)
possible
detection bias
Cordero- Randomized Allocation NR NR 1/26 vs. 0/20 3
Ampuero, 2013 controlled probably month follow-up
trial unconcealed, not (3.9% vs. 0%)
blinded
Sousa, 2014 Cohort Confounding NR 1/154 vs. 4/149 6/154 vs. 7/149
possible, possible (6.5% vs. 2.7%) 1 year follow-up
detection bias (3.9% vs. 4.7%)
Abbreviation: NR = not rated.
*Reported as antibiotic treatment versus no antibiotic treatment

34
IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Endourologic procedures

Records identified through database Additional records identified

searching through other sources
(n = 3970) (n = 3)

Records after duplicates removed

(n = 3969)

Records screened Records excluded

(n = 3969) (n = 3933)

Full-text articles excluded,

(n = 25)
Full-text articles assessed  Intervention not
for eligibility relevant (n = 2)
(n = 36)  Outcome (n = 6)
 Population (n = 15)
 Study type (n = 3)

Studies included in
qualitative synthesis
(n = 10)

Studies included in meta-

analysis
(n = 3)

35
IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table AE. GRADE Evidence Profile, PICO 13a

Population: Patients undergoing urologic surgery with mucosal breach
Intervention: Antibiotic prophylaxis
Comparator: No antibiotic prophylaxis

Absolute effect estimates

Outcome Study results and Certainty in effect estimates
Plain text summary
Timeframe measurements (Quality of evidence)
No antibiotics Antibiotics

Relative risk: 0.2 114 23

(CI 95% 0.05 - 0.8) per 1000 per 1000 Moderate Antibiotics probably
UTI Based on data from
Due to serious imprecision. reduce the risk of
167 patients in 2 Difference: 91 fewer per 1000 Borderline risk of bias.1 post-operative UTI.
studies (CI 95% 108 fewer - 23 fewer)

Relative risk: 0.05 63 3

(CI 95% 0.0 - 0.97) per 1000 per 1000 Moderate
Antibiotics probably
Sepsis Based on data from Downgraded due to serious
reduce the risk of
118 patients in 1 Difference: 60 fewer per 1000 imprecision. Borderline risk
sepsis.
studies (CI 95% 63 fewer - 2 fewer) of bias.2

Abbreviations: UTI = urinary tract infection, CI = confidence interval.

1. Risk of bias: No serious. Some concern with blinding because there may have been differential testing and adjudication. However, we
did not rate down because of a strong biologic rationale and extensive expert experience suggesting benefit. Imprecision: Serious.
2. Risk of bias: No serious. Some concern with blinding because there may have been differential testing and adjudication. However, we
did not rate down because of a strong biologic rationale and extensive expert experience suggesting benefit. Imprecision: Serious. Very
few events.

36
IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table AF. Study characteristics, patients with short-term urinary catheters

Author, year Study Location Number of Intervention Comparator Notable
design patients limitations
Cafferkey, Cohort study Ireland 206 Appropriate Inappropriate Did not
1992 antibiotics antibiotics or control for
no antibiotics key
confounders
Grabe, 1987 Randomized Sweden 222 Ciprofloxacin No antibiotics Not blinded
controlled
trial
Murphy, 1984 Cohort study Ireland 112 Appropriate Inappropriate Did not
antibiotics antibiotics, or control for
no antibiotics key
confounders
1. Cafferkey MT, Falkiner FR, Gillespie WA, Murphy DM. Antibiotics for the prevention of septicaemia in urology. Antimicrob
Chemother. 1982 Jun;9(6):471-7.
2. Grabe M, Forsgren A, Björk T, Hellsten S. Controlled trial of a short and a prolonged course with ciprofloxacin in patients undergoing
transurethral prostatic surgery. Eur J Clin Microbiol. 1987 Feb;6(1):11-7.
3. Murphy DM, Stassen L, Carr ME, Gillespie WA, Cafferkey MT, Falkiner FR. Bacteraemia during prostatectomy and other transurethral
operations: influence of timing of antibiotic administration. J Clin Pathol. 1984 Jun;37(6):673-6.

Figure AG. Forest plot, impact of antibiotics on sepsis in patients with asymptomatic bacteriuria
undergoing urologic surgery

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IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Urologic devices

Records identified through database

searching
(n = 1773)

Records screened Records excluded

(n = 1773) (n = 1768)

Full-text articles excluded,

(n = 4)
Full-text articles assessed
for eligibility  Outcome (n = 2)
(n = 5)  Population (n = 1)
 Study type (n = 1)

Studies included
(n = 1)

38
IDSA 2018 Asymptomatic Bacteriuria Guideline: Supplemental Materials

Table AH. GRADE Evidence Profile, PICO 19

Population: Patients with asymptomatic bacteriuria planning to undergo urologic device
implantation
Intervention: Urine culture-targeted antibiotics
Comparator: Usual pre-operative prophylactic antibiotics

Absolute effect estimates

Outcome Study results and Usual pre- Certainty in effect estimates

Plain text summary
Timeframe measurements operative Targeted (Quality of evidence)
prophylactic antibiotics
antibiotics
30 30 Targeted antibiotics
Based on data from per 1000 per 1000 Very Low
Device infection may not decrease the
454 patients in 1 Due to serious risk of bias,
risk of device
studies Difference: 0 fewer per 1000 indirectness, and imprecision1
infection.
1. Risk of bias: Serious. No attempt to control for key confounders.; Indirectness: Serious. The study compared patients who had
asymptomatic bacteriuria with patients who did not have asymptomatic bacteriuria; none received targeted antimicrobial treatment. All
patients received routine peri-operative antimicrobial prophylaxis.; Imprecision: Serious. Only 1 study.

39