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Pregnancy Care Guidelines

38 Asymptomatic bacteriuria
Asymptomatic bacteriuria is the persistent bacterial colonisation of the urinary tract without
symptoms. Testing during pregnancy allows treatment to be offered to reduce the risk of
progression to pyelonephritis.

Testing for asymptomatic bacteriuria in pregnancy allows treatment to be offered to reduce the risk of
progression to pyelonephritis.

38.1 Background
Asymptomatic bacteriuria is the persistent bacterial colonisation of the urinary tract (usually by Escherichia coli)
without symptoms. It is common in pregnancy.

38.1.1 Asymptomatic bacteriuria in Australia

Incidence: Incidence of asymptomatic bacteriuria during pregnancy has been reported to be 2–10% in the
United States (Andrews & Gilstrap 1992; Sweet 1977) and 2–5% in the United Kingdom (Little 1966; Campbell-
Brown et al 1987; Foley et al 1987). In Australia, available estimates suggest that asymptomatic bacteriuria
during pregnancy may be more common among Aboriginal and Torres Strait Islander women (Hunt 2004;
Bookallil et al 2005; Panaretto et al 2006).
Risk factors: The prevalence of infection is most closely related to socioeconomic status and is similar in
pregnant and non-pregnant women (Turck et al 1962; Whalley 1967). Other factors associated with an
increased risk of bacteriuria include a history of recurrent urinary tract infections, diabetes and anatomical
abnormalities of the urinary tract (Golan et al 1989).

38.1.2 Risks associated with asymptomatic bacteriuria in pregnancy

While asymptomatic bacteriuria in non-pregnant women is usually benign, in pregnancy it increases the likelihood
of kidney involvement (pyelonephritis), with an incidence of around 30% in affected women (Whalley 1967).
An association between untreated asymptomatic bacteriuria and low birth weight and preterm birth has also been
suggested (LeBlanc & McGanity 1964; Kincaid-Smith & Bullen 1965; Little 1966; Savage et al 1967). However, while a
reduction in preterm birth and low birth weight is consistent with understanding of the role of infection in
pregnancy complications (Smaill 2007; Smaill & Vasquez 2007), other factors may be involved (eg other
asymptomatic genitourinary infections) (Campbell-Brown et al 1987; MacLean 2001) or links with socioeconomic
status (Romero et al 1989). There may only be an association between asymptomatic bacteriuria and preterm birth if
the infection progresses to pyelonephritis (Meis et al 1995).

38.2 Testing for asymptomatic bacteriuria

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Universal testing for asymptomatic bacteriuria in pregnancy is recommended in the United Kingdom (NICE 2008),
the United States (USPSTF 2004; Nicolle et al 2005), Canada (Nicolle 1994) and Scotland (SIGN 2006), based on the
effectiveness of available treatments and the reduced risk of pyelonephritis.

38.2.1 Benefits of testing

Testing for asymptomatic bacteriuria has been shown to reduce the number of women per 1,000 who experience
pyelonephritis from 23.2 with no testing, to 16.2 with dipstick testing and 11.2 with urine culture (Rouse et al 1995).
Both tests were found to be cost beneficial compared to no testing.

38.2.2 Effectiveness of interventions to treat asymptomatic bacteriuria

A Cochrane review found that antibiotic treatment compared with placebo or no treatment is effective in clearing
asymptomatic bacteriuria (RR 0.25; 95%CI 0.14 to 0.48). The incidence of pyelonephritis was reduced by 75% (RR
0.23; 95%CI 0.13 to 0.41) (Smaill & Vasquez 2007).

Recommendation

Grade A 42
Routinely offer and recommend testing for asymptomatic bacteriuria early in pregnancy as treatment is effective
and reduces the risk of pyelonephritis.
Approved by NHMRC in December 2011; expires December 2016

38.2.3 Testing method 

Midstream urine culture is considered the standard for diagnosis of asymptomatic bacteriuria in pregnancy. 
Dipstick urinalysis of nitrites may be useful for excluding asymptomatic bacteriuria but is not accurate for diagnosis
(Deville et al 2004). A meta-analysis (Deville et al 2004) and a small number of RCTs (Teppa & Roberts 2005;
Karabulut 2007; Eigbefoh et al 2008; Mignini et al 2009) have shown high specificity (89–100%) but low sensitivity
(33–98%), with a mid range around 50%. Lower level studies have had similar results. 

Recommendation

Grade A 43
Use urine culture testing wherever possible, as it is the most accurate means of detecting asymptomatic
bacteriuria.
Approved by NHMRC in December 2011; expires December 2016

38.2.4 Timing of the test

There is no consensus in the literature about the optimal timing and testing frequency for asymptomatic bacteriuria.
However, in a prospective study (n=3,254), a single urine specimen obtained between 12 and 16 weeks gestation
identified 80% of women who ultimately had asymptomatic bacteriuria (Stenqvist et al 1989).

38.2.5 Testing in rural and remote areas

Due to difficulties in transporting specimens to laboratories, dipstick tests are commonly used in remote areas to
‘rule out’ asymptomatic bacteriuria, with samples from women testing positive then sent for culture to confirm
infection. While urine culture is the preferred method of testing, this process has been found to be cost effective

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(Rouse et al 1995). However, factors specific to conditions in rural and remote Australia (eg high humidity and
ambient temperatures) may contribute to under diagnosis and overtreatment. Considerations in testing for
asymptomatic bacteriuria in these areas include (Bookallil et al 2005):
whether specimens can be provided to pathology services within the timeframe in which they can still be
cultured (ideally within 24 hours)
the availability of appropriate storage facilities for dipstick tests
the consequences of treating all women with a positive dipstick result given the high rate of false positives
and the risk of increased resistance to antibiotics associated with over-prescribing
recall systems for women with a positive result on culture.

Recommendation

Practice point ZZ
Where access to pathology services is limited, dipstick tests may be used to exclude infection, with positive
results confirmed by urine culture. Appropriate storage of dipsticks is essential to the accuracy of these tests.
Approved by NHMRC in December 2011; expires December 2016

38.2.6 Repeat testing

Although most guidelines recommend a single urine culture at the first antenatal visit, two prospective studies have
concluded that urine should be cultured in each trimester of pregnancy to improve the detection rate of
asymptomatic bacteriuria (McIsaac et al 2005; Tugrul et al 2005). There has been no prospective evaluation of
repeated testing during pregnancy (Schnarr & Smaill 2008).

38.3 Practice summary: testing for asymptomatic bacteriuria

When
Early in antenatal care.

Who
Midwife
GP
obstetrician
Aboriginal and Torres Strait Islander health worker
multicultural health worker.

What

Discuss testing for asymptomatic bacteriuria

Explain that identifying urinary tract infection enables women to be treated with antibiotics and avoids
the risk of complications.

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Document and follow-up

Note the results of testing in the woman’s record and have a follow-up system in place so that
appropriate treatment is provided if a woman is found to have bacteriuria.

38.4 Resources
Widmer M, Lopez I, Gülmezoglu A et al (2015) Duration of treatment for asymptomatic bacteriuria during
pregnancy. Cochrane Database of Systematic Reviews 2015, Issue 11. Art. No.: CD000491.

References
Andrews WW & Gilstrap LC (1992) Urinary tract infections. In: Gleicher N editor(s). Principles and Practice of Medical Therapies in
Pregnancy. Appleton and Lange, pp913–7.

Bookallil M, Chalmers E, Bell A (2005) Challenges in preventing pyelonephritis in pregnant women in Indigenous communities. Rural
Remote Health 5: 395 (online).

Campbell-Brown M, McFadyen IR, Seal DV et al (1987) Is screening for bacteriuria in pregnancy worth while? Brit Med J 294: 1579–82.

Deville WL, Yzermans JC, van Duijn NP et al (2004) The urine dipstick test useful to rule out infections: a meta-analysis of the
accuracy. BMC Urology 4: 4.

Eigbefoh JO, Isabu P, Okpere E et al (2008) The diagnostic accuracy of the rapid dipstick test to predict asymptomatic urinary tract
infection of pregnancy. J Obstet Gynaecol 28(5): 490–95.

Foley ME, Farquharson R, Stronge JM (1987) Is screening for bacteriuria in pregnancy worthwhile? Brit Med J 295: 270.

Golan A, Wexler S, Amit A et al (1989) Asymptomatic bacteriuria in normal and high-risk pregnancy. Eur J Obstet Gynecol Reprod Biol
33: 101–8.

Hunt J (2004) Pregnancy Care and Problems for Women Giving Birth at Royal Darwin Hospital. Carlton: Centre for the Study of
Mothers’ and Children’s Health.

Karabulut A (2007) Asymptomatic bacteriuria in pregnancy: Can automated urinalysis be helpful for detection? J Turkish German
Gynecol Assoc Artemis 8(4): 367–71.

Kincaid-Smith P & Bullen M (1965) Bacteriuria in pregnancy. Lancet 1(7382): 395–99.

LeBlanc AL & McGanity WJ (1964) The impact of bacteriuria in pregnancy: a survey of 1300 pregnant patients. Biologie Medicale 22:
336–47.

Little PJ (1966) The incidence of urinary infection in 5000 pregnant women. Lancet 2(7470): 925–28.

MacLean AB (2001) Urinary tract infection in pregnancy. Int J Antimicrob Agents 17: 273–76.

McIsaac W, Carroll JC, Biringer A et al (2005) Screening for asymptomatic bacteriuria in pregnancy. J Obstet Gynaecol Can 27: 20–24.

Meis PJ, Michielutte R, Peters TJ et al (1995) Factors associated with preterm birth in Cardiff, Wales. II. Indicated and spontaneous
preterm birth. Am J Obstet Gynecol 173: 597–602.

Mignini L, Carroli G, Abalos E et al (2009) Accuracy of diagnostic tests to detect asymptomatic bacteriuria during pregnancy. Obstet
Gynecol 113 (2 Part 1): 346–52.

NICE (2008) Antenatal Care. Routine Care for the Healthy Pregnant Woman. National Collaborating Centre for Women’s and
Children’s Health. Commissioned by the National Institute for Health and Clinical Excellence. London: RCOG Press.

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Nicolle LE (1994) Screening for asymptomatic bacteriuria in pregnancy. In: Canadian Guide to Clinical Preventive Health Care. Ottawa:
Health Canada, pp100–106.

Nicolle LE, Bradley S, Colgan R et al (2005) Infectious diseases society of America guidelines for the diagnosis and treatment of
asymptomatic bacteriuria in adults. Clin Infect Dis 40: 643–54.

Panaretto KS, Lee HM, Mitchell MR et al (2006) Prevalence of sexually transmitted infections in pregnant urban Aboriginal and Torres
Strait Islander women in northern Australia. Aust NZ J Obstet Gynaecol 46(3) 217–24.

Romero R, Oyarzun E, Mazor M et al (1989) Meta-analysis of the relationship between asymptomatic bacteriuria and preterm
delivery/low birth weight. Obstet Gynecol 73: 576–82.

Rouse DJ, Andrews WW, Goldenberg RL et al (1995) Screening and treatment of asymptomatic bacteriuria of pregnancy to prevent
pyelonephritis: a cost-effectiveness and cost-beneficial analysis. Obstet Gynecol 86: 119–23.

Savage WE, Hajj SN, Kass EH (1967) Demographic and prognostic characteristics of bacteriuria in pregnancy. Medicine 46: 385–407.

Schnarr J & Smaill F (2008) Asymptomatic bacteriuria and symptomatic urinary tract infections in pregnancy. Eur J Clin Invest 38(S2):
50–57.

SIGN (2006) Management of Suspected Bacterial Urinary Tract Infection in Adults. A National Clinical Guideline. Edinburgh: Scottish
Intercollegiate Guidelines Network.

Smaill F (2007) Asymptomatic bacteriuria in pregnancy. Best Pract Res Clin Obstet Gynaecol 21(3): 439–50.

Smaill FM & Vazquez JC (2007) Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database of Systematic Reviews 2007,
Issue 2. Art. No.: CD000490. DOI: 10.1002/14651858.CD000490.pub2.

Stenqvist K, Dahlen-Nilsson I, Lidin-Janson G et al (1989) Bacteriuria in pregnancy. Frequency and risk of acquisition. Am J Epidemiol
129: 372–79.

Sweet RL (1977) Bacteriuria and pyelonephritis during pregnancy. Sem Perinatol 1: 25–40.

Teppa RJ & Roberts JM (2005) The Uriscreen test to detect significant asymptomatic bacteriuria during pregnancy. J Soc Gynecol
Invest 12(1): 50–53.

Tugrul S, Oral O, Kumru P et al (2005) Evaluation and importance of asymptomatic bacteriuria in pregnancy. Clin Exp Obstet Gynecol
32: 237–40.

Turck M, Goff BS, Petersdorf RG (1962) Bacteriuria in pregnancy; relationship to socioeconomic factors. New Engl J Med 266: 857–60.

USPSTF (2004) Screening for Asymptomatic Bacteriuria. Rockville (MD): Agency for Healthcare Research and Quality.

Whalley P (1967) Bacteriuria of pregnancy. Am J Obstet Gynecol 97: 723–38.

Last updated: 
17 May 2019

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Pregnancy, birth and baby

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