Original Investigation | Infectious Diseases

Bacteremia From a Presumed Urinary Source in Hospitalized Adults

With Asymptomatic Bacteriuria
Sonali D. Advani, MBBS, MPH; David Ratz, MS; Jennifer K. Horowitz, MA; Lindsay A. Petty, MD; Mohamad G. Fakih, MD, MPH; Kenneth Schmader, MD;
Lona Mody, MD, MSc; Tawny Czilok, MHI, RN; Anurag N. Malani, MD; Scott A. Flanders, MD; Tejal N. Gandhi, MD; Valerie M. Vaughn, MD, MSc

Abstract Key Points

Question What is the prevalence of
IMPORTANCE Guidelines recommend withholding antibiotics in asymptomatic bacteriuria (ASB),
bacteremia from a presumed urinary
including among patients with altered mental status (AMS) and no systemic signs of infection.
source in hospitalized patients with
However, ASB treatment remains common.
asymptomatic bacteriuria (ASB)?

OBJECTIVES To determine prevalence and factors associated with bacteremia from a presumed Findings In this 5-year, 68-hospital
urinary source in inpatients with ASB with or without AMS and estimate antibiotics avoided if a 2% cohort study of 11 590 hospitalized
risk of bacteremia were used as a threshold to prompt empiric antibiotic treatment of ASB. patients with ASB, only 1.4% developed
bacteremia from a presumed urinary
DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed patients hospitalized to source, while 72.2% received empiric
nonintensive care with ASB (no immune compromise or concomitant infections) in 68 Michigan antibiotic therapy for urinary tract
hospitals from July 1, 2017, to June 30, 2022. Data were analyzed from August 2022 to January 2023. infection. In the 2126 patients with
bacteriuria with altered mental status
MAIN OUTCOMES AND MEASURES The primary outcome was prevalence of bacteremia from a but no systemic signs of infection, only
presumed urinary source (ie, positive blood culture with matching organisms within 3 days of urine 0.7% developed bacteremia from a
culture). To determine factors associated with bacteremia, we used multivariable logistic regression presumed urinary source.
models. We estimated each patient’s risk of bacteremia and determined what percentage of patients
Meaning These findings suggest that
empirically treated with antibiotics had less than 2% estimated risk of bacteremia.
bacteremia from a presumed urinary
source was rare in patients with ASB,
RESULTS Of 11 590 hospitalized patients with ASB (median [IQR] age, 78.2 [67.7-86.6] years; 8595
even those presenting with altered
female patients [74.2%]; 2235 African American or Black patients [19.3%], 184 Hispanic patients
mental status.
[1.6%], and 8897 White patients [76.8%]), 8364 (72.2%) received antimicrobial treatment for UTI,
and 161 (1.4%) had bacteremia from a presumed urinary source. Only 17 of 2126 patients with AMS
but no systemic signs of infection (0.7%) developed bacteremia. On multivariable analysis, male sex + Supplemental content
(adjusted odds ratio [aOR], 1.45; 95% CI, 1.02-2.05), hypotension (aOR, 1.86; 95% CI, 1.18-2.93), 2 Author affiliations and article information are
or more systemic inflammatory response criteria (aOR, 1.72; 95% CI, 1.21-2.46), urinary retention listed at the end of this article.

(aOR, 1.87; 95% CI, 1.18-2.96), fatigue (aOR, 1.53; 95% CI, 1.08-2.17), log of serum leukocytosis (aOR,
3.38; 95% CI, 2.48-4.61), and pyuria (aOR, 3.31; 95% CI, 2.10-5.21) were associated with bacteremia.
No single factor was associated with more than 2% risk of bacteremia. If 2% or higher risk of
bacteremia were used as a cutoff for empiric antibiotics, antibiotic exposure would have been
avoided in 78.4% (6323 of 8064) of empirically treated patients with low risk of bacteremia.

CONCLUSIONS AND RELEVANCE In patients with ASB, bacteremia from a presumed urinary source
was rare, occurring in less than 1% of patients with AMS. A personalized, risk-based approach to
empiric therapy could decrease unnecessary ASB treatment.

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Open Access. This is an open access article distributed under the terms of the CC-BY-NC-ND License.

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Introduction
Urinary tract infection (UTI) is one of the most overdiagnosed infections, especially in hospitalized
patients, older adults, and catheterized patients.1 Recent data show almost 50% of antibiotic
prescriptions for outpatient UTIs are either inappropriate or unnecessary.2 Treatment of
asymptomatic bacteriuria (ASB) is even more common in hospitalized older adults and those
presenting with dementia and/or altered mental status (AMS).3-7 AMS remains one of the primary
indications for ASB treatment despite guidelines from the Infectious Diseases Society of America
(IDSA) recommending withholding antibiotic treatment in patients with ASB.8
One reason for ASB overtreatment is clinicians’ concern that poor outcomes (eg, bacteremia
from UTI) may occur if antibiotics are not started early.9,10 Evidence to guide treatment in these
situations are sparse. On the one hand, studies suggest antibiotic delays in patients with bacteremia
or severe sepsis may increase mortality.11 In contrast, antibiotic treatment of ASB has not been shown
to improve clinical outcomes and is instead associated with increased health care utilization, adverse
drug events, and Clostridioides difficile infection (CDI).6,12 Prior studies have suggested that
estimating a patient’s risk of an outcome (eg, bacteremia) and then treating with antibiotic therapy if
their risk exceeds 2% could balance potential under and overtreatment.13,14 However, there is no
validated way to estimate the risk of bacteremia in a hospitalized patient with ASB.
We sought to (1) determine the prevalence of bacteremia from a presumed urinary source in a
large, multihospital cohort of hospitalized patients with ASB and a subgroup of patients with AMS;
(2) examine factors associated with bacteremia from a presumed urinary source in patients with ASB;
and (3) estimate antibiotics avoided if a 2% risk of bacteremia were used as a threshold for empiric
antibiotic treatment of ASB.

Methods
Study Setting and Design
This cohort study includes data from 68 hospitals (53 urban and 15 rural, including a critical access
hospital) in the Michigan Hospital Medicine Safety (HMS) Consortium. HMS hospitals range in size
from 25 to 1131 beds with a median (IQR) bed size of 275 (151-392). This project was not regulated by
the University of Michigan Medical School’s institutional review board, which deemed the work to
be quality improvement and thus waived the requirement of informed consent. The Strengthening
the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline was followed.

Patient Selection
This study included a sample of adult patients admitted to nonintensive care unit settings in HMS
hospitals with a positive urine culture between July 1, 2017, and June 30, 2022. Patients were
consecutively reviewed with the first patient included daily. Patients were ineligible for inclusion if
they met any of the following criteria: (1) age younger than 18 years; (2) pregnant and/or
breastfeeding; (3) altered urinary tract anatomy, urologic surgery during hospitalization, or urinary
stent or nephrostomy tube in place during hospitalization; (4) intensive care unit admission within 3
days before or after urine culture; (5) under hospice care on admission; (6) patient directed
discharge; (7) concomitant infection (abstractors excluded any patient with documented antibiotic
treatment for a concomitant bacterial infection during the hospital encounter unless the infection
was potentially related to the UTI [eg, bacteremia, CDI]); (8) active treatment and/or prophylaxis for
UTI on admission; (9) solid organ or bone marrow transplant recipient; (10) HIV with CD4 count less
than 200 cells/mm3; (11) neutropenia (absolute neutrophil count <0.5 cells/μL on hospital day 1 or 2);
or (12) within the 30 days after discharge from index hospitalization already abstracted for
that patient.
For this study, patients were excluded if they had specific signs or symptoms of a UTI defined
per IDSA ASB guidelines8,16-19 (Box). Patients with isolated candiduria and Staphylococcus aureus

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bacteriuria were also excluded as candiduria frequently represents colonization or contamination,

and Staphylococcus aureus in urine usually represent hematogenous spread20,21 (eFigure 1 in
Supplement 1).

Data Collection
As previously described,6,7,22 trained abstractors collected data retrospectively from patient records
(eMethods in Supplement 1). Briefly, deidentified data were collected from 90 days before admission
until 30 days after discharge or sooner if follow-up was terminated by a major complication (eg,
death). Variables collected from the medical record include demographics, signs and symptoms,
laboratory findings, vital signs, antibiotic type and duration, and outcomes. Information on signs and
symptoms were collected from clinician and nursing documentation 3 days before through 3 days
after urine culture collection. Demographics like race, ethnicity, age, and sex were assessed to better
understand their association with bacteremia from a presumed urinary source. Thirty-day patient
outcomes were collected via medical record review and prospective patient phone call 30 days
following hospitalization. Patients who died or were discharged to hospice or another care facility
were not eligible for postdischarge phone calls.

Outcomes
The primary outcome was bacteremia from a presumed urinary source (positive blood culture with
matching organism within 3 days of urine culture). We assessed for possible variables associated with
bacteremia including age, sex, body mass index (BMI), complicated urologic history, comorbidities,
presence of dementia or AMS, nonspecific signs or symptoms (eg, foul smelling urine, fatigue) and
relevant laboratory results (ie, elevated peripheral white blood cell [WBC] count, urinalysis
parameters, and urine culture results). Secondary outcomes included duration of hospitalization

Box. Definitions

Bacteriuria culture. To be included, the blood culture had to

Bacteriuria or positive urine culture was defined if
flagged as abnormal by the hospital. While many
hospitals use bacterial growth of 103 or greater with
no more than 2 organisms or 102 with E.coli,15 some
use alternative definitions.
Signs and Symptoms
Specific Signs or Symptoms of UTI
Fever >38 C (without an alternate explanation),
rigors, urgency, frequency, dysuria, costovertebral
pain or tenderness, suprapubic pain/tenderness and
acute hematuria.16,17
Nonspecific Signs or Symptoms
Altered mental status with or without dementia,
fatigue, falls, functional decline, malaise, change in
color or odor of urine, acute or new onset urinary
retention, urinary incontinence, abdominal pain,
nausea, or vomiting.
Systemic Signs or Symptoms of Infection
Systemic inflammatory response syndrome (SIRS)
or leukocytosis or hypotension with systolic blood
pressure less than 90.18
have no more than 2 pathogens and be obtained
within 3 days of the positive urine culture
(patients with concomitant infections were
excluded).19
Urologic History
Complicated urologic history was defined as a
history of nephrolithiasis (kidney stones); urologic
surgery in prior 30 days (lithotripsy, ureteroscopy,
cystoscopy); prior suprapubic catheter or
nephrostomy tube within 30 days; history of urinary
obstruction, urinary retention, neurogenic bladder,
or urinary incontinence in the 30 days before the
hospital encounter.
CDI Events
CDI events were defined in patients with laboratory
diagnosis (positive C. difficile polymerase chain
reaction and/or glutamate dehydrogenase level with
toxin enzyme immunoassay testing) occurring ⱖ48
hours after urine culture or a new CDI event within
30 days after hospital discharge ascertained via
medical record or patient report on 30-day post-
discharge phone call.

Bacteremia Duration
Bacteremia from a presumed urinary source was Duration of hospitalization was assessed from the
defined if a patient had a positive blood culture day urine culture was performed (urinalysis or
growing at least 1 organism matching the urine urine culture).

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after urine culture and 30-day CDI event, mortality, readmission, and/or emergency
department visit.

Statistical Analysis
We calculated the prevalence of bacteremia from a presumed urinary source in all patients and in a
subgroup of patients with AMS with or without dementia. We assessed variables associated with
bacteremia initially in a bivariable analysis using χ2 tests or Wilcoxon rank-sum tests, as appropriate.
We treated age as a linear variable and BMI as a categorical variable. Missing variables (urine WBC,
leukocyte esterase, serum leukocytosis, BMI) were imputed using 10-fold multiple imputation. For
those with a urinalysis, we assessed variables associated with bacteremia in multivariable logistic
regression analysis accounting for clustering within hospitals with a random intercept. WBC counts
from urine were provided as ranges rather than exact values, so we categorized this variable and
dichotomized it for the final model as less than 25 vs 25 or higher. Serum WBC count was
log-transformed to improve model fit. Age was modeled linearly. We retained variables in the final
multivariable model that were significant or that were observed to have a confounding effect on the
association between another variable and risk of bacteremia. We expressed results as adjusted odds
ratios (aORs) with 95% CIs, using a 2-sided P value less than .05 to indicate significance, although log
odds ratios were used in the figure to preserve spatial relationships between variables. All analyses
were performed in SAS, version 9.4 (SAS Institute Inc). Data were analyzed from August 2022 to
January 2023.
Based on the multivariable model, we next calculated mean estimated probability of bacteremia
for each patient using various combinations of factors including sex, symptoms such as urinary
retention and fatigue, clinical signs such as tachycardia, and laboratory markers such as WBC
thresholds and presence of pyuria on urinalysis. Using a 2% risk of bacteremia as a cutoff for whether
a patient should receive empiric antibiotics or not, we first assessed the estimated risk of bacteremia
for each patient in our cohort. For patients below 2% risk, we then calculated—compared with their
actual antibiotic treatment—how many patients could have avoided antibiotic therapy for ASB. Here,
empiric therapy is defined as any antibiotic therapy on the day the urine culture was sent or the
day after.

Results
Baseline Demographics
Of 11 590 hospitalized patients with ASB (median [IQR] age, 78.2 [67.7-86.6] years); 8595 female
patients [74.2%]; 2235 African American/Black patients [19.3%], 184 Hispanic patients [1.6%], and
8897 White patients [76.8%]), 8364 (72.2%) received antimicrobial treatment for UTI, while only 161
(1.4%) developed bacteremia from a presumed urinary source. Demographics of the entire cohort
are described in Table 1. Nearly half (5059 patients [43.6%]) had AMS, 3210 (27.7%) had dementia,
1761 (15.2%) had an indwelling urinary catheter, 6323 (54.6%) had complicated urologic history,
11 039 (95.2%) had a urinalysis test (individual urinalysis parameters further described in Table 1), and
3589 (31.0%) had blood cultures obtained within 3 days of urine cultures. Of blood cultures, 401 of
3589 (11.2%) were obtained before the urine culture, 2836 of 3589 (79%) were obtained the same
day, and 487 of 3589 (13.6%) were obtained after the urine culture. Patients who did not receive
blood cultures had a significantly lower prevalence of systemic inflammatory response syndrome
(SIRS), hypotension, tachycardia, and leukocytosis than those who had blood cultures (eTable 1 in
Supplement 1).

Patients With AMS

Among patients with ASB, 5059 (43.6%) had AMS (Figure). Of these, 89 (1.8%) were found to have
bacteremia from a presumed urinary source (vs 72 [1.1%] in patients without AMS). Risk of
bacteremia in patients with AMS differed 4-fold based on whether they had systemic signs of

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Table 1. Baseline Demographics, Risk Factors, and Outcomes in Patients With Asymptomatic Bacteriuria

Bacteremia from a presumed urinary source, No. (%)

Risk factor Without (n = 11 429) With (n = 161) P value
Age
Median (IQR) 78.2 (67.7-86.6) 79.5 (72.2-88.2) .02
≥65 y 9123 (79.8) 140 (87.0) .02
≥75 y 6709 (58.7) 107 (66.5) .05
Sex
Male 2931 (25.6) 64 (39.8)
<.001
Female 8498 (74.4) 97 (60.2)
Race
American Indian or 28 (0.2) 0 (0)
Alaska Native
Asian 51 (0.4) 1 (0.6)
African American/Black 2210 (19.3) 25 (15.5)
.64
Native Hawaiian or 23 (0.2) 0 (0.0%)
other Pacific Islander
White 8765 (76.7) 132 (82.0)
Unknown 352 (3.1) 3 (1.9)
Ethnicity
Hispanic 183 (1.6) 1 (0.6)
Non-Hispanic 9737 (85.2) 132 (82.0) .11
Unknown 1509(13.2) 28 (16.4)
BMIa
≤18.5 711 (6.4) 9 (5.7)
18.6-25 3654 (32.8) 64 (40.5)
.24
25.1-30 3042 (27.3) 39 (24.7)
>30 3722 (33.4) 46 (29.1)
Vital signs on day of culture
Hypotension (SBP <90) 840 (7.3) 28 (17.4) <.001
Heart rate >90 bpm 5212 (45.6) 100 (62.1) <.001
≥2 SIRS criteria 3340 (29.2) 87 (54.0) <.001
Nonspecific symptomsb
No dementia nor AMS 5443 (47.6) 66 (41.0)
Dementia, no AMS 1016 (8.9) 6 (3.7)
.01
AMS, no dementia 2821 (24.7) 50 (31.1)
AMS and dementia 2149 (18.8) 39 (24.2)
Change in urine color or character 2134 (18.7) 43 (26.7) .01
Falls 2091 (18.3) 26 (16.1) .48
Fatigue (new or worsening) 3053 (26.7) 59 (36.6) .005
Functional decline (new or worsening) 904 (7.9) 22 (13.7) .008
Malaise (new or worsening) 676 (5.9) 13 (8.1) .25
Nausea or vomiting 2297 (20.1) 34 (21.1) .75
New urinary incontinence 2642 (23.1) 42 (26.1) .38
New urinary retention 884 (7.7) 26 (16.1) <.001
Abdominal pain 1945 (17.0) 19 (11.8) .08
Comorbidities
Indwelling catheter present 1729 (15.1) 32 (19.9) .10
Complicated urologic history in past 30 dc 6214 (54.4) 109 (67.7)
Kidney stones 185 (3.0) 3 (2.7)
Urologic surgery 81 (1.3) 2 (1.8)
<.001
Urinary obstruction 199 (3.2) 12 (11.0)
Urinary retention 1979 (31.8) 44 (40.4)
Urinary incontinence 4900 (78.8) 76 (69.7)

(continued)

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Table 1. Baseline Demographics, Risk Factors, and Outcomes in Patients With Asymptomatic Bacteriuria
(continued)

Bacteremia from a presumed urinary source, No. (%)

Risk factor Without (n = 11 429) With (n = 161) P value
Diabetes 4422 (38.7) 67 (41.6) .45
Moderate to severe chronic kidney disease 4709 (41.2) 87 (54.0) .001
Immunosuppression 380 (3.3) 5 (3.1) .88
Hemodialysis 190 (1.7) 3 (1.9) .75
Cancer history 2441 (21.4) 40 (24.8) .28
Congestive heart failure 3086 (27.0) 42 (26.1) .80
Liver disease 754 (6.6) 9 (5.6) .61
Spinal cord injury 171 (1.5) 1 (0.6) .74
Coming from SNF, SAR, LTAC, or similar 2591 (22.7) 28 (17.4) .11
Urinalysis on day of or before urine culture
Any 10 888 (95.3) 151 (93.8) .38
Pyuria
0-5 WBCs/hpf 1421 (13.3) 9 (6.0)
6-10 WBCs/hpf 1246 (11.6) 5 (3.3)
<.001
11-25 WBCs/hpf 1741 (16.3) 8 (5.3)
≥26 WBCs/hpf 6301 (58.8) 128 (85.3)
Leukocyte esterase
Absent 2136 (18.7) 23 (14.3)
.15
Any 9293 (81.3) 138 (85.7)
>1+ 8271 (72.4) 133 (82.6) .004
>2+ 6600 (57.7) 117 (72.7) <.001
Nitrite
Positive 4018 (36.9) 46 (30.5) .10
Serum WBC
<10 000/μL (Reference) 6914 (62.4) 40 (25.2)
10 001/μL-15 000/μL 2974 (26.9) 61 (38.4) <.001
>15 001/μL 1187 (10.7) 58 (36.5)
Urine pathogens
Escherichia coli 5670 (49.6) 109 (67.7) <.001 Abbreviations: AMS, Altered mental status; bpm, beats
Klebsiella spp 1890 (16.5) 28 (17.4) .77 per minute; BMI, Body Mass Index; CDI, Clostridioides
difficile infection; ED, emergency department; hpf,
Enterococcus spp 1287 (11.3) 8 (5.0) .01
high-powered field; LTAC, long-term acute care facility;
Proteus spp 830 (7.3) 12 (7.4) .93
SAR, subacute rehabilitation; SBP, systolic blood
Pseudomonas aeruginosa 552 (4.8) 4 (2.5) .17 pressure; SNF, skilled nursing facility; spp, several
Enterobacter spp 344 (3.0) 1 (0.6) .10 species; WBC, white blood cells.
a
Citrobacter spp 295 (2.6) 1 (0.6) .12 Body mass index is calculated as weight in kilograms
≥2 bacteria 1512 (13.2) 21 (13.0) .94 divided by height in meters squared.
b
Outcomes Symptoms include those documented in medical
30-d mortality 519 (4.5) 15 (9.3) .004 record at any point in the 3 days prior through 3 days
after urine culture collection.
30-d readmission 1888 (16.5) 23 (14.3) .48
c
Complicated urologic history defined as a history of
30-d ED visit 1257 (11.0) 16 (9.9) .669
nephrolithiasis (kidney stones), urologic surgery in
CDI event at 30 d 97 (0.8) 0 (0) .647 prior 30 days (new suprapubic catheter or
Duration of hospitalization, median (IQR) 4 (3-6) 6 (4-7) <.001 nephrostomy tube placement, lithotripsy,
Receipt of antibiotics the day of or day after 8207 (71.8) 157 (97.5) <.001 ureteroscopy, cystoscopy), urinary obstruction,
urine culture, urinary retention or neurogenic bladder, urinary
Total antibiotic duration among those on antibiotics 6 (4-8) 13 (9-15) <.001 incontinence in the 30 days before the hospital
day of culture or day after, median (IQR)
encounter.

infection (ie, evidence of SIRS or leukocytosis): 0.7% (17 of 2610) for patients without systemic signs
of infection (number needed to treat, 154) vs 2.9% (72 of 2449) for patients with systemic signs of
infection (number needed to treat, 34). Differences based on whether patients had dementia are
shown in the Figure.

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Variables and Outcomes Associated With Bacteremia From a Presumed

Urinary Source
In unadjusted comparisons, patients with ASB who developed bacteremia from a presumed urinary
source were older (median [IQR] age, 79.5 [72.2-88.2] years) than patients who did not develop
bacteremia (median [IQR] age, 78.2 [67.7-86.6] years; z score, 2.32; P = .02). Symptoms or
comorbidities associated with developing bacteremia from a presumed urinary source included
presentation with AMS with or without dementia, complicated urologic history, indwelling catheter,
change in urine characteristics, fatigue, functional decline, and urinary retention (see Table 1 for
details). Diagnostic findings associated with development of bacteremia from a presumed urinary
source included: serum leukocytosis, elevated urinalysis parameters (ie, pyuria or leukocyte
esterase), and growth of Escherichia coli (compared with other pathogens) (Table 1).
Patients with ASB who developed bacteremia from a presumed urinary source had higher
unadjusted mortality (9.3% vs 4.5%; χ 12 = 8.24; P = .004) and median (IQR) duration of
hospitalization after urine culture (6 [4-7] vs 4 [3-6] days; z score, 7.08; P < .001) than those without
bacteremia. Other outcomes including 30-day readmission, 30-day ED visit, and CDI event at 30
days were similar between the 2 groups (Table 1).

Adjusted Analysis
On multivariable analyses accounting for hospital clustering, we found that male sex (aOR, 1.45; 95%
CI, 1.02-2.05), hypotension (aOR, 1.86; 95% CI, 1.18-2.93), 2 or more SIRS criteria (aOR, 1.72; 95% CI,
1.21-2.46), urinary retention (aOR, 1.87; 95% CI, 1.18-2.96), fatigue (aOR, 1.53; 95% CI, 1.08-2.17), log
of serum leukocytosis (aOR, 3.38; 95% CI, 2.48-4.61), and pyuria with more than 25 WBC/hpf on
urinalysis (aOR, 3.31; 95% CI, 2.10-5.21) were associated with bacteremia from a presumed urinary
source (Table 2; eFigure 2 in Supplement 1). In contrast, older age, AMS, dementia, and change in
urine were not associated with a higher risk for bacteremia from a presumed urinary source (Table 2;
eFigure 2 in Supplement 1).

Estimated Risk of Bacteremia From a Presumed Urinary Source

In the absence of other findings, no single nonspecific sign or symptom (eg, AMS) or comorbidity
conferred a 2% or greater risk of bacteremia from a presumed urinary source. The mean estimated
probability of having bacteremia from a presumed urinary source ranged from 0.09% to 16.18%
across combinations of variables (see eTable 2 in Supplement 1). For example, mean (SD) estimated
probability of bacteremia in a male patient with ASB presenting with urinary retention (no fatigue or
tachycardia), serum leukocytosis (>20 000/mL), and less than 25 WBCs on urinalysis was 16.18%
(6.4%). In contrast, the mean (SD) estimated probability of bacteremia in a female patient with ASB
presenting without tachycardia, urinary retention, or fatigue, and with serum WBC less than
5000/mL and pyuria of 25 or lower WBCs on urinalysis was 0.09% (0.004%).

Figure. Bacteremia From a Presumed Urinary Source Among Hospitalized Patients With Bacteriuria and Altered Mental Status With or Without Dementia

5059 Patients with altered mental status and no other specific signs/symptoms of UTI

2188 With dementia (43.2%) 2871 Without dementia (56.8%)

1177 No SIRS, leukocytosis, 1011 SIRS, leukocytosis, 1433 No SIRS, leukocytosis, 1438 SIRS, leukocytosis,
or SBP <90 (53.8%) or SBP <90 (46.2%) or SBP <90 (49.9%) or SBP <90 (50.1%)

7 Bacteremia from a 32 Bacteremia from a 10 Bacteremia from a 40 Bacteremia from a

presumed urinary presumed urinary presumed urinary presumed urinary
source (0.6%) source (3.2%) source (0.7%) source (2.8%)

SBP indicates systolic blood pressure; SIRS, systemic inflammatory response syndrome; UTI, urinary tract infection.

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Risk-Stratified Approach to Empiric Antibiotic Therapy

Mean estimated probabilities of bacteremia from a presumed urinary source that were 2% or higher
(our prespecified cut off for considering empiric antibiotic treatment) have been highlighted in
eTable 2 in Supplement 1. Patients’ actual empiric treatment compared with their recommended
treatment if a 2% risk of bacteremia were used to determine empiric treatment is shown in Table 3.
Based on these results, using 2% as a cutoff to inform empiric antibiotic use in ASB would have
avoided treatment in 6323 patients with very low risk of bacteremia (of whom 0.7% [44 of 6323] had
bacteremia) and empirically treated an additional 206 patients with higher risk for bacteremia (of
whom 1 [0.5%] developed bacteremia).

Discussion
In this 68-hospital study of 11 590 hospitalized patients with ASB, 1.4% had bacteremia from a
presumed urinary source and only 0.7% of patients with AMS and no systemic signs of infection did.
No single risk factor conferred a 2% or greater risk of bacteremia. Specifically, older age, AMS,
dementia, and change in urine character were not associated with bacteremia. These data reinforce
prior evidence highlighting the poor yield of urine and blood cultures among hospitalized patients
without systemic signs of infection and support not empirically treating patients with AMS and no
systemic signs of infection.23-25
Our study highlights that bacteremia in adult inpatients with ASB is rare, compared with
estimates as high as in 24% to 56% in symptomatic patients.26,27 The probability of bacteremia
varies widely based on individual risk factors, clinical presentation, and laboratory findings. We found
that the highest risk group had a 16.2% mean estimated probability of bacteremia as compared with
0.09% in the lowest risk group. Our study also adds data on laboratory markers that help identify
patients at risk for bacteremia. Specifically, patients without specific signs or symptoms of UTI who
developed bacteremia were twice as likely to have pyuria with 25 or greater WBCs on urinalysis and
also more likely to have serum leukocytosis greater than 10 000/μL. Notably, no single characteristic
conferred 2% or greater risk of bacteremia; rather, patients at elevated risk generally had multiple
diagnostic findings, comorbidities, or symptoms.

Table 2. Risk Factors for Bacteremia in Hospitalized Adults With Asymptomatic Bacteriuria, Multivariable Model

Variable (n = 11 039) No. (%) aOR (95% CI) P valuea

Age, median (IQR), y 78.3 (67.9-86.6) 1.01 (1.00-1.02) .09
Male sex 2851 (25.8%) 1.45 (1.02-2.05) .04
Hypotension (SBP<90) 828 (7.5%) 1.86 (1.18-2.93) .008
≥2 SIRS criteria 3315 (30.0%) 1.72 (1.21-2.46) .003
Dementia without AMS 4846 (43.9%) 1.38 (0.97-1.96) .08 Abbreviations: AMS, altered mental status; aOR,
AMS (with or without dementia) 975 (8.8%) 0.5 (0.21-1.18) .11 adjusted odds ratio; hpf, high-powered field; SBP,
Change in urine color or character 2082 (18.9%) 1.36 (0.92-2.02) .12 systolic blood pressure; SIRS, systemic inflammatory
response syndrome; UA, Urinalysis; WBC, white
Fatigue 2985 (27.0%) 1.53 (1.08-2.17) .02
blood cells.
Urinary retention 860 (7.8%) 1.87 (1.18-2.96) .01 a
P < .05 was considered significant.
UA WBC/hpf >25 6477 (58.7%) 3.31 (2.10-5.21) <.001
b
Log serum WBC: A 1 unit increase in log WBC is exp
Log serum WBC, median (IQR)b 2.2 (1.9-2.5) 3.38 (2.48-4.61) <.001
(log (WBC) +1) – exp (log (WBC)).

Table 3. Receipt of Empiric Antibiotic Therapy in Patients With Asymptomatic Bacteriuria, Stratified by 2% Risk
for Bacteremia From a Presumed Urinary Source

Estimated risk of bacteremia, % (No.)

Receipt of antibiotics <2% (n = 9092) ≥2% (n = 1947)
Received on day of or day after urine culture obtained 69.5% (6323) 89.4% (1741)
Did not receive on day of or day after urine culture 30.5% (2769) 10.6% (206)

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IDSA guidelines for ASB highlight the dearth of evidence on whether antimicrobial therapy is
beneficial for bacteriuria in patients with delirium or AMS in the absence of specific signs or
symptoms of UTI.8 The guidelines suggest a strategy of watchful waiting in patients with AMS and no
systemic signs of infection while recommending empiric antibiotic therapy in patients with systemic
signs of infection. Our findings support this strategy, as patients with systemic signs of possible
infection were significantly more likely than those without systemic signs of infection (2.9% vs 0.7%)
to develop bacteremia. To obtain a thorough picture of a patient’s clinical condition, we used a 3-day
infection window for assessing signs and symptoms and capturing blood culture data consistent with
national guidance.28 Our data also highlight negligible rates of bacteremia in patients with AMS in
the absence of SIRS, hypotension, or leukocytosis, supporting the safety of deferring empiric
antibiotic therapy in this group. Moving forward, interventions that provide absolute risks
personalized to a patient’s presenting signs and symptoms could be one way to inform evidence-
based empiric antibiotic use—or avoidance. In our analyses, a risk-based approach would reduce
unnecessary antibiotic exposure in almost 70% of patients with low risk of bacteremia.
Little scientific evidence exists on risk factors and epidemiology of bacteremia from a urinary
source, especially in older adults.29 Prior studies have shown that diabetes, immunosuppression,
catheterization, and shaking chills are independent risk factors for bacteremia from a urinary
source.30-32 In our analysis, patients with diabetes, immunosuppression, and catheterization were
not at higher risk for bacteremia in the absence of specific signs or symptoms of UTI. This discrepancy
could indicate those risk factors are more prominent in symptomatic patients—a group we excluded.
Additionally, none of these studies investigated specific urinalysis pyuria thresholds.

Implications
Our study has important implications for risk stratifying inpatients with ASB. First, these data provide
assurance that history of dementia alone is not a risk factor for bacteremia, likely because ASB is so
common in this group. Second, if patients have altered mentation and cannot attest to having
specific signs or symptoms of UTI, clinicians should assess for SIRS, leukocytosis, and pyuria when
deciding who may possibly benefit from empiric antibiotic treatment. If the patient with ASB does
not have systemic signs of infection, they have a very low risk of bacteremia from a urinary source.
Finally, moving forward, a validated UTI risk calculator may help determine the need for empiric
antibiotic therapy in patients with positive urine cultures and could improve the precision of
stewardship interventions. Using these personalized risk estimates would allow us to decrease
unnecessary ASB treatment without substantially delaying early empiric therapy in those at highest
risk of bacteremia.

Limitations
Our study has limitations. First, this was an observational study dependent on presence of positive
urine culture and documentation of signs and symptoms in the medical record. Second, we excluded
concomitant infections, and hence, may not have captured the full scope of ASB in hospitalized
patients. Third, we do not have data related to varying methods of diagnosing CDI events or nuances
of urine culture reporting across hospitals. Fourth, our study only captures bacteremia in patients
with blood and urine cultures growing the same organism within the 3-day infection window, so it
may miss patients for whom blood or urine cultures were not obtained or were drawn after antibiotic
initiation. Without systematically drawing blood cultures on all patients, it is not possible to
determine the true prevalence of bacteremia in this population, but our data reflect clinical
experience. Similarly, although we exclude patients with documented concomitant infections, we
cannot be assured that all bacteremia was from a urinary source. Additionally, severely
immunocompromised patients and those in intensive care units were excluded, where the risk or
benefit calculation may be different. In real life, decisions are often made before urine culture results
are known (eg, based on urinalyses); thus, for a population of all-comers, we over-estimated the risk
of bacteremia.

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Conclusions
In our multihospital cohort of 11 590 hospitalized patients with ASB, bacteremia from a presumed
urinary source was rare. The risk of bacteremia in patients presenting with AMS was negligible in the
absence of systemic signs of infection (eg, leukocytosis or SIRS). A personalized, risk-based approach
to empiric antibiotic therapy in patients without specific signs or symptoms of a UTI could decrease
unnecessary ASB treatment without delaying early empiric therapy in those at highest risk of
bacteremia.

ARTICLE INFORMATION
Accepted for Publication: January 23, 2024.
Published: March 13, 2024. doi:10.1001/jamanetworkopen.2024.2283
Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2024
Advani SD et al. JAMA Network Open.
Corresponding Author: Sonali D. Advani, MBBS, MPH, FIDSA, Division of Infectious Diseases, Duke University
School of Medicine, 315 Trent Dr, Hanes House, Ste 154, Durham, NC 27710 (sonali.advani@duke.edu).
Author Affiliations: Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
(Advani); Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (Ratz); Division of Hospital
Medicine, University of Michigan, Ann Arbor (Horowitz, Czilok, Flanders, Vaughn); Division of Infectious Diseases,
University of Michigan, Ann Arbor (Petty, Gandhi); Quality Department, Ascension, St Louis, Missouri (Fakih);
Division of Geriatrics, Duke University School of Medicine, and Durham Veterans Affairs Healthcare System,
Durham, North Carolina (Schmader); Division of Geriatrics, University of Michigan, Ann Arbor (Mody); Trinity
Health Michigan, Ann Arbor (Malani); Division of General Internal Medicine, University of Utah School of Medicine,
Salt Lake City (Vaughn).
Author Contributions: Mr Ratz had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: Advani, Horowitz, Petty, Schmader, Mody, Vaughn.
Acquisition, analysis, or interpretation of data: Ratz, Petty, Fakih, Mody, Czilok, Malani, Flanders, Gandhi, Vaughn.
Drafting of the manuscript: Advani, Schmader, Mody.
Critical review of the manuscript for important intellectual content: Ratz, Horowitz, Petty, Fakih, Mody, Czilok,
Malani, Flanders, Gandhi, Vaughn.
Statistical analysis: Ratz, Petty.
Obtained funding: Advani, Gandhi.
Administrative, technical, or material support: Advani, Horowitz, Mody, Czilok, Flanders, Gandhi.
Supervision: Schmader, Mody, Malani, Flanders, Gandhi, Vaughn.
Conflict of Interest Disclosures: Dr Advani reported receiving grants from the US Centers for Disease Control and
Prevention (CDC), NIA Pepper Center, and Society for Healthcare Epidemiology of America Foundation; receiving
personal fees from GSK, Locus Biosciences, Infectious Diseases Society of America, Sysmex America, Biomerieux,
and IPEC Experts, LLC outside the submitted work. Dr Mody reported receiving grants from Veterans Affairs, the
CDC, Betty and D. Dan Kahn Foundation, and the National Institutes of Health (NIH) outside the submitted work.
Dr Malani reported being a shareholder of Pfizer pharmaceuticals. No other disclosures were reported.
Funding/Support: Dr Advani is funded by the NIH-National Institute of Diabetes and Digestive and Kidney
Diseases (grant No. K12DK100024). This work was also supported by Blue Cross Blue Shield of Michigan and Blue
Care Network as part of the BCBSM Value Partnerships program.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and
decision to submit the manuscript for publication.
Meeting Presentation: Data were presented as a poster (#504) at the SHEA Spring Annual Meeting, Seattle WA
on April 12, 2023.
Data Sharing Statement: See Supplement 2.

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REFERENCES
1. Mody L, Juthani-Mehta M. Urinary tract infections in older women: a clinical review. JAMA. 2014;311(8):
844-854. doi:10.1001/jama.2014.303
2. Clark AW, Durkin MJ, Olsen MA, et al. Rural-urban differences in antibiotic prescribing for uncomplicated urinary
tract infection. Infect Control Hosp Epidemiol. 2021;42(12):1437-1444. doi:10.1017/ice.2021.21
3. Fakih MG, Advani SD, Vaughn VM. Diagnosis of urinary tract infections: need for a reflective rather than
reflexive approach. Infect Control Hosp Epidemiol. 2019;40(7):834-835. doi:10.1017/ice.2019.98
4. Advani SD, Gao CA, Datta R, et al. Knowledge and practices of physicians and nurses related to urine cultures in
catheterized patients: an assessment of adherence to IDSA guidelines. Open Forum Infect Dis. 2019;6(8):ofz305.
doi:10.1093/ofid/ofz305
5. Advani SD, Schmader KE, Mody L. Clin-Star corner: what’s new at the interface of geriatrics, infectious diseases,
and antimicrobial stewardship. J Am Geriatr Soc. 2022;70(8):2214-2218. doi:10.1111/jgs.17907
6. Petty LA, Vaughn VM, Flanders SA, et al. Risk factors and outcomes associated with treatment of asymptomatic
bacteriuria in hospitalized patients. JAMA Intern Med. 2019;179(11):1519-1527. doi:10.1001/jamainternmed.
2019.2871
7. Petty LA, Vaughn VM, Flanders SA, et al. Assessment of testing and treatment of asymptomatic bacteriuria
initiated in the emergency department. Open Forum Infect Dis. 2020;7(12):ofaa537. doi:10.1093/ofid/ofaa537
8. Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic
bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68(10):e83-e110. doi:
10.1093/cid/ciz021
9. Korenstein D, Scherer LD, Foy A, et al. Clinician attitudes and beliefs associated with more aggressive diagnostic
testing. Am J Med. 2022;135(7):e182-e193. doi:10.1016/j.amjmed.2022.02.036
10. Baghdadi JD, Korenstein D, Pineles L, et al. Exploration of primary care clinician attitudes and cognitive
characteristics associated with prescribing antibiotics for asymptomatic bacteriuria. JAMA Netw Open. 2022;5(5):
e2214268. doi:10.1001/jamanetworkopen.2022.14268
11. Gharbi M, Drysdale JH, Lishman H, et al. Antibiotic management of urinary tract infection in elderly patients in
primary care and its association with bloodstream infections and all cause mortality: population based cohort
study. BMJ. 2019;364:l525. doi:10.1136/bmj.l525
12. Vaughn VM, Chopra V. Revisiting the panculture. BMJ Qual Saf. 2017;26(3):236-239. doi:10.1136/bmjqs-2015-
004821
13. Bunting-Early TE, Shaikh N, Woo L, Cooper CS, Figueroa TE. The need for improved detection of urinary tract
infections in young children. Front Pediatr. 2017;5:24. doi:10.3389/fped.2017.00024
14. Shaikh N, Hoberman A, Hum SW, et al. Development and validation of a calculator for estimating the
probability of urinary tract infection in young febrile children. JAMA Pediatr. 2018;172(6):550-556. doi:10.1001/
jamapediatrics.2018.0217
15. Miller JM, Binnicker MJ, Campbell S, et al. A guide to utilization of the microbiology laboratory for diagnosis of
infectious diseases: 2018 update by the Infectious Diseases Society of America and the American Society for
Microbiology. Clin Infect Dis. 2018;67(6):813-816. doi:10.1093/cid/ciy584
16. Nicolle LE. Asymptomatic bacteriuria: review and discussion of the IDSA guidelines. Int J Antimicrob Agents.
2006;28(suppl 1):S42-S48. doi:10.1016/j.ijantimicag.2006.05.010
17. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM; Infectious Diseases Society of America;
American Society of Nephrology; American Geriatric Society. Infectious Diseases Society of America guidelines for
the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654. doi:10.
1086/427507
18. Gando S, Shiraishi A, Abe T, et al; Japanese Association for Acute Medicine (JAAM) Sepsis Prognostication in
Intensive Care Unit and Emergency Room (SPICE) (JAAM SPICE) Study Group. The SIRS criteria have better
performance for predicting infection than qSOFA scores in the emergency department. Sci Rep. 2020;10(1):8095.
doi:10.1038/s41598-020-64314-8
19. Fukushima S, Hagiya H, Fujita K, et al. Clinical and microbiological characteristics of polymicrobial bacteremia:
a retrospective, multicenter study. Infection. 2022;50(5):1233-1242. doi:10.1007/s15010-022-01799-7
20. Gajdács M, Dóczi I, Ábrók M, Lázár A, Burián K. Epidemiology of candiduria and Candida urinary tract
infections in inpatients and outpatients: results from a 10-year retrospective survey. Cent European J Urol. 2019;
72(2):209-214. doi:10.5173/ceju.2019.1909

JAMA Network Open. 2024;7(3):e242283. doi:10.1001/jamanetworkopen.2024.2283 (Reprinted) March 13, 2024 11/12

Downloaded from jamanetwork.com by guest on 04/08/2024

 JAMA Network Open | Infectious Diseases Bacteremia From a Presumed Urinary Source in Adults With Asymptomatic Bacteriuria

21. Chihara S, Popovich KJ, Weinstein RA, Hota B. Staphylococcus aureus bacteriuria as a prognosticator for
outcome of Staphylococcus aureus bacteremia: a case-control study. BMC Infect Dis. 2010;10:225. doi:10.1186/
1471-2334-10-225
22. Vaughn VM, Gandhi TN, Hofer TP, et al. A statewide collaborative quality initiative to improve antibiotic
duration and outcomes in patients hospitalized with uncomplicated community-acquired pneumonia. Clin Infect
Dis. 2022;75(3):460-467. doi:10.1093/cid/ciab950
23. Leis JA, Gold WL, Daneman N, Shojania K, McGeer A. Downstream impact of urine cultures ordered without
indication at two acute care teaching hospitals. Infect Control Hosp Epidemiol. 2013;34(10):1113-1114. doi:10.1086/
673151
24. Mozafarihashjin M, Leis JA, Maze Dit Mieusement L, et al. Safety, effectiveness and sustainability of a
laboratory intervention to de-adopt culture of midstream urine samples among hospitalized patients. Infect
Control Hosp Epidemiol. 2021;42(1):43-50. doi:10.1017/ice.2020.385
25. Piggott KL, Trimble J, Leis JA. Reducing unnecessary urine culture testing in residents of long term care
facilities. BMJ. 2023;382:e075566. doi:10.1136/bmj-2023-075566
26. Siegman-Igra Y, Fourer B, Orni-Wasserlauf R, et al. Reappraisal of community-acquired bacteremia: a proposal
of a new classification for the spectrum of acquisition of bacteremia. Clin Infect Dis. 2002;34(11):1431-1439. doi:
10.1086/339809
27. Lark RL, Saint S, Chenoweth C, Zemencuk JK, Lipsky BA, Plorde JJ. Four-year prospective evaluation of
community-acquired bacteremia: epidemiology, microbiology, and patient outcome. Diagn Microbiol Infect Dis.
2001;41(1-2):15-22. doi:10.1016/S0732-8893(01)00284-X
28. US Centers for Disease Control and Prevention. Identifying healthcare-associated infections (HAI) for NHSN
surveillance. Accessed January 2024. https://www.cdc.gov/nhsn/pdfs/pscmanual/2psc_identifyinghais_
nhsncurrent.pdf
29. Peach BC, Garvan GJ, Garvan CS, Cimiotti JP. Risk factors for urosepsis in older adults: a systematic review.
Gerontol Geriatr Med. Published online April 6, 2016. doi:10.1177/2333721416638980
30. Lalueza A, Sanz-Trepiana L, Bermejo N, et al. Risk factors for bacteremia in urinary tract infections attended in
the emergency department. Intern Emerg Med. 2018;13(1):41-50. doi:10.1007/s11739-016-1576-6
31. Bahagon Y, Raveh D, Schlesinger Y, Rudensky B, Yinnon AM. Prevalence and predictive features of bacteremic
urinary tract infection in emergency department patients. Eur J Clin Microbiol Infect Dis. 2007;26(5):349-352.
doi:10.1007/s10096-007-0287-3
32. Shigemura K, Tanaka K, Osawa K, Arakawa S, Miyake H, Fujisawa M. Clinical factors associated with shock in
bacteremic UTI. Int Urol Nephrol. 2013;45(3):653-657. doi:10.1007/s11255-013-0449-4

SUPPLEMENT 1.
eFigure 1. Flow Diagram of Study Inclusion
eMethods. Michigan Hospital Medicine Safety (HMS) Collaborative Data Curation Methods
eTable 1. Baseline Demographics and Risk Factors in Patients With Asymptomatic Bacteriuria (ASB)
eFigure 2. Risk Factors for Bacteremia From a Presumed Urinary Source in Hospitalized Adults With Asymptomatic
Bacteriuria, Multivariable Model
eTable 2. Estimated Probabilities (Expressed as a %) by Patient Subgroups in Ascending Order of Risk

SUPPLEMENT 2.
Data Sharing Statement

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