Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults

1. The diagnosis of asymptomatic bacteriuria should be based on results of culture of a urine specimen collected in a manner that minimizes contamination (A-II) (table 1). Infectious Diseases Society of America—US Public Health Service Grading System for ranking recommendations in clinical guidelines. • For asymptomatic women, bacteriuria is defined as 2 consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts ⩾105 cfu/mL (B-II). • A single, clean-catch voided urine specimen with 1 bacterial species isolated in a quantitative count ⩾105 cfu/mL identifies bacteriuria in men (B-III). • A single catheterized urine specimen with 1 bacterial species isolated in a quantitative count ⩾102 cfu/mL identifies bacteriuria in women or men (A-II). 2. Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment (A-II). 3. Pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy, and they should be treated if the results are positive (A-I). • The duration of antimicrobial therapy should be 3–7 days (A-II). • Periodic screening for recurrent bacteriuria should be undertaken following therapy (A-III). • No recommendation can be made for or against repeated screening of culture-negative women in later pregnancy. 4. Screening for and treatment of asymptomatic bacteriuria before transurethral resection of the prostate is recommended (A-I). • An assessment for the presence of bacteriuria should be obtained, so that results will be available to direct antimicrobial therapy prior to the procedure (A-III). • Antimicrobial therapy should be initiated shortly before the procedure (A-II). • Antimicrobial therapy should not be continued after the procedure, unless an indwelling catheter remains in place (B-II). 5. Screening for and treatment of asymptomatic bacteriuria is recommended before other urologic procedures for which mucosal bleeding is anticipated (A-III). 6. Screening for or treatment of asymptomatic bacteriuria is not recommended for the following persons. • Premenopausal, nonpregnant women (A-I). • Diabetic women (A-I). • Older persons living in the community (A-II). • Elderly, institutionalized subjects (A-I). • Persons with spinal cord injury (A-II). • Catheterized patients while the catheter remains in situ (A-I). 7. Antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria that persists 48 h after indwelling catheter removal may be considered (B-I). 8. No recommendation can be made for screening for or treatment of asymptomatic bacteriuria in renal transplant or other solid organ transplant recipients (C-III). The purpose of this guideline is to provide recommendations for diagnosis and treatment of asymptomatic bacteriuria in adult populations >18 years of age. The recommendations were developed on the basis of a review of published evidence, with the strength of the recommendation and quality of the evidence graded using previously described Infectious Diseases Society of America (IDSA) criteria (table 1) [1]. Recommendations are relevant only for the treatment of asymptomatic bacteriuria and do not address prophylaxis for prevention of symptomatic or asymptomatic urinary infection. This guideline is not meant to replace clinical judgment. Screening of asymptomatic subjects for bacteriuria is appropriate if bacteriuria has adverse outcomes that can be prevented by antimicrobial therapy [2]. Outcomes of interest are short term, such as symptomatic urinary infection (including bacteremia with sepsis or worsening functional status), and longer term, such as progression to chronic kidney disease or hypertension, development of urinary tract cancer, or decreased duration of survival. Treatment of asymptomatic bacteriuria may itself be associated with undesirable outcomes, including subsequent antimicrobial resistance, adverse drug effects, and cost. If treatment of bacteriuria is not beneficial, screening of asymptomatic populations to identify bacteriuria is not indicated, unless performed in a research study to further explore the biology or clinical significance of bacteriuria. Thus, there are 2 topics of interest: whether asymptomatic bacteriuria is associated with adverse outcomes, and whether the interventions of screening and antimicrobial treatment improve these outcomes. “Asymptomatic bacteriuria,” or asymptomatic urinary infection, is isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen obtained from a person without symptoms or signs referable to urinary infection [3]. “Acute uncomplicated urinary tract infection” is a symptomatic bladder infection characterized by frequency, urgency, dysuria, or suprapubic pain in a woman with a normal genitourinary tract, and it is associated with both genetic and behavioral determinants [4]. “Acute nonobstructive pyelonephritis” is a renal infection characterized by costovertebral angle pain and tenderness, often with fever; it occurs in the same population that experiences acute uncomplicated urinary infection. “Complicated urinary tract infection,” which may involve either the bladder or kidneys, is a symptomatic urinary infection in individuals with functional or structural abnormalities of the genitourinary tract [5]. Uncomplicated urinary infection occurs rarely in men, and urinary infection in men is usually considered complicated. A “relapse” is a recurrent urinary tract infection after therapy resulting from persistence of the pretherapy isolate in the urinary tract. “Reinfection” is recurrent urinary tract infection with an organism originating from outside of the urinary tract, either a new bacterial strain or a strain previously isolated that has persisted in the colonizing flora of the gut or vagina [4]. “Pyuria” is the presence of increased numbers of polymorphonuclear leukocytes in the urine and is evidence of an inflammatory response in the urinary tract [6]. The recommendations in this guideline were developed after a review of studies published in English. These were identified through a search of the PubMed database supplemented by review of references of relevant papers to identify additional reports, particularly early studies not accessed through the PubMed search. In addition, experts in urinary infection were asked to identify any additional trials not accessed through review. Clinical studies include prospective, randomized clinical trials; prospective cohort studies; case-control studies; and other descriptive studies. When appropriate, the methodological rigor of studies was evaluated using accepted criteria (e.g., the CONSORT statement [7]). Studies were excluded if the study population was not adequately characterized to assess generalizability, if procedures for patient follow-up or exclusions may have introduced sufficient bias to limit the credibility of observations, or if there were insufficient numbers of patients enrolled to support valid statistical analysis. Asymptomatic bacteriuria is a microbiologic diagnosis determined with a urine specimen that has been collected in a manner to minimize contamination and transported to the laboratory in a timely fashion to limit bacterial growth. The usual quantitative definition is ⩾105 cfu/mL in 2 consecutive urine specimens [3], initially proposed after studies performed in the 1940s and 1950s [8, 9]. In these studies, a bacterial count of ⩾105 cfu/mL in a clean, voided specimen was confirmed by a concomitant count in a catheterized specimen in >95% of subjects in several asymptomatic clinical groups, whereas lower quantitative counts in the voided specimen were not usually confirmed by the catheterized specimen [8]. When the screening of asymptomatic women using multiple voided specimens was evaluated, bacteriuria documented in an initial voided urine specimen was confirmed in a second voided specimen, usually obtained several days later, only 80% of the time. If 2 successive bacteriuric voided specimens had similar positive culture results, a third consecutive specimen also yielded consistent results in 95% of cases [9, 10]. Some studies involving women have used a more restrictive criterion of 3 consecutive voided urine specimens collected over 3 weeks with consistent bacteriologic results [11, 12], whereas other studies have used a more permissive criterion of a single positive urine specimen yielding ⩾105 cfu/mL [13, 14]. Because transient bacteriuria is common in healthy young women [13, 15, 16], the prevalence will be lower if >1 specimen is required for identification of bacteriuria [13]. Microbiologic criteria for diagnosis of asymptomatic bacteriuria in men are not as well validated. The finding of a single voided urine specimen with ⩾105 cfu/mL of an Enterobacteriaceae was reproducible in 98% of asymptomatic ambulatory men when the culture was repeated within 1 week [17]. A voided specimen with the lower quantitative count of ⩾103 cfu/mL was 97% sensitive and 97% specific for identification of bacteriuria in ambulatory men, but most of these patients were symptomatic [18]. If urine specimens are collected using a freshly applied condom catheter and leg bag, however, ⩾105 cfu/mL is the appropriate quantitative criterion, with 90% validity for identifying asymptomatic bacteriuria in the voided specimen, compared with a paired catheterized specimen [19, 20]. With single urine specimens obtained by urethral catheterization, lower quantitative counts of ⩾102 cfu/mL are consistent with bacteriuria for both men and women [21, 22]. Patients who have chronic kidney disease, who are experiencing diuresis, or who are infected with selected fastidious organisms may have bacteriuria with lower quantitative counts in voided specimens, but the criteria for bacteriuria in such patients are not standardized [23]. Pyuria is evidence of inflammation in the genitourinary tract and is common in subjects with asymptomatic bacteriuria [13, 24–27]. Pyuria is present with asymptomatic bacteriuria in ∼32% of young women [13], 30%–70% of pregnant women [25, 26], 70% of diabetic women [24], 90% of elderly institutionalized patients [27], 90% of hemodialysis patients [28], 30%–75% of bacteriuric patients with short-term catheters in place [29], and 50%–100% of individuals with indwelling catheters in place Pyuria also other inflammatory of the genitourinary tract in patients with urine culture These may be either such as renal and or such as Thus, by the presence of is not sufficient to and the presence or of not symptomatic from asymptomatic urinary infection. The diagnosis of asymptomatic bacteriuria should be based on culture of a urine specimen collected in a manner that minimizes contamination (A-II). • For asymptomatic women, bacteriuria is defined as 2 consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts of ⩾105 cfu/mL (B-II). • A single, voided urine specimen with 1 bacterial species isolated in a quantitative count of ⩾105 cfu/mL identifies bacteriuria in asymptomatic men (B-III). • A single catheterized urine specimen with 1 bacterial species isolated in a quantitative count of ⩾102 cfu/mL identifies bacteriuria in women or men (A-II). Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment (A-II). Asymptomatic bacteriuria is but the prevalence in populations with and the presence of genitourinary abnormalities (table For healthy women, the prevalence of bacteriuria with from to healthy women years of living in the community The prevalence of bacteriuria young women is associated with was women but only of similar Pregnant and nonpregnant women have a similar prevalence of bacteriuria is more common in diabetic women, with a prevalence of and is usually with duration of and presence of of with of diabetic Asymptomatic bacteriuria is in healthy young men The prevalence in men after the of of and associated with to of men years of who in the community are bacteriuric Diabetic men do not to have an increased prevalence of compared with men of asymptomatic bacteriuria in selected patient with chronic or characterized by urinary or with indwelling urinary have a prevalence of asymptomatic of Patients with short-term indwelling urethral catheters bacteriuria at the of (table Patients with spinal cord injury have a prevalence of whether is by or by and condom Patients hemodialysis have a prevalence of asymptomatic bacteriuria of to of elderly women and of elderly men in are bacteriuric The of these elderly persons have chronic with the prevalence of bacteriuria in the most The clinical assessment of elderly bacteriuric to the presence or of symptoms may be and of or urine by should not be as of symptomatic infection of a indwelling catheter or is associated with bacteriuria of the time. remains the single most common organism isolated from bacteriuric women [11, this for women with acute uncomplicated urinary tract infection. isolated from women with asymptomatic bacteriuria are characterized by are isolated from women with symptomatic infection Enterobacteriaceae as and other organisms (including and are common as For men, are also in to and species with abnormalities of the genitourinary tract, including elderly institutionalized have a of organisms remains the single most common organism isolated from women, but other such as are more common in men and women with a urologic in place usually have which often and such as and The of asymptomatic bacteriuria in nonpregnant women has been described in short-term and prospective cohort studies. In young women, symptomatic urinary infection more in bacteriuric women in women within 1 week after a urine culture of bacteriuric women compared with of women without [13]. The increased of symptomatic infection at 1 after bacteriuria [13]. cohort studies also an increased of symptomatic urinary infection in women identified with asymptomatic bacteriuria at initial screening In a after years of symptomatic urinary infection and at least once in and of women with bacteriuria at and in and of without with bacteriuria at were also more to be bacteriuric at of whether antimicrobial therapy was In 3 prospective studies from and that enrolled women increased was bacteriuric women The of bacteriuria and was not as when the bacteriuric and were and and for other was In a study that enrolled women with a of years there were in the of or chronic kidney disease bacteriuric and women after years of follow-up In study of women initially enrolled at years of the of progression to chronic kidney disease and were similar for bacteriuric and subjects after years women and subjects not with to and after years of follow-up in an study A prospective, randomized bacteriuric women to a of therapy with or The had a lower prevalence of bacteriuria at but not at 1 of symptomatic infection 1 after therapy with a similar in the treatment and These studies support the that women are at an increased for symptomatic urinary infection and are more to have bacteriuria at asymptomatic bacteriuria is not associated with adverse outcomes, such as hypertension, chronic kidney disease, genitourinary cancer, or decreased duration of survival. The of asymptomatic bacteriuria with symptomatic urinary infection is to that both symptomatic and asymptomatic urinary infection, symptomatic infection to asymptomatic bacteriuria. treatment of asymptomatic bacteriuria the of symptomatic infection further of asymptomatic bacteriuria. Screening for and treatment of asymptomatic bacteriuria in nonpregnant women is not (A-I). identified with asymptomatic bacteriuria in early have a increased of pregnancy, compared with women without bacteriuria These women also are more to and to have of clinical trials have that antimicrobial treatment of asymptomatic bacteriuria the of subsequent from to (table of cohort studies and randomized clinical trials also support the that antimicrobial treatment of asymptomatic bacteriuria the of and of these studies were performed early in the antimicrobial with and the most common The and of from multiple studies in screening for and treatment of asymptomatic bacteriuria a of in developed of of screening and treatment for asymptomatic bacteriuria in pregnant women a in of for pregnant women, from to in a and to in a These are consistent with the early of with screening for and treatment of asymptomatic bacteriuria pregnancy. of clinical trials of antimicrobial therapy for the treatment of asymptomatic bacteriuria in pregnancy. In the studies that the of treatment of asymptomatic bacteriuria pregnancy, of antimicrobial therapy usually continued for the duration of the (table A prospective, randomized study of antimicrobial therapy to the of compared with days of or by urine culture screening and if bacteriuria similar outcomes for the 2 treatment A review that there was insufficient evidence to a duration of antimicrobial therapy for pregnant women and treatment Thus, the duration of antimicrobial therapy for treatment of bacteriuria in pregnant women has not been The appropriate screening is a urine culture Screening for has a for identification of bacteriuria in pregnant women The of screening is not well with a urine culture for a single screening specimen at weeks have a of later in (table of this may be prevented with repeated screening is not A single urine obtained for culture at week of was to be in a study An from the of the of that a single screening culture in the was if the prevalence of bacteriuria was and the of in bacteriuric women was Pregnant women should be screened for bacteriuria by urine culture at least once in early pregnancy, and they should be treated if the results are positive (A-I). • The duration of antimicrobial therapy should be 3–7 days (A-III). • Periodic screening for recurrent bacteriuria should be undertaken after therapy (A-III). • No recommendation can be made for or against repeated screening of culture-negative women in the later of pregnancy. cohort studies of diabetic women in of symptomatic urinary infection, or progression to diabetic initially bacteriuric and women at or years of A of therapy or therapy for diabetic women with asymptomatic bacteriuria and continued screening for bacteriuria 3 after a of 3 years of that antimicrobial therapy not or the of symptomatic urinary infection, it the of for urinary infection or other was of progression of diabetic such as in bacteriuric subjects who not antimicrobial Diabetic women who antimicrobial however, had as days of antimicrobial and more adverse antimicrobial Thus, there were for continued screening and treatment of asymptomatic bacteriuria in diabetic women, and there was evidence of Screening for or treatment of asymptomatic bacteriuria in diabetic women is not (A-I). cohort studies of asymptomatic bacteriuria have enrolled both and women These studies adverse outcomes in women with asymptomatic bacteriuria. A prospective, randomized study of or also enrolled women with a years Thus, these studies that outcomes of bacteriuria and treatment of bacteriuria in healthy women are similar to in nonpregnant A prospective, randomized clinical of antimicrobial treatment for bacteriuria enrolled ambulatory women who in a and a in the prevalence of asymptomatic bacteriuria at but there was in the of symptomatic A prospective cohort study of ambulatory years of for including subjects with adverse outcomes to bacteriuria cohort studies bacteriuria and for men and women at years of follow-up or men and women years years of follow-up screening for and treatment of asymptomatic bacteriuria in persons in the community is not recommended (A-II). randomized clinical trials of antimicrobial therapy or therapy for elderly of have of screening for or treatment of asymptomatic bacteriuria (table was in the of symptomatic infection or in and there were in chronic genitourinary symptoms associated with antimicrobial Treatment of asymptomatic bacteriuria was associated with increased adverse antimicrobial and with organisms of cohort studies similar for with and without bacteriuria women in the men in and women or men in clinical trials of treatment of asymptomatic bacteriuria in elderly Screening for and treatment of asymptomatic bacteriuria in elderly institutionalized of is not recommended (A-I). with spinal cord have a prevalence of and they also a of symptomatic urinary infection When asymptomatic bacteriuria was treated in a cohort of spinal early of bacteriuria after therapy was the usual days of of subjects were bacteriuric by days after of and after a of were bacteriuric by days increased antimicrobial When patients with a of spinal cord injury were for the results of of urine were but only symptomatic of which to antimicrobial treatment In a of symptomatic urinary infection and of bacteriuria were similar recipients of either antimicrobial or for patients with bladder by A prospective, randomized of antimicrobial treatment or treatment of asymptomatic bacteriuria enrolled patients who were treated with and a similar of symptomatic urinary infection an of days of of whether were there have been a of clinical and of results is by short of follow-up and study review and treatment only of symptomatic urinary tract infection in patients with spinal cord Asymptomatic bacteriuria should not be screened for or treated in spinal patients (A-II). 80% of acute patients with short-term indwelling urethral catheters antimicrobial usually for an indication other urinary infection This of antimicrobial assessment of outcomes to treatment of asymptomatic bacteriuria A prospective, cohort study of catheter-acquired 90% of were only 1 infection A case-control study that of bacteriuria with indwelling urethral increased but the for this was not and that antimicrobial therapy not the with A prospective, of treatment of in more of had indwelling urethral catheters in in of 2 weeks after therapy for catheterized subjects and clinical of treatment A prospective, of antimicrobial treatment of asymptomatic bacteriuria 48 h after removal of short-term catheters in women with catheter-acquired bacteriuria microbiologic and clinical outcomes at days in treated women of women randomized to therapy had microbiologic by developed No women in the treatment This study enrolled a selected of women characterized by young and experiencing a short of 3 A prospective, randomized of therapy therapy for bacteriuric patients with indwelling urethral catheters in place and organisms isolated a similar of both treated and patients for weeks of were also but of organisms in the to compared with only in the treatment A prospective, study of consecutive of antimicrobial treatment to bacteriuria in elderly patients with catheters in the of of with compared with the and there was of bacteriuria after often with organisms of Asymptomatic bacteriuria or should not screened for or treated in patients with an indwelling urethral catheter (A-I). • Antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria that persists 48 h after catheter removal may be Patients with asymptomatic bacteriuria who genitourinary procedures associated with mucosal bleeding have a of bacteremia and occurs in to of bacteriuric patients who transurethral and there is clinical evidence of sepsis in of these persons and prospective, randomized clinical trials support the of antimicrobial treatment in these in bacteriuric men transurethral resection of the In the of was to that of is relevant to other but any with a of mucosal bleeding should be considered a of asymptomatic bacteriuria is not for For of a indwelling catheter is associated with a of and antimicrobial treatment is not The appropriate for of antimicrobial therapy is not well h before the has been this is to be and the for before the of therapy the before or before the procedure is The to a for culture before the procedure and the duration of antimicrobial therapy are also not in clinical In the of an indwelling antimicrobial therapy can be after the procedure When an indwelling catheter remains in place after a it has been recommended by that antimicrobial therapy be continued the catheter is Screening for and treatment of asymptomatic bacteriuria before transurethral resection of the prostate is recommended (A-I). • An assessment for the presence of bacteriuria should be obtained, so results will be available to direct antimicrobial therapy prior to the procedure (A-III). • Antimicrobial therapy should be initiated shortly before the procedure (A-II). • Antimicrobial therapy should not be continued the procedure, unless an indwelling catheter remains in place (B-II). Screening for and treatment of asymptomatic bacteriuria is recommended before other urologic procedures in which mucosal bleeding is anticipated (A-III). studies performed early in the a prevalence of asymptomatic bacteriuria renal transplant in the after in of has introduced of of indwelling urethral and antimicrobial prophylaxis to and other These interventions also both asymptomatic bacteriuria and symptomatic urinary infection studies, including a review and a prospective cohort study have not an asymptomatic bacteriuria and survival. recipients with urinary infection and are also characterized by urologic abnormalities and are identified by of symptomatic urinary infection, bacteriuria Thus, with screening for bacteriuria is to provide a Some experts do screening for at least for the after renal for of renal transplant however, recommendation for screening for bacteriuria Screening for or treatment of bacteriuria has not been evaluated for other solid organ transplant for infection prevention in transplant recipients recommendation for screening for bacteriuria A study of women with and bacteriuria randomized to either antimicrobial therapy or antimicrobial therapy in the to or the of in the 2 studies involving patients have asymptomatic bacteriuria and infection in women, but there was an increased prevalence of bacteriuria men that was with counts clinical outcomes associated with bacteriuria in these populations have not been No recommendation can be made for screening for or treatment of asymptomatic bacteriuria in renal transplant or other solid organ transplant recipients (C-III). Asymptomatic bacteriuria is Pregnant women with asymptomatic bacteriuria are at an increased for adverse outcomes, and these can be prevented with antimicrobial treatment of asymptomatic bacteriuria. Thus, pregnant women should be screened for bacteriuria and treated if results are Asymptomatic bacteriuria is also a for patients who urologic interventions with mucosal and such patients should be treated prior to such For other adult asymptomatic bacteriuria has not been to be persons with bacteriuria are at an increased of symptomatic urinary infection, treatment of asymptomatic bacteriuria not the of symptomatic infection or improve other outcomes. Thus, in populations other for treatment has been documented to be beneficial, screening for or treatment of asymptomatic bacteriuria is not appropriate and should be relevant to asymptomatic bacteriuria further research and in appropriately clinical of the clinical and microbiologic if of in selected such as pregnant The of a second urine specimen to asymptomatic bacteriuria prior to treatment after an initial positive screening specimen in pregnant The duration of antimicrobial therapy for treatment of asymptomatic bacteriuria in pregnant women in appropriate clinical of symptomatic of urinary infection in elderly institutionalized populations with a prevalence of bacteriuria. of asymptomatic bacteriuria in subjects with chronic kidney of the and appropriate of individuals with indwelling urinary other indwelling catheters (e.g., urinary and individuals with asymptomatic bacteriuria with organisms but without indwelling a for or including with or who have solid organ further of the if of asymptomatic bacteriuria. The to duration of and antimicrobial for treatment of bacteriuria prior to genitourinary procedures in further clinical there are clinical of screening for and treatment of bacteriuria prior to a procedure with including and the following individuals for review and in the development of this and was by of has research from has research from and has on the for has been a for and has been a for and on the for and

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