Asymptomatic Bacteriuria

Abdulrahman A. AlMuhrij, MD
Urology resident
November 2015

Focus points
Asymptomatic Bacteriuria:
Non-catheterized patients.
Pregnant patients.
Diabetic patients.
Elderly patients.
Catheterized patients.

Definitions
Urinary tract infection:
UTI symptoms.
Pyuria (leukocyte esterase, WBC on UA).
Urine culture.
> 38 C

Lethargy /
confusion

chills

Pain

dysuria

Incontinence

frequency

Definitions
Asymptomatic Bacteriuria :
Bacteriuria.
Voided cultures 10^5 colony forming unit.
Single catheterized urine specimen with 10^2.

Symptoms free.

Why and Why not

Antibiotics resistant.
Treatment side effect.

Disease.
Complications.
Reinfection.

Epidemiology
Prevalence:
men:
68-79: 0%.
90-103: 5.4%
Hospitalized: 30-34%

Women:
Premenopausal: 1-5%
68-79: 13.6%
90-103: 22.4%
Hospitalized: 42-50%

Risk Factors

History of UTI (x7 folds).

Catheterization duration.
Pathogen virulence.
Increase in age.
Female gender.
Patient genetic variation.
Comorbidities.
Postmenopausal women.
Urinary stasis.
Sexual activity.

Microbiology

Escherichia coli (54-69%).

Klebsiella (12%).
Enterococcus feacalis (5%).
Proteus mirabilis (4%).
Pseudomonas aeruginosa.
Candida.

pathophysiology
Urinary mucosa.
P-fimbriated (E coli).
Lipopolysaccharides.
Hemolysin and cytotoxic necrotizing factor 1.

Pregnant Patients
Is it a risk factor for ASB?
Incidence:
ASB: 2-10%.
Lower UTI: 1-2%.
Upper UTI: <1%.
Should we treat ASB?
Similar organisms.
Risk factors for pyelonephritis:
Young, nulliparity, SCD, DM, progression of pregnancy, immuno
suppression.

Pregnant Patients

Why ASB is dangerous in pregnancy?

Pregnant Patients
Kidneys :
Increase renal length (1 cm).
Increase GFR (30-50%).

Collecting system:
Decrease peristalsis.

Ureters:
Decrease peristalsis.
Mechanical obstruction.

Bladder:
Smooth muscle relaxation.
Increased capacity, urinary stasis.

7th week of gestation.

Pregnant Patients
Recommended to screen ASB:
Early in pregnancy:
2-16 gestation week.
First prenatal visit.

Urine C/S.

Screening

Pregnant Patients

Treatment

Safety class (B,C).

Drug name

Fetal toxicity

route

Prior FDA safety

class

penicillins

Low risk

Oral, IV

cephalosporins

Low risk

Oral, IV

imipenem

Limited data

IV

meropenem

Limited data

IV

clindamycin

Low risk

Oral, IV

nitrofurantoin

controvesial

Oral

TMP/SMX

Risk of
teratogenesis

Oral, IV

gentamicin

Ototixicity/nephrot
oxicity

IV

ciprofloxacin

arthropathy

Oral, IV

Tetracycline,
doxycycline

Risk of
teratogenicity

Oral

Elderly Patients
Patients aged => 65 yo.
UTI:
15.5% (hospitalized patients).
6.2% disease related deaths.

ASB:
65-90 yo: 16%,21% (M,F)

Do we need to screen for ASB?

Elderly Patients

Treatment

Women, no symptoms:
Hydration, work-up.
Mild symptoms:
Delay treatment till culture result.
Cystitis:
(1st line) Nitrofurantoin or TMP/SMX:
Women 3-5 days, Men 7-14 days.
(2nd line) Cipro or levo.
Fosfomycin (single dose).
Amoxacillin-clavulanate.

Elderly Patients

Treatment

Pyelonephritis:
No hospitalization:
TMP/SMX (14 days).
Flouroquinolone (5-7 days)

Hospitalized patient:
Aminoglycoside (+- cipro/ampicillin)

Catheterized Patients
7% per day of catheterization.
Microbiology:
Biofilm organisms:
Proteus mirabilis,
Providencia stuartii,
Pseudomonas aerginosa,
Candida.

Catheterized Patients Treatment

Remove Foley's and reinsert, then collect a sample.
TMP-SMX or a fluoroquinolone (empiric).
The patient should be started on empirical antimicrobial therapy just bef
ore decatheterization and maintained on therapy for 2 days.

If symptomatic 7-14 days treatment course (48 hr after symptoms re

solution).

Diabetic Patients
Hypothesis?
Is DM a risk factor?
Blood sugar level correlate with ASB?

Antimicrobial
Prophylaxis fo
r Urologic Pro
cedures

Prevention
Increase fluid intake?
Low dose AB:
Nitro (50-100 mg).
TMP/SMX (half strength).
Self treatment.
Flouroquinolone or TMP/SMX .
Proanthocyanidin.
D-mannose.
Oral estrogen?
C.I.C. and condom catheter use.

 Who should we treat in ASB?

References
CAMPBELL-WALSH. Urology. Tenth edition.
Keri et al. Bacteriuria and urinary tract infections in the elderly.
Alexander P. et al. Urinary tract infection and bacteriuria in pregnanc
y.
Matthew Ferroni et al. Asymptomatic bacteriuria in non catheterized
adults.