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Asymptomaticbacteriuria
GeneralInformation
Description

isolationofspecifiedminimumquantitativecountofbacteriainappropriatelycollectedurinespecimen
obtainedfromapersonwithoutsignsorsymptomsofurinarytractinfection(1)

Definitions

specificquantitativedefinitionsvarywithpopulationbeingtested(1,3)
forasymptomaticwomen,bacteriuriaisdefinedas105colonyformingunits(CFU)/mLofa
singlebacterialstrainisolatedfrom2consecutivevoidedurinespecimens
forasymptomaticmen,bacteriuriaisdefinedas105CFU/mLofasinglebacterialspecies
isolatedfromasingleurinespecimen
forcatheterizedwomenormen,bacteriuriaisdefinedas102CFU/mLofasinglebacterial
speciesfromasinglecatheterizedspecimen

Epidemiology
Incidence/Prevalence
common,thoughprevalenceinpopulationvarieswidelywithage,sex,comorbidconditions,and
presenceofgenitourinaryabnormalities(1,2)
prevalenceincreaseswithadvancingageinhealthywomenandafterage60yearsinmen
rareinhealthyyoungmen
reportedprevalenceinselectedpopulations
1%5%inhealthypremenopausalwomen
1.9%9.5%inpregnantwomen
2.8%8.6%inpostmenopausalwomenaged5070years
9%27%inwomenwithdiabetes
0.7%11%inmenwithdiabetes
amongelderlypersons
10.8%16%incommunitydwellingelderlywomen
3.6%19%incommunitydwellingelderlymen
25%50%inelderlywomeninlongtermcarefacility
15%40%inelderlymeninlongtermcarefacility
23%89%inpatientswithspinalcordinjuriesandintermittentcatheteruse
57%inpatientswithspinalcordinjuriesandcondomcatheter
28%inpatientshavingdialysis
9%23%inpatientswithshorttermindwellingcatheter
100%inpatientswithlongtermindwellingcatheter
asymptomaticbacteriuriaidentifiedatleastoncein37%ofwomenand20%ofmen80years
old
basedoncohortstudyof330noninstitutionalizedelderlyadults80yearsoldfollowedfor18
months
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ReferenceScandJInfectDis200840(10):804
5%6%prevalenceinsexuallyactivenonpregnantyoungwomen
basedonprospectivecohortstudy
796womenaged1840yearswhostartedusingnewmethodofcontraceptionandhad1
urinarytractinfectioninpreviousyearwerefollowedfor6monthswithmonthlyurinecultures
anddailydiary
asymptomaticbacteriuriadefinedas100,000colonyformingunits/mLofurinarytract
pathogenonroutineculturefromasymptomaticwoman
5%6%pointprevalenceofasymptomaticbacteriuria,mostlyEscherichiacoli
21%24%periodprevalenceofasymptomaticbacteriuria(1episodein6months)
5%ofepisodesofasymptomaticbacteriuriapersisted
ReferenceNEnglJMed2000Oct5343(14):992fulltext,editorialcanbefoundinNEnglJ
Med2000Oct5343(14):1037
2%14%prevalenceofasymptomaticbacteriuriareportedinpatientswithdiabetes,with
highestratesinwomen
systematicreviewof22studiesevaluatingasymptomaticbacteriuriain6,281patients
prevalenceofasymptomaticbacteriuriacomparingpatientswithdiabetesvs.healthy
controls(p<0.05forall)
12.2%vs.4.5%generalpopulation
14.2%vs.5.1%women
2.3%vs.0.8%men
12.9%vs.2.7%childrenandadolescents
ReferenceDiabetesCare2011Jan34(1):230fulltext
10.9%prevalenceofasymptomaticbacteriuriareportedin202nonpregnantwomenaged3178
yearswithtype2diabetesinIran(BMCWomensHealth2006Feb236:4fulltext)

Riskfactors

increaseddetectionofasymptomaticbacteriuriaisassociatedwith(1,2)
femalegender
pregnancy
diabetes,particularlyinwomen
advancedage
structuralorfunctionalabnormalitiesofgenitourinarytractalsoincreaserisk,including(1,2)
spinalcordinjury
indwellingurinarycatheter(especiallylongterm)
permanenturetericstent
patientsonhemodialysis
patientswithchronicneurologicillnesses

EtiologyandPathogenesis
Pathogens

Escherichiacolimostcommonorganismisolatedinwomen(1,2)
othercommonlyisolatedorganismsinclude(1,2)
Klebsiellapneumoniae
coagulasenegativestaphylococci
groupBstreptococci(particularlyinpregnancy)
Enterococcusspecies
Gardnerellavaginalis(morecommoninmen)
gramnegativebacilli(morecommoninmen)
patientswithlongtermindwellingcathetersoftenhavepolymicrobialbacteriuria,including(1)
Pseudomonasaeruginosa
Proteusmirabilis(morecommoninmen)

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Morganellamorganii
Providenciastuartii

Pathogenesis
similartothatofclinicalurinarytractinfection
isolatedbacteriaaretypicallycommensalorganismsoftheperiurethralarea,vagina,orgut
hostgeneticpredisposition,incompletebladderemptying,orpresenceofforeignbodymayfacilitate
persistence
isolatesfromwomenwithasymptomaticbacteriuriamayhavefewervirulencefactorswhencompared
tothosefromwomenwithsymptomaticinfection(InfectDisClinNorthAm1997Sep11(3):513)
bacteriamaytravelupurethraintobladder,maytraveltokidneys
ReferenceInfectDisClinNorthAm2003Jun17(2):367

HistoryandPhysical
History

Chiefconcern(CC)

lackofsymptomsofurinarytractinfection(bydefinition)(1,2)

Physical

Generalphysical

lackoffindingssuggestiveofurinarytractinfection(1)

Diagnosis
Makingthediagnosis

InfectiousDiseasesSocietyofAmerica(IDSA)guidelinesfordiagnosisofasymptomaticbacteriuriain
adults(1)
lackofsignsandsymptomsofurinarytractinfection
diagnosisbasedonurinespecimencollectedinmannerthatminimizescontamination(IDSA
GradeAII)
forasymptomaticwomen2consecutivevoidedurinespecimenswithisolationofsame
bacterialstraininquantitativecounts100,000colonyformingunits(CFU)/mL(IDSAGrade
BII)
forasymptomaticmensinglevoidedurinespecimenwith1bacterialspeciesisolatedin
quantitativecount100,000CFU/mL(IDSAGradeBIII)
forwomenormensinglecatheterizedurinespecimenwith1bacterialspeciesisolatedin
quantitativecount100CFU/mL(IDSAGradeAII)
EuropeanAssociationofUrology(EAU)diagnosticcriteriaforasymptomaticbacteriuriaconcordant(3)

Differentialdiagnosis

symptomaticurinarytractinfection(1)
complicatedanduncomplicatedcystitis
complicatedanduncomplicatedpyelonephritis
prostatitis

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Testingoverview

whenscreeningisrecommended,urinecultureistheappropriatescreeningtest(1)
cultureshouldbecollectedinmannerthatminimizescontamination(IDSAGradeAII)(1)
testinginpregnancy
optimalfrequencyforscreeninginpregnancynotdetermined,InfectiousDiseaseSocietyof
America(IDSA)recommends(1)
screeningonceinearlypregnancy(IDSAGradeAI)
periodictestingforrecurrentbacteriuriaaftertreatmentforasymptomatic
bacteriuria(ASB)inwomenwithpositivecultures(IDSAGradeAIII)
noevidencebasedguidelineorconsensusonneedforrepeatscreeninginpregnant
womenwhotestnegativeinearlypregnancy
UnitedStatesPreventiveServicesTaskForce(USPSTF)stronglyrecommendsscreeningall
pregnantwomenforasymptomaticbacteriuriausingurinecultureat1216weeksgestation
(USPSTFGradeA)(AnnInternMed2008Jul1149(1):43fulltext,editorialcanbefoundat
AnnInternMed2008Jul1149(1):I37)
EuropeanAssociationofUrology(EAU)makesnorecommendationonscreeningduring
pregnancy(3)
forpatientsundergoingurologicprocedureswithpotentialmucosalbleeding
IDSArecommendsassessingforbacteriuriasuchthatresultswillbeavailabletoguidetherapy
priortoprocedure(IDSAGradeAIII)
EAUrecommendsurineculturepriortosuchprocedurewithdirectedpreoperativetherapy
(EAUGradeB,Level2)
testingforASBinimmunocompromisedhosts,particularlyrenaltransplantrecipients,is
recommendedbysomeexperts(1,3)
IDSA,andtheAmericanSocietyofTransplantationmakenorecommendationforthisissue
(Transplantation2010Mar2789(6):644)
EAUrecommendsconsiderationofscreeningandtreatmentonacasebycasebasisfor
immunocompromisedandseverelyillpatientsandadvisesagainstscreeningortreatmentfor
mostrenaltransplantrecipientswithotherwiseuncomplicatedmedicalhistories(3)

Urinestudies

urinecultureistheappropriatetestforscreening(1)
pyuriaiscommonwithasymptomaticbacteriuria(ASB),andisnotanindicationfortreatment(1,2)
leukocyteesteraseandnitratearenotusefultestsforscreening(1,2)

reagentteststrips(suchasdipstick)maynotbeadequateforscreeningpregnantwomenfor
asymptomaticbacteriuria
basedonprospectivecaseseries
893pregnantwomenscreenedatfirstprenatalvisit(womenonantibioticsorwithurinary
symptomsexcluded)
reagentteststripforblood,protein,nitrite,andleukocyteesterasewascomparedtomicroscopy
andculture
usinganyof4criteriahadonly33%sensitivity,91%specificity,18%positivepredictivevalue,
and96%negativepredictivevalueforbacteriuria
usingnitritetestalonehad19%sensitivity,99.5%specificity,69%positivepredictivevalue,and
95.6%negativepredictivevalue
ReferenceBMJ1998Feb7316(7129):435fulltext

Treatment
Treatmentoverview

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inpregnantwomenwithasymptomaticbacteriuria
rationalefortherapy:antibiotictreatmentofasymptomaticbacteriuriainpregnantwomenmay
reduceincidenceofpyelonephritisandlowbirthweightandpossiblypretermdelivery(level2
[midlevel]evidence)thoughtheabsoluteriskofpyelonephritisinpregnancyislow
choiceofantibioticisbasedoncultureandantibioticsusceptibilityresults
optimaldurationoftherapynotdetermined
37daysofantibioticsrecommended(IDSAGradeAI),similartothetreatmentof
symptomaticcystitis
47daycourseofantibioticsappearstobemoreeffectiveforreducingratesof
pyelonephritisinpregnantwomenwithasymptomaticbacteriuriacomparedtosingle
doses(level2[midlevel]evidence)
otherindicationsfortreatment
treatmentofasymptomaticbacteriuriarecommendedbeforeurologicproceduresinwhich
mucosalbleedingisexpected,includingtransurethralresectionofprostate(TURP)(IDSAGrade
AIIEAUGradeA,Level1b)
inpatientshavingTURP(commonlyextrapolatedtopatientshavinganyurologicproceduresin
whichmucosalbleedingisexpected)
treatmentshouldbeinitiatedshortly(upto72hours)beforetheprocedure(IDSAGrade
AII)
treatmentmaybediscontinuedaftertheprocedure,unlessanindwellingcatheterremains
inplace(IDSAGradeBII)
considertreatmentforasymptomaticwomenwithcatheteracquiredbacteriuriathatpersists48
hoursaftercatheterremoval(IDSAGradeBI)
treatmentofasymptomaticbacteriuriaisnotrecommendedinallotherpatientgroupsincluding
routinetreatmentofasymptomaticbacteriuriainolderwomenappearstoreducebacteriuriabut
doesnotappeartoimprovesymptoms(level2[midlevel]evidence)
treatmentofasymptomaticbacteriuriainwomenwithdiabetesmaynotpreventsymptomatic
urinarytractinfectionorcomplications(level2[midlevel]evidence)
treatmentofasymptomaticbacteriuriainhealthyyoungmennotrecommended(EAUGradeA,
Level1b)
treatmentofasymptomaticbacteriuriainyounggirlsmaynotreducesymptomsoraffectrenal
growthorscarring(level2[midlevel]evidence)

Recommendations

InfectiousDiseasesSocietyofAmerica(IDSA)guidelinesfortreatmentofasymptomaticbacteriuria

treatmentofasymptomaticbacteriuriarecommended(1)
inpregnantwomen(IDSAGradeAI)
durationoftreatment37days(IDSAGradeAII)
screenperiodicallyforrecurrentbacteriuriaaftertreatment(IDSAGradeAIII)
beforetransurethralresectionofprostate(TURP)
initiateantimicrobialtreatmentshortly(upto72hours)beforeprocedure(IDSAGradeA
II)
donotcontinueantimicrobialtreatmentafterprocedure,unlessindwellingcatheterpresent
(IDSAGradeBII)
beforeotherurologicproceduresinwhichmucosalbleedingisexpected(IDSAGradeAIII)
considertreatmentforasymptomaticwomenwithcatheteracquiredbacteriuriathatpersists48hours
aftercatheterremoval(IDSAGradeBI)(1)
screeningandtreatmentnotrecommendedfor(1)
premenopausal,nonpregnantwomen(IDSAGradeAI)
womenwithdiabetes(IDSAGradeAI)
elderlyinstitutionalizedpatients(IDSAGradeAI)
olderpersonslivingincommunity(IDSAGradeAII)
patientswithspinalcordinjury(IDSAGradeAII)
patientswithindwellingurethralcatheter(IDSAGradeAI)

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pyuriaaccompanyingasymptomaticbacteriuriaisnotanindicationforantimicrobialtreatment(IDSA
GradeAII)(1)
norecommendationcanbemadefortreatmentofasymptomaticbacteriuriainrenaltransplantorother
solidorgantransplantpatients(IDSAGradeCIII)(1)

EuropeanAssociationofUrology(EAU)guidelinesonurologicalinfections

EuropeanAssociationofUrologyrecommendationsforscreeningforasymptomaticbacteriuria
(3)
screeningforandtreatmentofasymptomaticbacteriuriaisrecommended
beforeinvasivegenitourinaryprocedurewithriskofmucosalbleeding(EAUGradeA,
Level1b)
patientssubjectedtoplacement/exchangesofnephrostomytubesandinternalstents(EAU
GradeC,Level4)
screeningforandtreatmentofasymptomaticbacteriurianotrecommendedfor
patientswithoutriskfactors(femalesandyoungmales)(EAUGradeA,Level1b)
postmenopausalwomen(EAUGradeA,Level1b)
patientswithwellregulateddiabetesmellitus(EAUGradeA,Level1b)
elderlyinstitutionalizedpatients(EAUGradeA,Level1b)
patientswithdysfunctionaland/orreconstructedlowerurinarytracts(EAUGradeB,
Level2b)
patientssubjectedtouncomplicatedplacement/exchangesofindwellingcatheters(EAU
GradeC,Level4)
patientshavingsurgicalproceduresnotenteringtheurinarytract(EAUGradeC,Level4)
benefitofscreeningandtreatingasymptomaticbacteriuriainimmunocompromisedpatientsor
patientwithseverediseaseshouldbeconsideredindividuallyoncasebycasebasis(EAUGrade
C,Level4)
treatmentofasymptomaticbacteriurianotrecommendedfor
womenwithrecurrentsymptomaticurinarytractinfection(UTI)(EAUGradeA,Level
1b)
patientswithcathetersinurinarytract(EAUGradeC,Level4)
patientswithrenaltransplants(EAUGradeC,Level4)
norecommendationismadebyEAUonscreeningforasymptomaticbacteriainpregnantwomenafter
reviewofavailableevidencein2015

Medications

Pregnantwomen

InfectiousDiseasesSocietyofAmerica(IDSA)recommendsantibiotictreatmentfor37days(IDSA
GradeAII)(1)
optionsforuseinpregnantwomenwithasymptomaticbacteriuria(2)
FDAPregnancyCategoryB(safetyforuseinpregnancyhasnotbeenestablished)
amoxicillin
amoxicillinclavulanate(Augmentin)
ampicillin
cefuroxime(Ceftin)
cephalexin(Keflex)
nitrofurantoin(Furadantin)
FDAPregnancyCategoryC(noadequatewellcontrolledstudiesinwomenonlyuseifpotential
benefitjustifiespotentialrisktofetus)
fluoroquinolones,includingthefollowing,aregenerallyavoidedinpregnancyif
alternativesexist
ciprofloxacin(Cipro)
levofloxacin(Levaquin)

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norfloxacin(Noroxin)
FDAPregnancyCategoryD(thereispositiveevidenceofhumanfetalrisk,butthebenefitsfrom
useinpregnantwomenmaybeacceptabledespitetherisk)
trimethoprim/sulfamethoxazole(Bactrim,Septra)isgenerallyavoidedinfirsttrimester
(concernforcongenitalmalformationsfromtrimethoprim)andinlatethirdtrimester
(concernforkernicterusfromsulfamethoxazoleinthenewborn)ifsaferoptionsexist
EuropeanAssociationofUrology2015guidelinesmakenorecommendationonscreeningortreatment
inpregnantwomen(3)

antibiotictreatmentofasymptomaticbacteriuriainpregnantwomenmightreduceincidenceof
maternalpyelonephritis,pretermbirth,andinfantlowbirthweight,althoughoverallqualityof
evidencelow(level2[midlevel]evidence)
basedonCochranereviewoftrialswithmethodologiclimitations
systematicreviewof14randomizedorquasirandomizedtrialscomparingantibioticsvs.
placeboornotreatment(control)inpregnantwomenwithasymptomaticbacteriuriaonantenatal
screening
overallqualityofdataandapplicabilitytomodernpracticelow
alltrialshadmultiplemethodologiclimitationsincludingunclearornoallocation
concealment,highexclusionrate,lackofblinding,missingdataonpyelonephritisfor
somewomen,andhighlosstofollowup
alltrialspublishedbetween1960and1987
mosttrialsevaluatedantibioticsorantisepticsnolongerroutinelyusedfortreatmentof
bacteriuria(suchasmethenamine,sulphormethoxine,tetracycline),only1trialused
antimicrobialsusceptibilitytesting
treatmentdurationvariedfromsingledose(1trial),to37days(4trials),to3weeks(1
trial),to6weeks(1trial),orwascontinueduntildelivery(5trials)orupto6weeks
followingdelivery(2trials)
associationbetweenantibioticuseandpyelonephritis
overall
rateofpyelonephirits0%16.5%withtreatmentvs.2.5%36.4%incontrols
anyantibioticuseassociatedwithreducedpyelonephiritisinanalysisof11trials
with1,932women,resultslimitedbysignificantheterogeneity
riskratio(RR)0.23(95%CI0.130.41)
NNT68withpyelonephritisin21%ofcontrolgroup
bydurationoftherapy
singledoseantibioticsassociatedwithreducedpyelonephritis(RR0.44,95%CI
0.210.92)in1trialwith173patients
shortcourseantibiotics(37days)associatedwithnonsignificantreductionin
pyelonephiritis(RR0.31,95%CI0.091.16)inanalysisof3trialswith483
patients,resultslimitedbysignificantheterogeneity
intermediatecourseantibiotics(36weeks)associatedwithdecreasedriskof
pyelonephritis(RR0.17,95%CI0.080.37)inanalysisof2trialswith433patients
continuoustreatmentassociatedwithdecreasedriskofpyelonephritis(RR0.16,
95%CI0.040.57)inanalysisof4trialswith843patients,resultslimitedby
significantheterogeneity
associationbetweenantibioticuseandlowbirthweightinfant(<2,500g)
antibioticsassociatedwithoverallreducedriskoflowbirthweightinfantinanalysisof6
trialswith1,437infants
RR0.64(95%CI0.450.93)
NNT13102withlowbirthweightinfantin14%ofcontrolgroup
bydurationoftherapy
singledoseantibioticshadnosignificanteffectin1trialwith413patients
shortcourseantibiotics(37days)notreportedinanytrials
intermediatecourseantibiotics(36weeks)hadnosignificanteffectin1trialwith
278patients
continuoustreatmentassociatedwithreducedrisk(RR0.54,95%CI0.330.87)in
analysisof4trialswith746patients

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associationbetweenantibioticuseandpretermbirth(<37weeks)
antibioticsassociatedwithreducedriskoverallinanalysisof2trialswith242women
RR0.27(95%CI0.110.62)
NNT512withpretermbirthin22%ofcontrolgroup
bydurationoftherapy
singledoseantibioticsnotreportedinanytrials
shortcourseantibiotics(37days)reducedrisk(5.4%vs.37.5%withcontrol,p=
0.0075)in1trialwith69patients
intermediatecourseantibiotics(36weeks)notreportedinanytrials
continuoustreatmentreducedrisk(6%vs.30%withcontrol,p=0.039)in1trial
with271patients
nosignificantdifferencebetweengroupsinseriousadverseneonataloutcomein1trialwith273
infants(outcomenotassessedinothertrials)
ReferenceCochraneDatabaseSystRev2015Aug7(8):CD000490
DynaMedcommentaryalltrialsinCochraneaboveperformedbetween1960and1987,with12
ofthe14trialperformedinthe1960s,whenmethodsusedforgestationaldatingandaccessto
caredifferedthiscombinedwithhigheventratesinthecontrolgroups,prolongedcoursesof
antibioticsusedandlackofreportingofadverseeventslimitedtheaccuracyofthesefindings
andtheirgeneralizabilitytothemodernday

untreatedasymptomaticbacteriuriamayslightlyincreaseriskofpyelonephritis,butmaynot
affectriskofpretermbirth(level2[midlevel]evidence)
basedoncohortstudywithembeddedrandomizedtrial
4,283womenwithsingletonpregnancyin8hospitalsand5ultrasoundcentersinthe
Netherlandsscreenedforasymptomaticbacteriuriawithsingledipslidebetween16and22
weeksgestationwerefollowedto6weekspostpartum
248women(5.8%)hadasymptomaticbacteriuria
85womenwithasymptomaticbacteriuriarandomizedtonitrofurantoin100mgtwicedaily
for5daysvs.placebo
163womenwithasymptomaticbacteriuriawhochosenottoparticipateintrialwere
followedwithouttreatment(94%refusedparticipationbecausetheydidnotwantto
receiveantibioticsduringpregnancyforasymptomaticcondition)
pyelonephritisoccurredin29women(0.7%)overall
0women(0%)innitrofurantoingroup(notsignificantvs.untreatedorplacebotreated
bacteriuriapositivewomen)
1woman(2.5%)inplacebogroup(notsignificantvs.nitrofurantointreatedwomen)
5women(2.4%)inuntreatedorplacebotreatedbacteriurapositivegroup(p<0.05vs.
bacteriurianegativewomen)
24women(0.6%)whowerebacteriurianegative
pretermbirth(<37weeks)occurredin220women(5.1%)overall
2women(5%)innitrofurantoingroup(notsignificantvs.untreatedorplacebotreated
bacteriuriapositivewomen)
11women(5.3%)inuntreatedorplacebotreatedbacteriurapositivegroup(notsignificant
vs.bacteriurianegativewomen)
207women(5.1%)whowerebacteriurianegative
similarresultsinanalysisofpretermbirthat<34weeks
urinarytractinfectiontreatedwithantibioticsduringpregnancyoccurredin363women(8.5%)
overall
4women(10%)innitrofurantoingroup(notsignificantvs.untreatedorplacebotreated
bacteriuriapositivewomen)
42women(20.2%)inuntreatedorplacebotreatedbacteriurapositivegroup(p<0.05vs.
bacteriurianegativewomen)
317women(7.9%)whowerebacteriurianegative
nosignificantdifferencesinadversematernalorneonataloutcomesincludinggestational
diabetes,pregnancyinducedhypertension,preeclampsia,kidneystones,meanbirthweight,
smallforgestationalage,perinataldeath,oradmissiontoneonatalintensivecareunit
ReferenceLancetInfectDis2015Nov15(11):1324

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insufficientevidencetorecommendanyantibioticregimenoverothersforpregnantwomenwith
asymptomaticbacteriuria
basedonCochranereviewlimitedbyclinicalheterogeneity
systematicreviewof5randomizedtrialscomparingdifferentantibioticregimensin1,140
pregnantwomenwithasymptomaticbacteriuria
metaanalysisnotperformedduetoheterogeneityofinterventions
nosignificantdifferencesinpersistentorrecurrentinfectionincomparisonsof
pivmecillinam400mgvs.ampicillin500mg4timesdailyfor7daysin1trialwith65
women
cephalexin1gvs.pivmecillinam200mgpluspivampicillin250mgtwicedailyfor3days
in1trialwith47women
cycloserinevs.sulphadimidinein1trialwith160women
nosignificantdifferencesinpersistentinfectioncomparingfosfomycintrometamol3gfor1day
vs.cefuroximefor5daysin1trialwith84women
comparingnitrofurantoinfor7daysvs.1dayin1trialwith741women
persistentinfectionin13.8%vs.24.3%(p<0.0001,NNT10)
symptomaticinfectionpriortodeliveryin3.4%vs.2.8%(notsignificant)
ReferenceCochraneDatabaseSystRev2010Sep8(9):CD007855fulltext
DynaMedcommentarypivmecillinamandpivampicillinnotavailableintheUnitedStates
cycloserinehasahighsideeffectprofileandistypicallynotusedexceptastreatmentforsome
mycobacterialinfectionssulfonamidessuchassulphadimidine(whichisnolongeravailable),
arenotfirstlineagentsinearlypregnancy
forcultureprovengroupBstreptococcalinfectionininfant,drugofchoiceispenicillinG
100,000units/kgIVevery12hoursfor10days(seeGroupBstreptococcalinfectionininfants
lessthan3monthsold)

insufficientevidencetodetermineifsingledoseantibiotictreatmentassociatedwithsimilarrate
ofpyelonephritiscomparedtoshortcoursetreatmentinpregnantwomenwithasymptomatic
bacteriuria
basedonCochranereview
systematicreviewof13randomizedorquasirandomizedtrialscomparingsingledoseantibiotic
treatmentvs.47dayantibioticcoursein1,622pregnantwomenwithasymptomaticbacteriuria
antibioticsincludedamoxicillin,ampicillin,nitrofurantoin,cephalexin,fosfomycintrometamol,
fosfomycin,amoxicillinclavulanate,cotrimoxazole,trimethoprim,andothersulfonamides
10trialscomparedsingledoseto47daycourseofsameantimicrobialagent
nosignificantdifferencesin
pyelonephritis(riskratio3.09,95%CI0.5717.55)inanalysisof2trialsevaluating
cotrimoxazoleortrimethoprimin102women
rateswerehigherwithsingledose(5of54patients)comparedto47day
course(1of48patients)
analysislimitedbysmallsamplesizeandconfidenceintervalincluding
clinicallymeaningfuldifferences
curerateinanalysisof10trialswith1,286women
resultslimitedbysignificantheterogeneity
6trialssuggestedhighercurerateswith47daycourse,buteffectnot
correlatedwithtypeofantibioticgiven
recurrenceofasymptomaticbacteriuriainanalysisof6trialswith313women
pretermbirthinanalysisof3trialswith804women
singledoseantibiotictreatmentassociatedwithfewersideeffectsinanalysisof9trials
with1,244women
riskratio0.77(95%CI0.610.97)
NNT13167withsideeffectsin20%of47daycoursegroup
ReferenceCochraneDatabaseSystRev2015Nov11(11):CD000491

Otheradults

Generaladultpopulation

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antibioticsmayincreaserateofadverseeventsbutmaynotreducesymptomaticurinarytract
infectionorcomplicationsinadultswithasymptomaticbacteriuria(level2[midlevel]evidence)
basedonCochranereviewlimitedbystatisticalandclinicalheterogeneity
systematicreviewof9randomizedorquasirandomizedtrialscomparingantibioticsvs.placebo
ornotreatment(control)in1,614adultswithasymptomaticbacteriuria
reviewlimitedbyheterogeneityinantibioticsusedanddurationoftreatmentandfollowup
durationoftreatmentrangedfromsingledoseto6months,followuprangedfrom6monthsto8
years
antibioticsassociatedwith
increaseinbacteriologicalcureinanalysisof9trialswith1,154adults,resultslimitedby
significantheterogeneity
riskratio(RR)2.32(95%CI1.114.83)
NNT121withbacteriologicalcurein44%ofcontrolgroup
increaseinadverseeventsinanalysisof4trialswith921adults
RR3.77(95%CI1.410.15)
NNH11250withadverseeventsin1%ofcontrolgroup
nosignificantdifferencesin
symptomaticurinarytractinfectioninanalysisof5trialswith1,046adults,resultslimited
bysignificantheterogeneity
complicationsinanalysisof3trialswith814adults
mortalityinanalysisof6trialswith761adults
ReferenceCochraneDatabaseSystRev2015Apr8(4):CD009534

Patientswithdiabetes

screeningforandtreatmentofasymptomaticbacteriuriaNOTrecommendedforpatientswithwell
regulateddiabetesmellitus(EAUGradeA,Level1b)
treatmentofasymptomaticbacteriuriainwomenwithdiabetesmaynotpreventsymptomatic
urinarytractinfectionorcomplications(level2[midlevel]evidence)
basedonrandomizedtrialwithblindingremovedafter6weeksandallocationconcealmentnot
stated
99womenwithdiabetesandasymptomaticbacteriuriarandomizedtotrimethoprim
sulfamethoxazole(160mg/800mg)vs.placeboorallytwicedailyfor2weeks
urinecultureobtainedevery3monthsforupto3years
recurrentasymptomaticinfectionstreatedforprogressivelylongertimeperiodsin
antibioticgroup,butnottreatedincontrolgroup
symptomaticurinarytractinfectionstreatedwithantibioticsinbothgroups
84womenhadtype2diabetes,15womenhadtype1diabetes
nosignificantdifferencesinsymptomaticurinarytractinfection,pyelonephritis,orhospital
admissionforurinarytractinfection
ReferenceNEnglJMed2002Nov14347(20):1576fulltext,editorialcanbefoundinNEngl
JMed2002Nov14347(20):1617,commentarycanbefoundinJFamPract2003Feb52(2):98,
NEnglJMed2003Mar6348(10):957,ACPJClub2003MayJun138(3):69

Men

screeningforandtreatmentofasymptomaticbacteriuriaNOTrecommendedforhealthyyoungmen
(EAUGradeA,Level1b)

Elderly

screeningforandtreatmentofasymptomaticbacteriuriaNOTrecommendedforpostmenopausal
women(EAUGradeA,Level1b)(3)
routinetreatmentofasymptomaticbacteriuriainolderwomenappearstoreducebacteriuria
butmaybeassociatedwithadverseeffect(level2[midlevel]evidence)
basedonsmallrandomizedtrial

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50olderwomenwithasymptomaticbacteriuriarandomizedtoantibioticsvs.placebo
urineculturespositiveat6monthsin9of23womengivenantibioticsvs.18of27givenplacebo
(p=0.05)
morewomeninantibioticgroupreportedsymptomsofurinarytractinfection
ReferenceJAmGeriatrSoc1996Mar44(3):293
eradicatingbacteriuriaappearstohavenoshorttermeffectonseverityofchronicincontinence
innursinghomeresidents(level2[midlevel]evidence)
basedonrandomizedtrialwithallocationconcealmentnotstated
191nursinghomeresidentswithchronicurinaryincontinenceandbacteriuriawererandomized
toimmediatevs.delayed(by23weeks)treatmentwithnorfloxacin400mgorallytwicedaily
for7days
nosignificantdifferenceinoverallseverityofurinaryincontinence
ReferenceAnnInternMed1995May15122(10):749,commentarycanbefoundinAnnIntern
Med1996Feb1124(3):373

Youngchildren

treatmentofasymptomaticbacteriuriaingirlsmaynotreducefuturesymptomaticinfectionsor
affectrenalgrowthorscarring(level2[midlevel]evidence)
Cochranereviewincluded3ofthesetrials
systematicreviewof3randomizedtrialscomparingantibioticsvs.notreatmentin449
children(allgirls)aged418yearswithasymptomaticbacteriuria
treatmentdurationrangedfrom7daysto2yearscontrolgroupsgivenantibioticsif
symptomaticinfectiondeveloped
persistentbacteriuriaat6monthsin22.2%inantibioticsgroupvs.66.6%innotreatment
group(p<0.05)in1trialwith42girls
nosignificantdifferencebetweengroupsinpersistentbacteriuriaat2years(riskratio
[RR]0.32,95%CI0.033.44)inanalysisof2trialswith241girls,butresultslimitedby
significantheterogeneitylargertrialshowedsignificantreductionwithantibiotics
antibioticsdecreasedriskofpersistentbacteriaat45years(RR0.54,95%CI0.420.7)in
analysisof3trialswith444girls
nosignificantdifferencesin
cystitis(RR1.67,95%CI0.55.52)in1trialwith205girls
pyelonephritis(RR0.55,95%CI0.151.92)inanalysisof2trialswith247girls
renalgrowthinanalysisof2trialswith355girls
ReferenceCochraneDatabaseSystRev2012Feb15(2):CD006943

Antimicrobialstewardship

about30%ofpatientswithasymptomaticbacteriuriamayreceiveantibioticswithoutclear
indication
basedonretrospectivecohortstudy
1,167patientswhohadurinecultureswith105colonyformingunits(CFU)/mLofbacteria
wereevaluated
219patientshadasymptomaticbacteriuria(positiveurineculture105CFU/mLwithout
symptomsorsignssuggestingurinarytractinfection)
70(32%)patientswereinappropriatelytreatedandgivenantibiotics
factorsassociatedwithinappropriatetreatedinmultivariateanalysis
femalegender(adjustedoddsratio[OR]3.38,95%CI1.199.66)
olderage(adjustedOR1.03,95%CI11.06)
pyuria(adjustedOR4.07,95%CI1.312.71)
hematuria(adjustedOR4.48,95%CI2.099.58)
positivenitriteonurinalysis(adjustedOR2.21,95%CI1.014.85)
ReferenceBMCInfectDis2015Jul2615:289fulltext

ComplicationsandPrognosis
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Complications

complicationsforpregnantwomenmayinclude(1,2)
lowbirthweightinfant
prematuredelivery
pyelonephritis
untreatedasymptomaticbacteriuriainpregnantwomenmaybeassociatedwithincreasedrisk
forpretermdeliveryandlowbirthweight
basedonsystematicreviewwithincompletedescriptionoftrialquality
systematicreviewof19studiesevaluatingoutcomesinpregnantwomenwithtreatedor
untreatedbacteriuria
reducedlikelihoodofpretermdeliveryinpatientswithoutbacteriuriacomparedtopatientswith
untreatedbacteriuria(relativerisk[RR]0.505,95%CI0.3650.698)inanalysisof4studieswith
6,034patients
incidenceoflowbirthweightlowerinpatientsreceivingantibioticsforasymptomatic
bacteriuriacomparedtothosewithuntreatedbacteriuria(RR0.56,95%CI0.4290.731)in
analysisof8trialswith1,795patients
ReferenceObstetGynecol1989Apr73(4):576
asymptomaticbacteriuriainyoungadultwomenmaybeassociatedwithincreasedriskfor
symptomaticurinarytractinfection,butfrequentlyresolvesspontaneously
basedonprospectivecohortstudy
796womenaged1840yearswhostartedusingnewmethodofcontraceptionandhad1
urinarytractinfection(UTI)inpreviousyearwerefollowedfor6monthswithmonthlyurine
culturesanddailydiary
asymptomaticbacteriuriadefinedas100,000colonyformingunits/mLofurinarytract
pathogenonroutineculturefromasymptomaticwoman
symptomaticUTIdefinedas
symptomsofdysuria,urinaryfrequency,orurinaryurgencyplus
100urinarytractpathogens/mLor,intheabsenceofurineculture,diagnosisofUTIby
healthcareproviderortreatmentofurinarytractsymptomswithantibiotics
asymptomaticbacteriuriaassociatedwithincreasedriskforsymptomaticUTIwithin1week(p<
0.001)whichoccurredin
23(8%)of295culturesfollowingasymptomaticbacteriuria
44(1%)of5,436culturesfollowingfindingof<100,000urinarytractpathogens/mL
ReferenceNEnglJMed2000Oct5343(14):992fulltext,editorialcanbefoundinNEnglJ
Med2000Oct5343(14):1037

Prognosis

pregnantwomenandpersonshavingtraumaticurologicinterventionsatincreasedriskforadverse
outcomesandrequiretreatment(1)
asymptomaticbacteriuria(ASB)inpregnancyisassociatedwithincreasedriskofpyelonephritis,
pretermdelivery,andlowinfantbirthweight
ASBinpatientsundergoingurologicproceduresisassociatedwithahighrateofpostprocedure
bacteremiaandsepsis
ratesofbacteremiaashighas60%inpatientswithASB
sepsisreportedtooccurin6%10%ofthosewhodevelopbacteremia
ReferenceJUrol1987Aug138(2):245
asymptomaticbacteriuriaassociatedwithincreasedriskforsymptomaticurinarytractinfection(UTI)
inpatientswithdiabetesbuttreatmentnotshowntopreventdevelopmentofinfection
patientswithdiabetesandasymptomaticbacteriuriamayhaveincreasedriskfor
hospitalizationforurosepsis
basedonprospectivecohortstudy
496adultswithdiabetesfollowedformean2.9years
7.3%prevalenceofasymptomaticbacteriuria
29patients(5.8%)weresubsequentlyhospitalizedwithurosepsis

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urosepsisoccurredin5of36(13.9%)withvs.24of460(5.2%)withoutprior
asymptomaticbacteriuria(p=0.05)
ReferenceDiabetologia2005Jul48(7):1288fulltext
womenwithtype2diabetesandasymptomaticbacteriuriamayhaveincreasedriskfor
symptomaticUTI
basedonprospectivecohortstudy
378womenwithtype2diabetesfollowedfor18months
riskforsymptomaticUTIwas34%forwomenwithand19%forwomenwithout
asymptomaticbacteriuriaatbaseline(p=0.006)
nostatisticaldifferencesin258womenwithtype1diabetes
ReferenceArchInternMed2001Jun11161(11):1421
DynaMedcommentarythesestudiesdonotdemonstratethattreatmentofasymptomatic
bacteriuriaisbeneficial
asymptomaticbacteriurianotassociatedwithlongtermadverseoutcomes
asymptomaticbacteriurianotassociatedwithlongtermadverseoutcomessuchashypertension,
chronickidneydisease,genitourinarycancer,ormortality(1)
asymptomaticEscherichiacolibacteriuriainwomenNOTassociatedwithadverserenal
outcomes
basedoncohortstudy
490womenhadpolymerasechainreactionforE.coliinurinesamples,thenblood
samplesaftermean11.5years
48(10%)hadE.colibacteriuria
meancreatinineclearanceonfollowupdidnotdifferinwomenwithvs.without
bacteriuria(87vs.85mL/minute)
nestedcasecontrolstudycomparedwomenwhohadendstagerenaldisease
(hemodialysisorrenaltransplant)vs.controlsatmean13.8years,bothgroupshad14%
prevalenceofE.colibacteriuria
ReferenceArchInternMed2007Feb12167(3):253fulltext
asymptomaticbacteriurianotindependentriskfactorformortalityinelderlyfemales
basedoncohortstudy
1,491elderlyfemalepatientslivingingeriatriccenterorcontinuingcareretirement
communitiesfollowedfor9years
318women(21%)developedasymptomaticbacteriuria
asymptomaticbacteriurianotrelatedtomortalityinadjustedanalysis(relativerisk1.1,p>
0.2)
ReferenceAnnInternMed1994May15120(10):827,correctioncanbefoundinAnn
InternMed1994Dec1121(11):901,commentarycanbefoundinAnnInternMed1994
Dec1121(11):896
asymptomaticbacteriuriaNOTassociatedwithfasterdeclineinrenalfunctionor
developmentofhypertensioninwomenwithdiabetes
basedonprospectivestudyof644women(meanage51years)withdiabetes(296type1,
348type2)followedformean6years
17%prevalenceofasymptomaticbacteriuria
noassociationbetweenasymptomaticbacteriuriaanddecreaseincreatinineclearanceor
developmentofhypertension
ReferenceArchInternMed2006Nov13166(20):2222fulltext

PreventionandScreening
Screening

InfectiousDiseasesSocietyofAmerica(IDSA)screeningguidelinesforasymptomatic
bacteriuriainadults(1)
pregnantwomen
screenpregnantwomenbyurinecultureatleastonceearlyinpregnancy,andtreatif
positiveculture(IDSAGradeAI)
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screenperiodicallyforrecurrentbacteriuriaaftertreatment(IDSAGradeAIII)
norecommendationfororagainstscreeningculturenegativewomenlaterinpregnancy
beforetransurethralresectionofprostate(TURP)
screeningrecommendedbeforeTURP(IDSAGradeAI)
assessforbacteriuria,resultscandirectantimicrobialtreatmentpriortoprocedure(IDSA
GradeAIII)
screenforbacteriuria(andtreatifnecessary)beforeotherurologicproceduresinwhichmucosal
bleedingisexpected(IDSAGradeAIII)
norecommendationfororagainstscreeningortreatmentofasymptomaticbacteriuriainrenal
transplantorothersolidorgantransplantpatients(IDSAGradeCIII)
screeningandtreatmentnotrecommendedfor
premenopausal,nonpregnantwomen(IDSAGradeAI)
womenwithdiabetes(IDSAGradeAI)
elderlyinstitutionalizedpersons(IDSAGradeAI)
olderpersonslivingincommunity(IDSAGradeAII)
patientswithspinalcordinjury(IDSAGradeAII)
patientswithindwellingurethralcatheter(IDSAGradeAI)
EuropeanAssociationofUrologyrecommendationsforscreeningforasymptomaticbacteriuria
(3)
screeningforandtreatmentofasymptomaticbacteriuriaisrecommended
beforeinvasivegenitourinaryprocedurewithriskofmucosalbleeding(EAUGradeA,
Level1b)
patientssubjectedtoplacement/exchangesofnephrostomytubesandinternalstents(EAU
GradeC,Level4)
screeningforandtreatmentofasymptomaticbacteriurianotrecommendedfor
patientswithoutriskfactors(femalesandyoungmales)(EAUGradeA,Level1b)
postmenopausalwomen(EAUGradeA,Level1b)
patientswithwellregulateddiabetesmellitus(EAUGradeA,Level1b)
elderlyinstitutionalizedpatients(EAUGradeA,Level1b)
patientswithdysfunctionaland/orreconstructedlowerurinarytracts(EAUGradeB,
Level2b)
patientssubjectedtouncomplicatedplacement/exchangesofindwellingcatheters(EAU
GradeC,Level4)
patientshavingsurgicalproceduresnotenteringtheurinarytract(EAUGradeC,Level4)
benefitofscreeningandtreatingasymptomaticbacteriuriainimmunocompromisedpatientsor
patientwithseverediseaseshouldbeconsideredindividuallyoncasebycasebasis(EAUGrade
C,Level4)
treatmentofasymptomaticbacteriurianotrecommendedfor
womenwithrecurrentsymptomaticurinarytractinfection(UTI)(EAUGradeA,Level
1b)
patientswithcathetersinurinarytract(EAUGradeC,Level4)
patientswithrenaltransplants(EAUGradeC,Level4)

UnitedStatesPreventiveServicesTaskForcerecommendationsonscreeningforasymptomatic
bacteriuria
UnitedStatesPreventiveServicesTaskForce(USPSTF)stronglyrecommendsscreeningall
pregnantwomenforasymptomaticbacteriuriausingurinecultureat1216weeksgestation
(USPSTFGradeA)
ReferenceAnnInternMed2008Jul1149(1):43fulltext,supportingsystematicreviewcanbe
foundinAnnInternMed2008Jul1149(1):W20fulltext,editorialcanbefoundinAnnIntern
Med2008Jul1149(1):I37,summarycanbefoundinAmFamPhysician2010Feb1581(4):505

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