Antimicrobial treatment of asymptomatic bacteriuria in noncatheterized adults: a systematic review

Impact of restrictive urinalysis reflex to culture criteria at a large community hospital

Treatment of asymptomatic bacteriuria (ASB) is a common, but often unnecessary, practice. Our objective was to determine the impact of restrictive urinalysis reflex to culture (UARC) criteria on rate of urine cultures (UC) ordered and ASB treatment. Criteria were modified from positive leukocyte esterase, positive nitrites, or white blood cells (WBC) >10 cells to only WBC >10 cells. This pre-post study evaluated UARCs ordered in the emergency department or inpatient units. The primary outcome was the proportion of reflex UCs prevented. Secondary outcomes included the frequency of repeat UARCs and stand-alone UCs, gram-negative rod (GNR) bacteremia, and ASB treatment. In the pre-intervention, there were 4761 UARCs compared to 5420 in the post-intervention; 37.9 % and 21.4 % reflexed to UCs, a 43.5 % reduction in UCs. The rate of repeat UARCs, stand-alone UCs, and GNR bacteremia in the pre- and post-interventions were similar. ASB treatment rate was numerically lower in the post-intervention.

Pivmecillinam with Amoxicillin/Clavulanic acid as step down oral therapy in febrile Urinary Tract Infections caused by ESBL-producing Enterobacterales (PACUTI)

BACKGROUND

Oral treatment alternatives for febrile urinary tract infections are limited in the era of increasing antimicrobial resistance. We aim to evaluate if the combination of pivmecillinam and amoxicillin/clavulanic acid is non-inferior to current alternatives for step-down therapy in adult patients with febrile urinary tract infection.

METHODS

We plan to perform an investigator-initiated non-inferiority trial. Adult hospitalised patients treated with 1-5 days of intravenous antibiotics for acute febrile urinary tract infection caused by extended spectrum beta-lactamase (ESBL) producing Enterobacterales will be randomised 1:1 to either control (7-10 days of either oral ciprofloxacin 500 mg twice daily or oral trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily or intravenous ertapenem 1 g once daily, depending on sex, drug allergy, glomerular filtration rate and susceptibility testing) or intervention (10 days of pivmecillinam 400 mg three times daily and amoxicillin/clavulanic acid 500/125 mg three times daily). The primary outcome will be clinical cure 10 days (+/- 2 days) after antibiotic treatment completion. Clinical cure is defined as being alive with absence of fever and return to non-infected baseline of urinary tract symptoms without additional antibiotic treatment or re-hospitalisation (for urinary tract infection) based on a centralised allocation-blinded structured telephone interview. We plan to recruit 330 patients to achieve 90% power based on a sample size simulation analysis using a two-group comparison, one-sided alpha of 2.5%, an absolute non-inferiority margin of 10% and expecting 93% clinical cure rate and 10% loss to follow-up. The primary endpoint will be analysed using generalised estimated equations and reported as risk difference for both intention-to-treat and per protocol populations. Patients are planned to be recruited from at least 10 centres in Sweden from 2023 to 2026.

DISCUSSION

If the combination of pivmecillinam and amoxicillin/clavulanic acid is found to be non-inferior to the control drugs there are potential benefits in terms of tolerability, frequency of interactions, outpatient treatment, side effects, nosocomial infections and drive for further antimicrobial resistance compared to existing drugs.

TRIAL REGISTRATION

NCT05224401. Registered on February 4, 2022.

Implementation of an asymptomatic bacteriuria assessment protocol for patients discharged from the emergency department

Objective

We evaluated the impact of an asymptomatic bacteriuria (ASB) assessment protocol on the number of antibiotics prescribed for ASB after discharge from the emergency department (ED).

Design

Single-center, before-and-after, retrospective cohort study.

Setting

The study was conducted at a large community health system in North Carolina.

Patients

Eligible patients were discharged from an ED without an antibiotic prescription and had a positive urine culture result after discharge from May through July 2021 (preimplementation group) and October through December 2021 (postimplementation group).

Methods

Patient records were reviewed to determine the number of antibiotic prescriptions for ASB on follow-up call before and after implementation of an ASB assessment protocol. Secondary outcomes included 30-day admissions, 30-day ED visits, 30-day UTI-related encounters, and projected antibiotic days of therapy.

Results

The study included 263 patients: 147 in the preimplementation group and 116 in the postimplementation group). There were significantly fewer antibiotic prescriptions for ASB in the postimplementation group (50% vs 87%; P < .0001). There were no differences in the incidence of 30-day admissions (7% vs 8%; P = .9761), 30-day ED visits (14% vs 16%; P = .7805), or 30-day UTI-related encounters (0% vs 0%, NA).

Conclusions

Implementation of an ASB assessment protocol for patients discharged from the ED significantly reduced the number of antibiotic prescriptions for ASB on follow-up call without an increase in 30-day admissions, ED visits, or UTI-related encounters.

Sustained impact of an antibiotic stewardship initiative targeting asymptomatic bacteriuria and pyuria in the emergency department

OBJECTIVE

To determine whether a multifaceted initiative resulted in maintained reduction in inappropriate treatment of asymptomatic pyuria (ASP) or bacteriuria (ASB) in the emergency department (ED).

DESIGN

Single-center, retrospective study.

METHODS

Beginning in December 2015, a series of interventions were implemented to decrease the inappropriate treatment of ASP or ASB in the ED. Patients discharged from the ED from August to October 2015 (preintervention period), from December 2016 to February 2017 (postintervention period 1), and from November 2019 to January 2020 (postintervention period 2) were included if they had pyuria and/or bacteriuria without urinary symptoms. The primary outcome was the proportion of patients prescribed antibiotics within 72 hours of discharge from the ED. The secondary outcome was the number of patients returning to the ED with symptomatic UTI within 30 days of discharge.

RESULTS

We detected a significant decrease in the proportion of patients with ASP or ASB who were inappropriately treated when comparing the preintervention group and post-intervention group 1 (100% vs 32.4%; P < .001). This reduced frequency of inappropriate treatment was noted 3 years after the intervention, with 28% of patients receiving treatment for ASP or ASB in postintervention group 2. (P was not significant fin the comparison with postintervention group 1.) Among the 3 groups analyzed, we detected no difference in the numbers of patients returning to the ED with a symptomatic UTI within 30 days of ED discharge regardless of whether patients received antibiotics.

CONCLUSIONS

A multifaceted intervention resulted in a significant decrease in inappropriate use of antibiotics for ASP and/or ASB that was maintained 3 years after implementation.

Antimicrobial utilization and stewardship in patients with uncomplicated urinary tract infections managed by pharmacists in the community: A sub-study of the RxOUTMAP trial

BACKGROUND

Urinary tract infections (UTIs) often lead to suboptimal antibacterial use. Pharmacists are accessible primary care professionals who have an important role to play in antimicrobial stewardship. Our objective was to evaluate the appropriateness of pharmacists' antibacterial prescribing for patients with uncomplicated UTI.

METHODS

We conducted a prospective registry trial with 39 community pharmacies in New Brunswick, Canada. Adult patients were enrolled if they presented to the pharmacy with either symptoms of UTI with no current antibacterial treatment (pharmacist-initial arm) or an antibacterial prescription for UTI from a physician (physician-initial arm). Pharmacists assessed patients; patients with complicating factors or red flags for systemic illness or pyelonephritis were excluded. Pharmacists prescribed antibacterial therapy or modified antibacterial therapy, provided education only, or referred to a physician, as appropriate. Antibacterial therapy prescribed was compared between study arms.

RESULTS

Seven hundred fifty patients were enrolled (87% pharmacist-initial arm). The most commonly prescribed agents in the pharmacist-initial arm were nitrofurantoin (88.4%), sulfamethoxazole-trimethoprim (TMP-SMX) (7.8%), and fosfomycin (2.1%); in the physician-initial arm, nitrofurantoin (55.3%), TMP-SMX (25.5%), and fluoroquinolones (10.6%) were prescribed. Therapy was guideline concordant for 95.1% of patients in the pharmacist-initial arm and 35.1% of patients in the physician-initial arm (p < 0.001). For guideline-discordant therapy from physicians, pharmacists prescribed to optimize therapy for 45.9% of patients.

CONCLUSION

Treatment was highly guideline concordant when pharmacist initiated, with physicians prescribing longer treatment durations and more fluoroquinolones. This represents an important opportunity for antimicrobial stewardship interventions by pharmacists in the community.

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

Prevalence, impact, and management strategies for asymptomatic bacteriuria in the acute care elderly patient: a review of the current literature

Introduction: It is unclear how to prevent the negative impact of inappropriate urine cultures in older acute care patients who have a high rate of asymptomatic bacteriuria.Areas covered: A nonsystematic literature review of the definition, impact, and management of elderly acute care patients with asymptomatic bacteriuria (ASB).Expert opinion: In the elderly, patients with ASB include those with extra-urinary tract diseases (e.g. pneumonia) and those with symptoms/signs that resolve without antibiotic therapy, but the diagnosis of ASB is unclear in febrile patients responding to antibiotics. We consider four management strategies that could decrease the negative impact of culturing the urine including unnecessary antibiotic therapy in those with ASB: (1) Prevent urine testing in patients with extra-urinary tract reasons for their acute care (2) Cancel urine cultures if the urine dipstick is negative. (3) Avoid catheterization in stable patients who cannot provide a urine specimen on demand and (4) Withhold antibiotics in stable non-febrile elderly patients who do not have new local urinary tract symptoms or decompensation on follow-up, and pursue further investigations for another etiology/diagnosis.

Screening for Asymptomatic Bacteriuria in Adults: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Among the general adult population, women (across all ages) have the highest prevalence of asymptomatic bacteriuria, although rates increase with age among both men and women. Asymptomatic bacteriuria is present in an estimated 1% to 6% of premenopausal women and an estimated 2% to 10% of pregnant women and is associated with pyelonephritis, one of the most common nonobstetric reasons for hospitalization in pregnant women. Among pregnant persons, pyelonephritis is associated with perinatal complications including septicemia, respiratory distress, low birth weight, and spontaneous preterm birth.

OBJECTIVE

To update its 2008 recommendation, the USPSTF commissioned a review of the evidence on potential benefits and harms of screening for and treatment of asymptomatic bacteriuria in adults, including pregnant persons.

POPULATION

This recommendation applies to community-dwelling adults 18 years and older and pregnant persons of any age without signs and symptoms of a urinary tract infection.

EVIDENCE ASSESSMENT

Based on a review of the evidence, the USPSTF concludes with moderate certainty that screening for and treatment of asymptomatic bacteriuria in pregnant persons has moderate net benefit in reducing perinatal complications. There is adequate evidence that pyelonephritis in pregnancy is associated with negative maternal outcomes and that treatment of screen-detected asymptomatic bacteriuria can reduce the incidence of pyelonephritis in pregnant persons. The USPSTF found adequate evidence of harms associated with treatment of asymptomatic bacteriuria (including adverse effects of antibiotic treatment and changes in the microbiome) to be at least small in magnitude. The USPSTF concludes with moderate certainty that screening for and treatment of asymptomatic bacteriuria in nonpregnant adults has no net benefit. The known harms associated with treatment include adverse effects of antibiotic use and changes to the microbiome. Based on these known harms, the USPSTF determined the overall harms to be at least small in this group.

RECOMMENDATIONS

The USPSTF recommends screening pregnant persons for asymptomatic bacteriuria using urine culture. (B recommendation) The USPSTF recommends against screening for asymptomatic bacteriuria in nonpregnant adults. (D recommendation).

International Society for Companion Animal Infectious Diseases (ISCAID) guidelines for the diagnosis and management of bacterial urinary tract infections in dogs and cats

Urinary tract disease is a common clinical presentation in dogs and cats, and a common reason for antimicrobial prescription. This document is a revision and expansion on the 2011 Antimicrobial Use Guidelines for Treatment of Urinary Tract Disease in Dogs and Cats, providing recommendations for diagnosis and management of sporadic bacterial cystitis, recurrent bacterial cystitis, pyelonephritis, bacterial prostatitis, and subclinical bacteriuria. Issues pertaining to urinary catheters, medical dissolution of uroliths and prophylaxis for urological procedures are also addressed.

Prevalence of Escherichia coli Resistant to Beta-Lactam Antibiotics among Patients with Chronic Obstructive Pulmonary Disease and Urinary Tract Infection

Urinary tract infection (UTI), which is typically caused by Escherichia coli (E. coli), is an insufficiently recognized co-morbidity among patients with chronic obstructive pulmonary disease (COPD). Adequate treatment can be complicated by resistance of the causative pathogen to beta-lactam antibiotics, which often produce beta-lactamase enzymes that destroy the antibiotic. The beta-lactamase family of enzymes is extremely diverse, including different types of enzyme and mutant forms. In this study, we analyzed 580 patients with COPD (236 females and 344 males) and thus found 218 patients with co-morbid UTIs, including 58 patients with UTI caused by E. coli (38 females and 20 males). We also investigated cases of uncomplicated symptomatic and asymptomatic UTI caused by E. coli and the presence of resistance to beta-lactam antibiotics among those patients. The E. coli strains resistant to beta-lactam antibiotics were selected for their ability to grow on selective media, before DNA microarrays were applied for specific identification of three beta-lactamase gene types (i.e., TEM, SHV and CTX-M). Overall, 83% of E. coli strains responsible for UTIs in COPD patients carried extended-spectrum beta-lactamase genes. The most prevalent were those producing CTX-M, with CTX-M-15 being predominant. The rare CTX-M-27 and TEM-15 genes were also detected in two samples. Three samples contained several extended-spectrum beta-lactamase genes simultaneously (CTX-M-15 or CTX-M-14 plus SHV-5 or TEM-15). This high prevalence of resistant E. coli strains necessitates rational antibiotic selection when treating UTI to prevent COPD exacerbations. Additionally, antibiotic therapy should be aligned with and adapted to existing and potential COPD co-morbidities.

Outcomes of Urinary Tract Infection Management by Pharmacists (RxOUTMAP): A study of pharmacist prescribing and care in patients with uncomplicated urinary tract infections in the community

Background

Pharmacists have the authorization to prescribe medications for the treatment of uncomplicated urinary tract infections (UTI) in some provinces. However, there are limited data on the outcomes of this care by pharmacists. Our objective was to evaluate the effectiveness, safety and patient satisfaction with pharmacist prescribing and care in patients with uncomplicated UTI.

Methods

We conducted a prospective registry trial in 39 community pharmacies in the Canadian province of New Brunswick. Adult patients were enrolled if they presented to the pharmacy with either symptoms of UTI with no current antibacterial treatment (Pharmacist-Initial Arm) or if they presented with a prescription for an antibacterial to treat UTI from another health care provider (Physician-Initial Arm). Pharmacists assessed patients and if they had complicating factors or red flags for systemic illness or pyelonephritis, they were excluded from the study. Pharmacists either prescribed antibacterial therapy, modified antibacterial therapy, provided education only or referred to physician, as appropriate. The primary outcome was clinical cure at 2 weeks and the secondary outcomes included adverse events and patient satisfaction.

Results

A total of 750 patients were enrolled (87.4% in the Pharmacist-Initial Arm), average age was 40.9 (SD 16.0) years. Clinical cure was achieved in 88.9% of patients. Of those that did not have sustained symptom resolution, most (5.5% overall) had symptom recurrence after completion of therapy. Adverse events were reported by 7.2% of patients and 88.9% of those continued their medication. Most adverse events were gastrointestinal-related and transient. The patient satisfaction survey reflected very high levels of satisfaction for the care they received, as well as for trust and accessibility of the pharmacist.

Conclusion

Pharmacist management of uncomplicated UTI is effective, safe, and patient satisfaction appears very high.

Use of Automated Urine Microscopy Analysis in Clinical Diagnosis of Urinary Tract Infection: Defining an Optimal Diagnostic Score in an Academic Medical Center Population

A retrospective case record study was conducted that established a scoring tool based on clinical and iQ200 parameters, able to predict or rule out the clinical diagnosis of UTI in the majority of adult patients in an academic hospital. Automated standardized quantitative urine analysis, such as iQ200 analysis, is on the rise because of its high accuracy and efficiency compared to those of traditional urine analysis. Previous research on automated urinalysis focused mainly on predicting culture results but not on the clinical diagnosis of urinary tract infection (UTI). A retrospective analysis was conducted of consecutive urine samples sent in for culture because of suspected UTI. UTI was defined by expert opinion, based on reported symptoms, conventional urine sediment analysis, and urine cultures. Parameters of iQ200 analysis and clinical symptoms and signs were compared between cases and controls. Optimal cutoff values were determined for iQ200 parameters, and multivariate logistic regression analysis was used to identify the set of variables that best predicts the clinical diagnosis of UTI for development of a scoring tool. A total of 382 patients were included. Optimal cutoff values of iQ200 analysis were 74 white blood cells (WBC)/μl, 6,250 "all small particles" (ASP)/μl, and a bacterial score of 2 on an ordinal scale of 0 to 5. The scoring tool attributed 1 point for frequent micturition or increased urge, 2 points for dysuria, 1 point for a bacterial score of ≥2, 2 points for WBC/μl of ≥50, and an additional point for WBC/μl of ≥150. This score had a sensitivity of 86% and a specificity of 92% when using a threshold of <4 points. The combination of iQ200 analysis and a simple survey could predict or rule out UTIs in a majority of patients in an academic medical center.

Management of Bacteriuria in Veterans Affairs Hospitals

Background

Bacteriuria contributes to antibiotic overuse through treatment of asymptomatic bacteriuria (ASB) and long durations of therapy for symptomatic urinary tract infections (UTIs), yet large-scale evaluations of bacteriuria management among inpatients are lacking.

Methods

Inpatients with bacteriuria were classified as asymptomatic or symptomatic based on established criteria applied to data collected by manual chart review. We examined frequency of treatment of ASB, factors associated with treatment of ASB, durations of therapy, and frequency of complications including Clostridium difficile infection, readmission, and all-cause mortality within 28 days of discharge.

Results

Among 2225 episodes of bacteriuria, 64% were classified as ASB. After excluding patients with non-UTI indications for antibiotics, 72% of patients with ASB received antibiotics. When evaluating only patients not meeting SIRS criteria, 68% of patients with ASB received antibiotics. The mean (±SD) days of antibiotic therapy for ASB, cystitis, CA-UTI and pyelonephritis were 10.0 (4.5), 11.4 (4.7), 12.0 (6.1), and 13.6 (5.3), respectively. In sum, 14% of patients with ASB were treated for greater than 14 days, and fluoroquinolones were the most commonly used empiric antibiotic for ASB [245/691 (35%)]. Complications were rare but more common among patients with ASB treated with antibiotics.

Conclusions

The majority of bacteriuria among inpatient veterans is due to ASB with high rates of treatment of ASB and prolonged durations of therapy for ASB and symptomatic UTIs.

Clinical Practice Guidelines for the Antibiotic Treatment of Community-Acquired Urinary Tract Infections

Urinary tract infections (UTIs) are infectious diseases that commonly occur in communities. Although several international guidelines for the management of UTIs have been available, clinical characteristics, etiology and antimicrobial susceptibility patterns may differ from country to country. This work represents an update of the 2011 Korean guideline for UTIs. The current guideline was developed by the update and adaptation method. This clinical practice guideline provides recommendations for the diagnosis and management of UTIs, including asymptomatic bacteriuria, acute uncomplicated cystitis, acute uncomplicated pyelonephritis, complicated pyelonephritis related to urinary tract obstruction, and acute bacterial prostatitis. This guideline targets community-acquired UTIs occurring among adult patients. Healthcare-associated UTIs, catheter-associated UTIs, and infections in immunocompromised patients were not included in this guideline.

A methodological protocol for selecting and quantifying low-value prescribing practices in routinely collected data: an Australian case study

Background

Growing imperatives for safety, quality and responsible resource allocation have prompted renewed efforts to identify and quantify harmful or wasteful (low-value) medical practices such as test ordering, procedures and prescribing. Quantifying these practices at a population level using routinely collected health data allows us to understand the scale of low-value medical practices, measure practice change following specific interventions and prioritise policy decisions. To date, almost all research examining health care through the low-value lens has focused on medical services (tests and procedures) rather than on prescribing. The protocol described herein outlines a program of research funded by Australia’s National Health and Medical Research Council to select and quantify low-value prescribing practices within Australian routinely collected health data.

Methods

We start by describing our process for identifying and cataloguing international low-value prescribing practices. We then outline our approach to translate these prescribing practices into indicators that can be applied to Australian routinely collected health data. Next, we detail methods of using Australian health data to quantify these prescribing practices (e.g. prevalence of low-value prescribing and related costs) and their downstream health consequences. We have approval from the necessary Australian state and commonwealth human research ethics and data access committees to undertake this work.

Discussion

The lack of systematic and transparent approaches to quantification of low-value practices in routinely collected data has been noted in recent reviews. Here, we present a methodology applied in the Australian context with the aim of demonstrating principles that can be applied across jurisdictions in order to harmonise international efforts to measure low-value prescribing. The outcomes of this research will be submitted to international peer-reviewed journals. Results will also be presented at national and international pharmacoepidemiology and health policy forums such that other jurisdictions have guidance to adapt this methodology.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0585-9) contains supplementary material, which is available to authorized users.

Preoperative urinary tract infection increases postoperative morbidity

BACKGROUND

Preoperative urinary tract infection (UTI) may be associated with surgical site infections secondary to hematogenous spread of bacteria. The association between preoperative UTI and postoperative complications has not been evaluated in general surgery populations.

MATERIALS AND METHODS

Patients undergoing elective general surgery procedures from 2011 to 2013 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. Patients with UTI present at the time of surgery (PATOS) were identified as cases. Patients without UTI PATOS were selected and matched 2:1 on age, American Society of Anesthesiologists class, and Current Procedural Terminology code with identified cases. Univariate and multivariate analyses compared postoperative outcomes between the two groups.

RESULTS

A total of 434,802 patients were identified for inclusion in the study, with an overall preoperative UTI rate of 0.1% (n = 363). On univariate analysis, the UTI group had a significantly higher incidence of overall complications, infectious complications, and noninfectious complications. Multivariate analysis confirmed that patients with UTI had a higher risk of postoperative complications compared with those without preoperative UTI (odds ratio [OR] 1.551, 95% confidence interval [CI] 1.071-2.247). This relationship persisted for both infectious (OR 1.515, 95% CI 1.000-2.296) and noninfectious (OR 1.683, 95% CI 1.012-2.799) complications.

CONCLUSIONS

We demonstrated an increased rate of 30-d complications in elective general surgery patients with UTI PATOS. These findings suggest that diligent efforts to diagnose and treat UTI before surgery may result in improved outcomes. Furthermore, surgeons should consider postponing elective procedures to allow for the complete resolution of preoperative UTI.

Treatment for Positive Urine Cultures in Hospitalized Adults: A Survey of Prevalence and Risk Factors in 3 Medical Centers

BACKGROUND

Antibiotic treatment for asymptomatic bacteriuria (ASB) is prevalent but often contrary to published guidelines.

OBJECTIVE

To evaluate risk factors for treatment of ASB.

DESIGN

Retrospective observational study.

SETTING

A tertiary academic hospital, county hospital, and community hospital.

PATIENTS

Hospitalized adults with bacteriuria.

METHODS

Patients without documented symptoms of urinary tract infection per Infectious Diseases Society of America (IDSA) criteria were classified as ASB. We examined ASB treatment risk factors as well as broad-spectrum antibiotic usage and quantified diagnostic concordance between IDSA and National Healthcare Safety Network criteria.

RESULTS

Among 300 patients with bacteriuria, ASB was present in 71% by IDSA criteria. By National Healthcare Safety Network criteria, 71% of patients had ASB; within-patient diagnostic concordance with IDSA was moderate (kappa, 0.52). After excluding those given antibiotics for nonurinary indications, antibiotics were given to 38% (62/164) with ASB. Factors significantly associated with ASB treatment were elevated urine white cell count (65 vs 24 white blood cells per high-powered field, P<.01), hospital identity (hospital C vs A, odds ratio, 0.34 [95% CI, 0.14-0.80], P =.01), presence of leukocyte esterase (5.48 [2.35-12.79], P<.01), presence of nitrites (2.45 [1.11-5.41], P=.03), and Escherichia coli on culture (2.4 [1.2-4.7], P=.01). Of patients treated for ASB, broad-spectrum antibiotics were used in 84%.

CONCLUSIONS

ASB treatment was prevalent across settings and contributed to broad-spectrum antibiotic use. Associating abnormal urinalysis results with the need for antibiotic treatment regardless of symptoms may drive unnecessary antibiotic use.

Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections

BACKGROUND

Women suffering from recurrent urinary tract infections (rUTIs) are routinely treated for asymptomatic bacteriuria (AB), but the consequences of this procedure on antibiotic resistance are not fully known. The aim of this study was to evaluate the impact of AB treatment on antibiotic resistance among women with rUTIs.

METHODS

The study population consisted of 2 groups of women who had previously been enrolled in a randomized clinical trial: group A was not treated, and group B was treated. All women were scheduled for follow-up visits every 6 months, or more frequently if symptoms arose. Microbiological evaluation was performed only in symptomatic women. All women were followed up for a mean of 38.8 months to analyze data from urine cultures and antibiograms.

RESULTS

The previous study population consisted of 673 women, but 123 did not attend the entire follow-up period. For the final analysis, 257 of the remaining 550 patients were assigned to group A, and 293 to group B. At the end of follow-up, the difference in recurrence rates was statistically significant (P < .001): 97 (37.7%) in group A versus 204 (69.6%) in group B. Isolated Escherichia coli from group B showed higher resistance to amoxicillin-clavulanic acid (P = .03), trimethoprim-sulfamethoxazole (P = .01), and ciprofloxacin (P = .03) than that from group A.

CONCLUSIONS

This study shows that AB treatment is associated with a higher occurrence of antibiotic-resistant bacteria, indicating that AB treatment in women with rUTIs is potentially dangerous.

Asymptomatic Bacteriuria in Noncatheterized Adults

Asymptomatic bacteriuria (ASB) is a common finding and frequently detected in premenopausal nonpregnant women, institutionalized patients, patients with diabetes mellitus, and the ambulatory elderly population. Despite clear recommendations regarding diagnosis and management of ASB in these populations from the Infectious Diseases Society of America (IDSA), there remains an alarming rate of antimicrobial overuse. This article reviews definitions of ASB, epidemiology of ASB, literature surrounding ASB in diabetic patients, risk factors of ASB, microbiologic data regarding bacterial virulence, use of ASB strains for treatment of symptomatic urinary tract infection, and approaches to addressing translational barriers to implementing IDSA recommendations regarding diagnosis and management of ASB.