Management of Asymptomatic Bacteriuria (ASB)

In infants and children, we recommend against screening for or treating asymptomatic bacteriuria.

In healthy premenopausal, nonpregnant women or healthy postmenopausal women, we recommend against screening for or treating ASB.

In pregnant women, we recommend screening for and treating ASB. Remarks: A recent study in the Netherlands suggested that nontreatment of ASB may be an acceptable option for selected low-risk women. However, the committee felt that further evaluation in other populations was necessary to confirm the generalizability of this observation. We suggest a urine culture collected at 1 of the initial visits early in pregnancy. There is insufficient evidence to inform a recommendation for or against repeat screening during the pregnancy for a woman with an initial negative screening culture or following treatment of an initial episode of ASB.

In pregnant women with ASB, we suggest 4–7 days of antimicrobial treatment rather than a shorter duration. Remarks: The optimal duration of therapy will vary depending on the antimicrobial given; the shortest effective course should be used.

In older, community-dwelling persons who are functionally impaired, we recommend against screening for or treating ASB.

In older persons resident in long-term care facilities, we recommend against screening for or treating ASB.

In older patients with functional and/or cognitive impairment with bacteriuria and delirium (acute mental status change, confusion) and without local genitourinary symptoms or other systemic signs of infection (e.g. fever or hemodynamic instability), we recommend assessment for other causes and careful observation rather than antimicrobial treatment.

In older patients with functional and/or cognitive impairment with bacteriuria and without local genitourinary symptoms or other systemic signs of infection (fever, hemodynamic instability) who experience a fall, we recommend assessment for other causes and careful observation rather than antimicrobial treatment of bacteriuria. Values and preferences: This recommendation places a high value on avoiding adverse outcomes of antimicrobial therapy such as Clostridioides difficile infection, increased antimicrobial resistance, or adverse drug effects, in the absence of evidence that such treatment is beneficial for this vulnerable population. Remarks: For the bacteriuric patient with fever and other systemic signs potentially consistent with a severe infection (sepsis) and without a localizing source, broad-spectrum antimicrobial therapy directed against urinary and nonurinary sources should be initiated.

In patients with diabetes, we recommend against screening for or treating ASB. Remarks: The recommendation for nontreatment of men is inferred from observations in studies that have primarily enrolled women.

In renal transplant recipients who have had renal transplant surgery >1 month prior, we recommend against screening for or treating ASB. Remarks: There is insufficient evidence to inform a recommendation for or against screening or treatment of ASB within the first month following renal transplantation.

In patients with nonrenal solid organ transplant (SOT), we recommend against screening for or treating ASB. Values and preferences: This recommendation places a high value on avoidance of antimicrobial use so as to limit the acquisition of antimicrobial-resistant organisms or Clostridioides difficile infection in SOT patients, who are at increased risk for these adverse outcomes. Remarks: In nonrenal SOT recipients, symptomatic urinary tract infection is uncommon and adverse consequences of symptomatic urinary tract infection are extremely rare; the risk of complications from ASB is, therefore, probably negligible.

In patients with high-risk neutropenia (absolute neutrophil count <100 cells/mm³, ≥7 days’ duration following chemotherapy), we make no recommendation for or against screening for or treatment of ASB (knowledge gap). Remarks: For patients with high-risk neutropenia managed with current standards of care, including prophylactic antimicrobial therapy and prompt initiation of antimicrobial therapy when febrile illness occurs, it is unclear how frequently ASB occurs and how often it progresses to symptomatic UTI. Patients with low-risk neutropenia (>100 cells/mm³, ≤7 days, clinically stable) have only a very small risk of infection and there is no evidence to suggest that, in this population, ASB has greater risk than for nonneutropenic populations.

In patients with spinal cord injury (SCI), we recommend against screening for or treating ASB. Remarks: Clinical signs and symptoms of urinary tract infection experienced by patients with SCI may differ from the classic genitourinary symptoms experienced by patients with normal sensation. The atypical presentation of urinary tract infection in these patients should be considered in making decisions with respect to treatment or nontreatment of bacteriuria.

In patients with a short-term indwelling urethral catheter (<30 days), we recommend against screening for or treating ASB. Remarks: Considerations are likely to be similar for patients with indwelling suprapubic catheters, and it is reasonable to manage these patients similar to patients with indwelling urethral catheters, for both short-term and long-term suprapubic catheterization.

In patients with indwelling catheters, we make no recommendation for or against screening for and treating ASB at the time of catheter removal (knowledge gap). Remarks: Antimicrobial prophylaxis given at the time of catheter removal may confer a benefit for prevention of symptomatic UTI for some patients. The evidence to support this observation is largely from studies enrolling surgical patients who receive prophylactic antimicrobials at the time of short-term catheter removal, generally without screening to determine if ASB is present. It is unclear whether or not the benefit is greater in patients with ASB.

In patients with long-term indwelling catheters, we recommend against screening for or treating ASB.

In patients undergoing elective nonurologic surgery, we recommend against screening for or treating ASB.

In patients who will undergo endoscopic urologic procedures associated with mucosal trauma, we recommend screening for and treating ASB prior to surgery. Values and preferences: This recommendation places a high value on the avoidance of the serious postoperative complication of sepsis, which is a substantial risk for patients undergoing invasive endourologic procedures in the presence of bacteriuria. Remarks: In individuals with bacteriuria, these are procedures in a heavily contaminated surgical field. High-quality evidence from other surgical procedures shows that perioperative antimicrobial treatment or prophylaxis for contaminated or clean-contaminated procedures confers important benefits.

In patients who will undergo endoscopic urologic procedures, we suggest that a urine culture be obtained prior to the procedure and targeted antimicrobial therapy prescribed rather than empiric therapy.

In patients with ASB who will undergo a urologic procedure, we suggest a short course (1 or 2 doses) rather than more prolonged antimicrobial therapy. Remarks: Antimicrobial therapy should be initiated 30–60 minutes before the procedure.

In patients planning to undergo surgery for an artificial urine sphincter or penile prosthesis implantation, we suggest not screening for or treating ASB. Remarks: All patients should receive standard perioperative antimicrobial prophylaxis prior to device implantation.

In patients living with implanted urologic devices, we suggest not screening for or treating ASB.