Criteria & Principles
Refer to uncomplicated cystitis, pyelonephritis, CA-UTI, or asymptomatic bacteriuria pages for additional guidance. Additionally, UTI Evaluation page may be helpful guidance for challenging evaluations in patients with altered mental status, neurogenic bladder, and CA-UTI. There is additional information to answer your questions here.
Risks Associated with Treating Asymptomatic Bacteriuria (ASB)
What is ASB? Presence of bacteria in the urine irrespective of pyuria (ex: WBC >10) and without urinary symptoms.2
How common is ASB? Occurs in >15% of women and men older than 70 years old and continues to increase after age 80. It is extremely common in spinal cord injuries including up to 89% with intermittent catheter use and 100% with long-term indwelling catheter.3
Who should be treated for ASB? Pregnant women and patients undergoing endourologic procedures due to fetal benefit and concern for translocation of bacteria during surgery, respectively. There is currently no consensus on the management of ASB in high-risk febrile neutropenia and patients within 1 month of kidney transplant.2
Harm of treating ASB: Consequences of treating ASB include increased risk for antibiotic resistance, adverse effects (8-fold increase for C. difficile infection), risk for future symptomatic UTIs, and healthcare costs without benefit in patient care outcomes.4,5
NOTE: In 2023, 66% (43/65) of DUH patients who received antibiotics for a UTI indication and subsequently developed C. difficile were deemed to have been inappropriately treated for ASB
Treatment
Duration
*Initial IV therapy (e.g. ceftriaxone) is recommended for hospitalized patients with concern for pyelonephritis, concurrent bloodstream infection, and/or hemodynamic instability. Prior urine cultures in the past 6-12 months may be helpful to guide empiric antimicrobial selection.
| Complicated Urinary Tract Infection Guidance | ||||
| Agent | Dosing# | Duration of Therapy | Comments | |
| 1st line | Nitrofurantoin | 100mg PO BID | 7 days | Avoid if pyelonephritis or CrCl < 40 mL/min |
| 2nd line |
Beta-lactam (e.g. cefuroxime) |
See individual customID pages | 10-14 days^ | ^Shorter durations (e.g. 7 days total) may be considered in patients with rapid clinical response & initial IV therapy |
| 3rd line |
TMP/SMX |
1 DS PO BID |
7 days* |
Caution, resistance rates at DUHS to E. coli are > 20% for TMP-SMX and > 10% for quinolones. *Use duration of 10-14 days if delayed response. |
| Ciprofloxacin | 500mg PO BID | 7 days* | ||
| Fosfomycin (restricted) | 3g PO q48-72h x 3 doses | 3 doses |
Has activity against VRE, MRSA, ESBL-producing gram-negative rods. Reserve for patients with resistant organisms. Avoid in pyelonephritis. |
|
#Dose adjustments may be required for renal dysfunction
**The choice between these agents should be individualized and based on patient allergy, renal function, and compliance or previous use history.
NOTE: Fosfomycin is restricted to ID telephone approval
Severity
All Severity
References
1. Gupta K. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infec Dis 2011;52:e103-e120.
2. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 May 2;68(10):e83-e110
3. Luu T, Albarillo FS. Asymptomatic Bacteriuria: Prevalence, Diagnosis, Management, and Current Antimicrobial Stewardship Implementations. Am J Med. 2022 Aug;135(8):e236-e244.
4. Cai T, Mazzoli S, Mondaini N, et al. The Role of Asymptomatic Bacteriuria in Young Women with Recurrent Urinary Tract Infections: To Treat or Not to Treat?” Clin Infect Dis. 2015 Sept 15;55(6):e771-777
5. Rotjanapan P, Dosa D, Thomas KS. Potentially inappropriate treatment of urinary tract infections in two Rhode Island nursing homes. Arch Intern Med. 2011;171(5):438-443.
6. Drekonja DM, Trautner B, Carla Amundson, MA, et al. Effect of 7 vs 14 Days of Antibiotic Therapy on Resolution of Symptoms Among Afebrile Men With Urinary Tract Infection: A Randomized Controlled Trial. JAMA 2021;326(4):324-331.
7. Yahav D, et al. Seven Versus 14 Days of Antibiotic Therapy for Uncomplicated Gram-negative Bacteremia: A Noninferiority Randomized Controlled Trial. Clin Infect Dis 2019;69(7):1091-1098.