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Antibiotic treatment of ASB is indicated in two conditions:
Treatment of ASB in other conditions (nonpregnant women, diabetic women, indwelling catheter, patients with spinal cord injury, or the elderly living in the community) does not provide any known clinical benefit, does not reduce the risk of symptomatic infection nor improve morbidity or mortality.It increases health care cost, adverse drug side effects, development of resistant organisms, and reinfection rate. (1,4)
Inadequate evidence to guide management in nonurologic procedure and solid organ transplant (1,4)
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MEDICATION
- Pregnancy
- Intrapartum antibiotic prophylaxis with IV penicillin or clindamycin (penicillin allergy) is recommended for women with GBS bacteriuria occurring at any stage of pregnancy and of any colony count to prevent GBS disease in the newborn (2)[C].
- No consensus on choice of antibiotics and duration of treatment in pregnancy, however, the cure rate is higher for the 4 to 7 days of treatment than 1-day treatment. (1)[A]
- Choice of antibiotics should be guided by bacterial pathogen, local resistance rate, adverse effects, and comorbidities of patients. (5)
- Common oral antibiotics (FDA-B) that have been used
- Nitrofurantoin 100 mg BID for 5 days (low level of resistance, may cause hemolysis in glucose-6-phosphate dehydrogenase deficiency)
- Amoxicillin/clavulanate 500/125 BID for 5 to 7 days
- Cefuroxime 250 mg BID for 5 days
- Cephalexin 500 mg BID for 5 days
- Fosfomycin 3 g for 1 single dose (not effective when glomerular filtration rate is less than 30 mL/min, may be used in highly resistant bacteria such as methicillin-resistant Staphylococcus aureus [MRSA], vancomycin-resistant enterococci [VRE], and extended-spectrum beta-lactamase [ESBL]-producing organism bacteria) (6)
- Avoid trimethoprim in 1st trimester and near term. Avoid sulfa after 32 weeks' gestation.
- Contraindicated: fluoroquinolones (FDA-C), tetracyclines (FDA-D)
- Prior to invasive urologic interventions
- Initiate antibiotic the night before or immediately before the procedure. (1)[A]
- Antibiotic should be continued until the indwelling catheter is removed postprocedure (1)[B].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
No consensus on screening frequency of ASB in pregnancy, but monthly screening of urine culture after ASB treatment is recommended except GBS (1,2). á
Patient Monitoring
Development of any signs/symptoms of UTI should warrant antibiotic treatment. á
DIET
Daily cranberry juice may reduce the frequency of ASB during pregnancy, but it has not been confirmed in large study (see "Additional Reading"Ł). á
PATIENT EDUCATION
Patient should seek medical attention when UTI symptoms develop. á
COMPLICATIONS
- Late pregnancy pyelonephritis occurs in 20-35% of women with untreated bacteriuria (20- to 30-fold higher than women with negative initial screening urine cultures or in whom bacteriuria was treated). Pyelonephritis is associated with premature delivery and worse fetal outcomes (infant with group B streptococcal infections, low-birth-weight infant). Antimicrobial treatment will decrease the risk of subsequent pyelonephritis from 20-35% to 1-4% and the risk of having a low-birth-weight baby from 15% to 5%.
- If bacteriuria remains untreated in patients who undergo traumatic urologic procedures, up to 60% develop bacteremia after the procedure and 5-10% progress to severe sepsis/septic shock.
REFERENCES
11 Nicolle áLE, Bradley áS, Colgan áR, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.22 Zolotor áAJ, Carlough áMC. Update on prenatal care. Am Fam Physician. 2014;89(3):199-208.33 Nicolle áLE. Asymptomatic bacteriuria. Curr Opin Infect Dis. 2014;27(1):90-96.44 Mody áL, Juthani-Mehta áM. Urinary tract infections in older women: a clinical review. JAMA. 2014;311(8):844-854.55 Trautner áBW, Grigoryan áL. Approach to a positive urine culture in a patient without urinary symptoms. Infect Dis Clin North Am. 2014;28(1):15-31.66 Keating áGM. Fosfomycin trometamol: a review of its use as a single-dose oral treatment for patients with acute lower urinary tract infections and pregnant women with asymptomatic bacteriuria. Drugs. 2013;73(17):1951-1966.
ADDITIONAL READING
- Ragnarsd │ttir áB, Svanborg áC. Susceptibility to acute pyelonephritis or asymptomatic bacteriuria: host-pathogen interaction in urinary tract infections. Pediatr Nephrol. 2012;27(11):2017-2029.
- Wing áDA, Rumney áPJ, Preslicka áCW, et al. Daily cranberry juice for the prevention of asymptomatic bacteriuria in pregnancy: a randomized, controlled pilot study. J Urol. 2008;180(4):1367-1372.
CODES
ICD10
- N39.0 Urinary tract infection, site not specified
- B96.20 Unsp Escherichia coli as the cause of diseases classd elswhr
- B96.1 Klebsiella pneumoniae as the cause of diseases classd elswhr
ICD9
- 791.9 Other nonspecific findings on examination of urine
- 041.49 Other and unspecified Escherichia coli [E. coli]
- 041.3 Klebsiella pneumoniae
- 646.50 Asymptomatic bacteriuria in pregnancy, unspecified as to episode of care or not applicable
SNOMED
- 236704009 Asymptomatic bacteriuria
- 71057007 Infection due to Escherichia coli (disorder)
- 186435004 Friedlanders bacillus infection (disorder)
- 31563000 asymptomatic bacteriuria in pregnancy (disorder)
- 61373006 Bacteriuria (finding)
CLINICAL PEARLS
- ASB is a common and benign disorder for which treatment is not indicated in most patients.
- The presence of pyuria, leukocyte esterase, and nitrite is common in ASB and not an indication for antimicrobial treatment.
- Antibiotic treatment is indicated for ASB in pregnancy and patients who require urologic procedure in which mucosal bleeding is anticipated.
- Treatment of ASB in other conditions does not decrease the frequency of UTI or improve outcome.
- Overtreatment of ASB may result in negative consequences such as antimicrobial resistance, adverse drug reaction, and unnecessary cost.