{"id":5396,"date":"2025-06-26T16:09:25","date_gmt":"2025-06-26T04:09:25","guid":{"rendered":"https:\/\/www.awanuilabs.co.nz\/north\/auckland\/?p=5396"},"modified":"2025-06-27T09:05:51","modified_gmt":"2025-06-26T21:05:51","slug":"diagnostic-stewardship-asymptomatic-bacteriuria","status":"publish","type":"post","link":"https:\/\/www.awanuilabs.co.nz\/north\/auckland\/2025\/06\/26\/diagnostic-stewardship-asymptomatic-bacteriuria\/","title":{"rendered":"Diagnostic stewardship &#8211; asymptomatic bacteriuria"},"content":{"rendered":"\n<p>Awanui Labs Auckland has successfully implemented a pre-analytical pathway for UTI diagnostic stewardship through e-order, which requests clinical information for laboratory processing of urine specimens.&nbsp; The information we have been receiving from clinicians is immensely useful in accurate interpretation of urine microscopy and culture results, and facilitates clinically-relevant reporting.&nbsp;<\/p>\n\n\n\n<p>As recommended by local and international best practice guidelines, evidence of compatible clinical features is required for microbiological investigation of UTI.<\/p>\n\n\n\n<p class=\"has-medium-font-size\"><strong><em>So when should we investigate for asymptomatic bacteriuria (ASB)?<\/em><\/strong><\/p>\n\n\n\n<p>Asymptomatic bacteriuria (ASB) is defined as the presence of <strong>one or more species of bacteria in urine culture <\/strong>(at significant colony counts of &gt;10<sup>8<\/sup> CFU\/L)<strong> in the absence of signs or symptoms attributable to UTI, regardless of the presence or absence of pyuria<\/strong>.<sup>1<\/sup>&nbsp;<\/p>\n\n\n\n<p>A recent systematic review and meta-analysis revealed that there were <strong>only two indications<\/strong> for investigation of ASB, for which there is evidence of benefit<sup>1<\/sup>:<\/p>\n\n\n\n<ul>\n<li>Pregnant women: screening for ASB recommended early in pregnancy (ideally at 12-16 weeks gestation).&nbsp; If present, ASB should be treated with the shortest effective course of antimicrobials.&nbsp; Antimicrobials reduce the risk of pyelonephritis and adverse pregnancy outcomes.&nbsp; There is insufficient evidence of benefit for repeat screening during the pregnancy.<\/li>\n\n\n\n<li>Prior to invasive endoscopic urological surgery associated with mucosal trauma (e.g. transurethral resection of the prostate (TURP) or bladder, ureteroscopy, lithotripsy, percutaneous stone surgery).&nbsp; Targeted short-course antimicrobial therapy (1-2 doses initiated 30-60 mins prior to procedure) is administered to prevent post-operative sepsis.<\/li>\n<\/ul>\n\n\n\n<p>There is no evidence of benefit of ASB screening and treatment for any other types of surgery.<\/p>\n\n\n\n<p class=\"has-medium-font-size\"><strong><em>Should asymptomatic bacteriuria (ASB) be screened for in non-catheterised cognitively-impaired elderly patients<\/em><\/strong><strong>?<\/strong><\/p>\n\n\n\n<p>New onset or worsening confusion is one of the most common reasons for suspecting UTI in the elderly.&nbsp; There are several studies which have investigated whether ASB is associated with an altered mental state in the elderly.<\/p>\n\n\n\n<p>1. <strong>There is no evidence of association between ASB and delirium<\/strong><sup>2<\/sup><\/p>\n\n\n\n<ul>\n<li>There was only an association between <strong>symptomatic<\/strong> UTI and delirium.&nbsp; In the studies included, the diagnosis of delirium was made according to DSM\/ ICD criteria\/ validated rating scales, and a diagnosis of UTI was predicated on the presence of UTI symptoms.&nbsp;&nbsp; These include localised urinary (dysuria, urgency, increased frequency, new suprapubic\/ costovertebral angle\/ flank tenderness) or systemic (documented fever, hypothermia, chills, rigors, new hypotension\/ tachycardia) signs and symptoms.<\/li>\n\n\n\n<li>There was insufficient evidence to assign causality or direction of causality (i.e. whether UTI precedes delirium, or the other way round), or whether they simply share common risk factors.&nbsp; <\/li>\n<\/ul>\n\n\n\n<p>2. <strong>Patients with delirium\/ altered mental state without features of sepsis should not be investigated for UTI with urine culture (a positive culture would be representative of ASB)<\/strong><sup>3-5<\/sup><\/p>\n\n\n\n<ul>\n<li>In the absence of clinical features of UTI, any association seen in observational studies between ASB and delirium or non-specific symptoms of altered mental state (confusion, restlessness, agitation) is attributable to host factors, and consistent with high frequency of both conditions in the elderly [i.e. high prevalence of perineal colonisation leading to ASB plus altered mental status due to other age-related factors].&nbsp;<\/li>\n\n\n\n<li>Altered mental status by itself is an inappropriate indication for urine culture, as are changes in urine characteristics (colour, smell). &nbsp;<\/li>\n<\/ul>\n\n\n\n<p>3. <strong>There is no benefit to treating ASB associated with delirium\/ \u201cconfusion\u201d and antimicrobial treatment may even be harmful<\/strong><sup>6-11<\/sup><\/p>\n\n\n\n<ul>\n<li>ASB in non-catheterised nursing home residents is generally benign and not associated with serious clinical illness.&nbsp; Change in mental status is likely to be multifactorial and should not prompt investigation or empiric antimicrobial therapy for UTI.&nbsp;<\/li>\n\n\n\n<li>Treatment makes no difference to physical or mental functioning, and a significant proportion will continue to have ASB despite treatment and at 3 months post-treatment.&nbsp; These patients likely have persistent perineal and distal urethral colonisation leading to persistently positive urine culture results.<\/li>\n\n\n\n<li>Diagnosis of ASB in nursing home residents is associated with increased antibiotic utilisation which is a mediator of resistant gram negative bacilli isolated from urine.<\/li>\n\n\n\n<li>Delirious patients treated for ASB are more likely to develop <em>C. difficile<\/em>-associated disease, and treatment may be associated with worse functional recovery (new\/ permanent residence in long term care facility or functional decline).\u00a0 There is no evidence of survival benefit or faster symptomatic improvement of delirium symptoms with antimicrobial treatment. \u00a0<\/li>\n<\/ul>\n\n\n\n<p>4.  <strong>PINCHES-ME helps direct referrers to consider other causes of delirium, instead of assuming a positive dipstick is indicative of UTI diagnosis. <\/strong><\/p>\n\n\n\n<ul>\n<li>It can be difficult to discern localising signs of UTI in elderly patients with delirium; however, the false positive rate of dipstick\/urine cultures in the absence of UTI \/ sepsis symptoms, may mask the true cause of delirium. \u00a0A new delirium ideally needs a proper clinical assessment.\u00a0 <\/li>\n\n\n\n<li><strong>PINCHES-ME<\/strong> is a useful mnemonic that directs referrers to consider other causes of delirium as well [<strong>P<\/strong> \u2013 Pain; <strong>I<\/strong> \u2013 Infection; <strong>N<\/strong> \u2013 Nutrition; <strong>C<\/strong> \u2013 Constipation; <strong>H<\/strong> \u2013 Hydration\/Hypoxia; <strong>E<\/strong> \u2013 Endocrine\/Electrolyte; <strong>S<\/strong> \u2013 Stroke\/Seizure; <strong>M<\/strong> \u2013 Medication\/Toxins; <strong>E <\/strong>\u2013 Environmental].<\/li>\n<\/ul>\n\n\n\n<p>In summary, there is no evidence of benefit to the screening and treatment of ASB in non-catheterised, cognitively-impaired elderly patients who have no localised\/ systemic features of sepsis; however, there is some evidence of harm.&nbsp; It is recommended, instead, that these patients are carefully assessed for other causes of confusion or delirium.<\/p>\n\n\n\n<p class=\"has-medium-font-size\"><strong>References<\/strong><\/p>\n\n\n\n<p>1.&nbsp; Nicolle L, Gupta K, Bradley S, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68(10):1611-5.<br>2.&nbsp;Krinitski D, Kasina R, Kloppel S, et al. Associations of delirium with urinary tract infections and asymptomatic bacteriuria in adults aged 65 and older: A systematic review and meta-analysis. J Am Geriatr Soc. 2021;69(11):3312-23.<br>3.&nbsp;Mayne S, Bowden A, Sundvall P, et al. The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing &#8211; a systematic literature review. BMC Geriatr. 2019;19(1):32.<br>4.&nbsp;Sundvall P, Ulleryd P, Gunnarsson R. Urine culture doubtful in determining etiology of diffuse symptoms among elderly individuals: a cross-sectional study of 32 nursing homes. BMC Fam Pract. 2011;12:36.<br>5. Claeys K, Trautner B, Leekha S, et al. Optimal Urine Culture Diagnostic Stewardship Practice-Results from an Expert Modified-Delphi Procedure. Clin Infect Dis. 2022;75(3):382-9.<br>6.&nbsp;Das R, Towle V, Van Ness P, et al. Adverse outcomes in nursing home residents with increased episodes of observed bacteriuria. Infect Control Hosp Epidemiol. 2011;32(1):84-6.<br>7.&nbsp;Dasgupta M, Brymer C, Elsayed S. Treatment of asymptomatic UTI in older delirious medical in-patients: A prospective cohort study. Arch Gerontol Geriatr. 2017;72:127-34.<br>8.&nbsp;Joo P, Grant L, Ramsay T, et al. Effect of inpatient antibiotic treatment among older adults with delirium found with a positive urinalysis: a health record review. BMC Geriatr. 2022;22(1):916.<br>9.&nbsp;Potts L, Cross S, MacLennan W, et al. A double-blind comparative study of norfloxacin versus placebo in hospitalised elderly patients with asymptomatic bacteriuria. Arch Gerontol Geriatr. 1996;23(2):153-61.<br>10.&nbsp;Rotjanapan P, Dosa D, Thomas K. Potentially inappropriate treatment of urinary tract infections in two Rhode Island nursing homes. Arch Intern Med. 2011;171(5):438-43.<br>11.&nbsp;Dufour A, Shaffer M, D&#8217;Agata E, et al. Survival After Suspected Urinary Tract Infection in Individuals with Advanced Dementia. J Am Geriatr Soc. 2015;63(12):2472-7.<\/p>\n","protected":false},"excerpt":{"rendered":"Awanui Labs Auckland has successfully implemented a pre-analytical pathway for UTI diagnostic stewardship through e-order, which requests clinical information for laboratory processing of urine specimens.&nbsp; The information we have been receiving from clinicians is immensely useful in accurate interpretation of urine microscopy and culture results, and facilitates clinically-relevant reporting.&nbsp; As recommended by local and international [&hellip;]","protected":false},"author":18,"featured_media":4155,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3],"tags":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.2 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Diagnostic stewardship - asymptomatic bacteriuria - News - Awanui Labs - Auckland<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.awanuilabs.co.nz\/north\/auckland\/2025\/06\/26\/diagnostic-stewardship-asymptomatic-bacteriuria\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Diagnostic stewardship - asymptomatic bacteriuria - News - Awanui Labs - Auckland\" \/>\n<meta property=\"og:description\" content=\"Awanui Labs Auckland has successfully implemented a pre-analytical pathway for UTI diagnostic stewardship through e-order, which requests clinical information for laboratory processing of urine specimens.&nbsp; 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