Urinary Tract Infections (Infectiology, Vol. 1)

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No additional studies published since were identified which addressed the question of treatment of ASB in older functionally impaired residents in the community. Thus, the recommendation for nontreatment remains the same. Prospective cohort studies in long-term care residents published since have evaluated adherence to minimum clinical criteria [80] for initiation of antimicrobial therapy for UTI in bacteriuric patients.

Treatment of presumed UTI, despite absence of these minimum signs and symptoms, is common [81, 82]. Antimicrobial therapy, regardless of route of administration, conferred no survival benefit, even when adjusted for functional status, highest recorded temperature, or mental status change adjusted hazard ratio for death, 1. No additional benefit, and some adverse outcomes, has been reported because of treatment [84—86]. In another study, an increased frequency of bacteriuric episodes was significantly associated with an increased frequency of receiving an antimicrobial and of subsequent isolation of multidrug-resistant gram-negative bacilli in urine, but not changes in mental status or admission to hospital for UTI [87].

Several investigators have evaluated potential biomarkers to assist in differentiating ASB from symptomatic UTI in older residents of nursing homes, given the clinical uncertainty in identifying symptomatic infection in residents with bacteriuria [89—93]. Studies of inflammatory responses in bacteriuric long-term care residents degree of pyuria, interleukin-6 [IL-6], and heparin-binding protein have not reliably correlated with typical localizing or nonspecific symptoms associated with presumed UTI fatigue, anorexia, confusion, falls, aggression, restlessness or with ASB [89, 90].

Neutrophil-driven inflammatory responses including pyuria or urine IL-6 do not reliably discriminate between ASB and symptomatic UTI and are not, at present, helpful to distinguish between them [90—93]. We make strong recommendations because there is low- or moderate-quality evidence that there is no benefit and high-quality evidence of harm. There are high-quality data to suggest that adverse effects are particularly common following the use of antimicrobials in this population, including CDI and isolation of organisms with increased antimicrobial resistance.

Evaluation of potential biomarkers to differentiate symptomatic UTI and ASB in older functionally impaired persons should be pursued. Identifying objective criteria to diagnose symptomatic UTI is essential to facilitate optimal management for these older populations, including limiting inappropriate antimicrobial use. Classic symptoms of UTI include focal genitourinary symptoms such as urinary frequency, urgency, dysuria, and costovertebral angle tenderness [80]. Patients without focal genitourinary symptoms are generally considered asymptomatic [81, 82].

However, bacteriuric patients without these symptoms but with systemic signs such as change in mental status, delirium, or falls, may present a diagnostic challenge. In practice, these patients are often treated with antibiotics for UTI [85]. This is particularly true in patients with dementia or other conditions that limit the ability to communicate.

Observational evidence suggests that patients with delirium are more likely to have bacteriuria than patients without delirium [94, 95]. However, confounding factors such as age, comorbidities, and reduced mobility were not fully adjusted for in these observational studies, and there is a high probability of residual confounding. Therefore, a causal relationship between bacteriuria and delirium has not been established. In a larger prospective cohort study of nursing home residents [94], change in mental status was associated with bacteriuria plus pyuria in patients treated for UTI odds ratio [OR], 1.

IL-6 concentrations also did not differ between bacteriuric residents with and without nonspecific symptoms [89]. Thus, observational data suggest that the relationship between delirium and bacteriuria is likely attributable to underlying host factors, and consistent with a high frequency of both of these events in these older populations rather than a true inflammatory or infection-related association. Outcomes of antimicrobial treatment or no treatment in patients with ASB and mental status change or delirium have been reported for only a few studies.

Older residents of a long-term care ward with ASB, without fever or UTI symptoms, were randomized to treatment with norfloxacin mg twice daily or placebo for 7 days 29 patients in each group and evaluated on a behavioral rating scale before treatment, at end of treatment, and 1 and 3 months posttreatment [98]. The mean scores were higher worse in the treatment group, but not statistically different at any time, and worsened in both groups Although details of the individual behavioral features are not provided, antimicrobial treatment did not improve mean behavioral scores in these patients with ASB.

Other outcomes such as CDI and antimicrobial resistance were not reported. The impact of treatment vs no treatment of ASB on death, permanent institutionalization, or functional decline was assessed in patients with and without delirium. In 68 delirious patients in whom ASB was treated, there was no significant functional recovery when compared to 22 patients without treatment unadjusted RR, 1. Delirium tends to have a fluctuating course. Careful observation of patients with delirium and evaluation for other contributing factors, such as dehydration, is a strategy for reducing unnecessary antimicrobial use for bacteriuria [95].

It is unknown whether antimicrobial therapy for ASB in patients with delirium is beneficial when fever or other systemic signs of infection are present and no other localizing source of infection is apparent []. For older patients with severe clinical presentations consistent with sepsis syndrome and for whom an alternate infection site is not apparent, institution of empiric antimicrobial therapy effective for potential UTI, as well as other sites of infection, may be appropriate pending culture results.

Falls are common among older populations who also have a high prevalence of ASB, and often lead to a diagnosis of UTI and initiation of antimicrobial therapy, in the absence of consistent genitourinary symptoms or systemic signs of infection such as fever or change in hemodynamic status. Whether these patients had symptoms of urgency or frequency that contributed to a fall on the way to the toilet is not documented.

These studies suggest that most older residents who fall do not have ASB and falls should not immediately trigger suspicion for UTI; other causes are much more likely. Bacteriuria is usually unrelated and simply a confounding factor. Neither of these studies directly addresses whether antimicrobial therapy of bacteriuria in residents who have had a fall and do not have genitourinary symptoms or systemic signs of infection modifies adverse outcomes such as sepsis or death, so the evidence base is rated as low quality.

However, taken together with evidence that the treatment of ASB in patients without minimal criteria for UTI is not associated with any demonstrable benefits and antimicrobials have an important risk of harm, the panel believed that the adverse consequences of antimicrobial therapy almost certainly outweigh any desirable consequences of therapy in patients who have fallen and have ASB. In patients who fall and have fever or hemodynamic instability, careful evaluation to identify a site of infection is warranted. We make a strong recommendation because there is high certainty for harm and low certainty of any benefit from treatment of ASB in older adults.

Current evidence does not suggest a causal relationship between bacteriuria and presentations without classic localizing UTI symptoms, such as changes in mental status or falls. Treatment of ASB in patients with delirium has not been shown to have any beneficial impact in clinical outcomes compared to no treatment, including reducing severity or duration of delirium and reducing risk of sepsis, death, or hospitalizations all low or very low certainty.

There is high certainty that antimicrobials cause harm. Treatment probably increases the risk of antibiotic-associated diarrhea, including CDI, and increases the risk of antimicrobial resistance for the individual patient, the institution, and the community [87, 88, ]. This recommendation places a high value on avoiding adverse outcomes of antimicrobial therapy in the functionally impaired older individual in the absence of evidence that such treatment is beneficial.

Since bacteriuria is often detected and treated in patients with delirium or falls, further studies—ideally randomized—to evaluate the risks and benefits of antimicrobial treatment and determine if there is any improvement in mental status, frequency of repeat falls, or benefits in nonlocalizing clinical signs and symptoms, should be undertaken. The updated literature review looked for RCTs that compared antimicrobial therapy to no antimicrobial therapy in patients with ASB and diabetes. We did not identify any new studies to inform this recommendation. The previous recommendation against treating women with diabetes who had ASB was based on 1 RCT [22] and 2 prospective cohort studies [, ].

The randomized trial compared antimicrobial therapy or no therapy for women with diabetes and ASB, and the prospective cohort studies compared outcomes among patients initially with and without ASB. Rates of pyelonephritis were also not significantly different between the antimicrobial and placebo groups 0. Antimicrobial use for symptomatic UTI, prophylaxis, or other infections was significantly more common in the treatment group.

These subjects received nearly 5 times more days of antimicrobial therapy than the control group. In the prospective cohort studies [—], there were no between-group differences in the outcomes of symptomatic UTI, progression to diabetic complications, and mortality. Among the prespecified subgroups of interest gender, type 1 vs type 2 diabetes, and poorly controlled vs well-controlled diabetes there was no evidence to inform specific recommendations.

Antimicrobials may not reduce the risk of symptomatic urinary infection, including pyelonephritis in people with diabetes and ASB. Men with diabetes were included in only 1 cohort study and outcomes were similar. There is high-quality evidence that antimicrobials increase the risk of adverse effects. Based on the lack of demonstrated benefit and the possible harms that occur with additional antimicrobial use, we recommend against screening for or treating ASB in persons with diabetes.

There is a subgroup of diabetic women who experience a high frequency of recurrent symptomatic UTI [22]. Further studies to characterize these high-risk women and describe predictors and outcomes of ASB and efficacy of antimicrobial treatment would be warranted. Randomized trials of treatment or nontreatment of ASB in diabetic men are needed. ASB is common following renal transplantation, and symptomatic UTI is the most frequent infection identified in these patients [, ].

Unique outcomes of concern potentially attributable to UTI include graft loss, acute graft rejection, and impaired long-term graft function. The impact of UTI may be more severe in the immediate posttransplant period ie, within the first month , when patients are at highest risk for infectious complications because of exposures to new and more intensive immunosuppressive therapy, indwelling urologic devices, and urologic interventions.

Prophylactic antimicrobial therapy, usually TMP-SMX, is routinely used for the prevention of Pneumocystis jirovecii pneumonia during the initial 6 months following renal transplant. Renal transplant patients with ASB have an increased frequency of symptomatic UTI, including pyelonephritis [16, —]. These include female sex, comorbidities, urologic variables, and some immunosuppressive therapies. Retrospective studies, most of which do not differentiate ASB and symptomatic UTI, have reported associations of early, but not late, graft pyelonephritis with graft loss [—], pyelonephritis with decreased long-term creatinine clearance [, ], and late UTI with graft loss [].

Other studies report no adverse outcomes attributable to UTI for either early [] or long-term [, —] graft survival or renal function. More than one-half of positive cultures were identified in the first month after transplantation, when screening was most frequent. All episodes of bacteriuria were treated with antimicrobials.

ASB was not associated with poorer graft function. Two retrospective comparative cohort studies report no association of untreated ASB with poorer outcomes in renal transplant recipients [, ]. El-Amari et al [] identified episodes of asymptomatic E. Only 1 untreated patient progressed to symptomatic infection with the same organism. There were no episodes of acute graft rejection observed in either group. Green et al [] evaluated a single episode of ASB identified in patients from 1 to 12 months after transplantation; Other outcomes, including changes in serum creatinine, graft loss, pyelonephritis, or urosepsis were similar for treated and untreated patients.

These retrospective studies are subject to confounding, however, as physicians would, presumably, be more likely to treat patients with a positive urine culture if they were judged to have a poorer clinical status. Two prospective, randomized, open-label comparative trials evaluated treatment or nontreatment of ASB following renal transplant. Moradi et al [] enrolled 88 patients at least 1 year after transplant, who were then followed for 9—12 months. Patients with Proteus mirabilis infection were excluded.

Outcomes of bacteriuric episodes, symptomatic UTI, and renal function were similar between treated and nontreated subjects. The report does not describe criteria used for identification of symptomatic episodes. Urine was screened for bacteriuria every 2 weeks for the first 3 months after transplantation, monthly to the first year, and every 1—3 months thereafter.

Regimens for treatment of recurrent episodes varied for reinfection or relapse. Outcomes were analyzed as intention to treat and per protocol. The primary outcome of acute pyelonephritis occurred with equal frequency in both groups in all analyses. There were also no differences in any of the secondary outcomes of long-term 12—24 months graft function, all-cause mortality, cumulative incidence of lower UTI, acute graft rejection, CDI, colonization or infection due to multidrug-resistant bacteria, and graft loss by the end of the follow-up period.

Only 16 3. Of the 9 episodes of pyelonephritis in subjects in the intention-to-treat analysis, 3 were not preceded by ASB with the same organism, 3 were preceded by bacteriuria with a time interval too short to allow treatment, and 2 were preceded by bacteriuria recognized over 40 days before pyelonephritis, so a causal link could not be presumed. Thus, no benefits of treatment of ASB were identified. This study is also evidence of the limited feasibility of consistently identifying and treating all episodes of bacteriuria as a strategy to maintain a sterile urine in renal transplant recipients.

Consistent identification of episodes of ASB in renal transplant patients requires frequent screening as ASB commonly recurs. Antimicrobial-resistant organisms are common in renal transplant recipients, and a high proportion of resistant organisms causing ASB may not be effectively treated with oral therapy. Treatment of ASB probably promotes reinfection with organisms increasingly resistant to antimicrobials, potentially compromising treatment of symptomatic UTI, which is also frequent in these patients. There is also high-quality evidence that antimicrobial therapy has an important risk of adverse effects.

There may be subgroups of transplant recipients at higher risk for developing pyelonephritis indwelling devices, combined transplant. Further evaluation of these patients and whether proactive management of ASB can prevent pyelonephritis is worthy of additional study. In addition, the efficacy and practicality of screening for and treatment of ASB within 1 month of transplantation needs to be evaluated given the higher risk for infection and complications from infection in the early posttransplant period.

No studies were identified which addressed the question of treatment or nontreatment of ASB in SOT patients other than renal transplant recipients. As with renal transplants, most nonrenal transplant recipients receive prophylactic antimicrobial therapy to prevent infections for the initial 6 months following transplantation. A prospective registry study reported that the incidence of symptomatic UTI per patient-days for patients with at least 1 year of follow-up was 0.

ASB was not reported. After 6 months, rates of genitourinary infection per days, excluding uncomplicated cystitis and ASB, were kidney 0. Any serious adverse consequences of ASB in nonrenal transplant recipients would be even more uncommon than symptomatic UTIs and are, therefore, almost certainly negligible.

Signs & Symptoms of Urinary Tract Infections - Dr Sudeep Singh Sachdeva

Even with the most optimistic assumptions about antimicrobial efficacy, screening and treatment of ASB in nonrenal SOT recipients would impart only negligible benefits high-quality evidence. Thus, it is reasonable to make a recommendation for SOT patients other than kidney transplant, which is no stronger than that for kidney transplant patients. However, 1 study [] reported that 2 neutropenic patients with P.

This suggests ASB may be a source for bacteremia in some neutropenic patients. Current management for patients with high-risk neutropenia typically includes prophylactic antimicrobial therapy, which also usually resolves bacteriuria, when present []. These patients are also monitored closely, and broad-spectrum antimicrobial therapy is initiated promptly when a febrile episode occurs. With current management strategies for high-risk neutropenic patients, the urinary tract is an infrequent source for bacteremia.

While no studies specifically address this question, screening for bacteriuria with specific antimicrobial treatment, if present, seems unlikely to provide important additional benefits when current standard of care for these patients is followed. These studies should include patients with neutropenia attributable to causes other than chemotherapy, and patients with indwelling bladder catheters.

Treatment of ASB in studies enrolling primarily males with SCI and without indwelling catheters is usually followed by early recurrence of bacteriuria after antimicrobial therapy, and reinfecting strains are more likely to be resistant to antimicrobials []. Studies which evaluated antimicrobial treatment or prophylaxis, compared with placebo or no treatment, enrolled patients managed with intermittent catheterization and observed no differences in rates of symptomatic UTI between treatment groups [, ]. The evidence is limited by the small numbers of patients enrolled, and relatively short durations of follow-up.

Guidelines of the European Association of Urology for urological infections also conclude that screening for and treatment of ASB in patients with SCI are not recommended []. The inoculation of a nonpathogenic E. The inoculation of this E.

Trimethoprim Alone in the Treatment and Prophylaxis of Urinary Tract Infection

Two RCTs in a small number of patients with neurogenic bladders 20 and 27 patients, respectively reported that this approach protected against symptomatic UTI [, ]. However, the small numbers of subjects, methodological limitations, and limited current feasibility of establishing and maintaining bacteriuria means the role of bacterial interference to prevent symptomatic UTI in the SCI population remains undefined. These studies do, however, support the concept of a protective effect of ASB and the conclusion that nontreatment of spontaneously developed long-term E.

Patients with neurogenic bladder, such as those with SCI, are often bacteriuric and have genitourinary symptoms that might be compatible with symptomatic UTI, posing a diagnostic problem for clinicians. In contrast to patients with normal sensation, many patients with SCI and symptomatic UTI do not present with classic symptoms of UTI, such as dysuria, and may have symptoms not considered consistent with a presentation for UTI in other populations.

This difficulty in ascertainment of the symptoms in a bacteriuric SCI patient is the likely reason for treatment of many patients with ASB [].

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There is also high-quality evidence that antimicrobials cause harm through adverse effects and costs, as well as increasing the risk for antimicrobial-resistant infections in the individual and the community. ASB is associated with variable degrees of pyuria, so the validity of conventional urinalysis with dipstick is uncertain to interpret in SCI patients. Some studies have shown promising early results using urinary concentrations of the acute phase reactant IL-6, but more evidence is needed before this or other biomarkers can be routinely adopted in clinical settings []. Further studies in SCI patients managed with intermittent or indwelling catheterization are needed to evaluate the significance of nonspecific symptoms, including incontinence and cloudy and malodorous urine, and the outcomes with early or delayed antimicrobial therapy.

The universal formation of biofilm along the indwelling catheter means all patients ultimately develop bacteriuria if an indwelling catheter remains in situ. Once bacteriuria is established in a catheterized urinary tract, antimicrobials can temporarily suppress the bacteriuria, but recurrence with the same or different species, often with organisms of increased antimicrobial resistance, occurs universally. For patients who develop bacteriuria, symptomatic UTI is infrequent.

Tambyah et al [] reported that of Only 15 of the 7. Only 1 episode of bacteremia was considered probably attributable to bacteriuria in newly catheterized patients. A retrospective cohort study of episodes of catheter-associated bacteriuria in patients reported Only 3 episodes of bacteremia 0. Studies that have reported an association have generally not adjusted for known and important confounders. Following matching and adjustment, UTI was no longer associated with mortality. A systematic review of studies of CAUTI, mortality, and length of stay in critically ill patients reported that CAUTI was associated with significantly increased mortality and length of stay in unmatched studies, but after adjustment for other prognostic factors there was no association of mortality with UTI [].

A prospective randomized clinical trial compared antimicrobial treatment together with catheter change to no antimicrobials or catheter change in 60 ICU patients with ASB []. There were no differences in outcomes of mortality, recurrent bacteriuria, or duration of mechanical ventilation between the 2 groups. Three patients in each group developed urosepsis. A Cochrane review published in addressed the question of whether antimicrobial prophylaxis given during short-term urinary catheter usage confers clinical benefits [].

The main finding was that bacteriuria was reduced by antimicrobial prophylaxis during catheterization, but the outcome measures and study populations were heterogeneous. In 5 of 6 studies, the outcome measured was ASB, and 4 of these studies were in surgical patients. Most patients with short-term indwelling catheters do not acquire bacteriuria, and short-term catheter-associated bacteriuria does not appear to increase the risk for sepsis or death.

When bacteriuria occurs, it infrequently results in symptomatic infection or bacteremia. In the acute care hospital setting, the risk of CDI is high; thus, avoiding antimicrobials is particularly important in hospitalized patients. Patients with short-term catheters are also at high risk for nosocomial infections with antimicrobial-resistant organisms, so avoiding antimicrobials is important to the individual and the community. No additional clinical trials that screened for ASB at the time of catheter removal and, if present, randomized patients to treatment or no treatment, were published since One RCT in women, published in [], addressed this topic and was included in prior guidelines [6, 18].

Background

Thus, selected women in whom bacteriuria persists after catheter removal may be at increased short-term risk for symptomatic UTI. However, the generalizability of these observations to the current cohort of women with short-term indwelling catheters is unclear, as women in this study were enrolled only if there was a negative urine culture at catheter insertion, no antimicrobial therapy while the catheter remained in situ, and bacteriuria documented at catheter removal and persisting 48 hours after catheter removal.

Many of these women were also catheterized for gynecologic procedures, and current recommendations for limiting indwelling catheter use means these procedures would now likely be managed without an indwelling catheter. Whether antimicrobial treatment at the time of removal of a short-term urinary catheter prevents subsequent symptomatic UTI has been addressed in a meta-analysis []. The analysis included 6 studies, in addition to the study described above []; 5 of these enrolled only surgical patients. These studies initiated antimicrobial therapy shortly before catheter removal, irrespective of whether ASB was present or not.

Six of the studies were RCTs. The studies were heterogeneous in design and, in general, had a high risk of selection and attrition bias. We make a strong recommendation because there is very low certainty of any benefit and high-quality evidence of harm. There are no studies generalizable to current practice specifically addressing the question of whether screening for or treating ASB at the time of catheter removal confers benefits or results in adverse outcomes.


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While selected patient groups, such as patients with recent surgery for urinary tract reconstruction, may possibly benefit from treatment of ASB at catheter removal, the extent of benefit, association with bacteriuria, and specific patient groups who may benefit is uncertain. While the benefits of antimicrobial therapy at catheter removal are uncertain, there is high-quality evidence that antimicrobials cause harm including adverse effects and increasing costs, as well as increasing the risk of antimicrobial-resistant infections in the individual and the community.

Individuals with chronic indwelling catheters are, generally, always bacteriuric, usually with a polymicrobial flora [19]. Residents of long-term care facilities who have chronic indwelling catheters have an increased frequency of febrile UTI compared with bacteriuric residents without catheters [, ]. Kunin et al [] reported increased mortality in residents with chronic indwelling catheters, but when adjusted for other differences between catheterized and noncatheterized long-term care facility residents, the CI included no effect. In a subsequent larger prospective study among residents [], he reported a significant independent association of chronic urinary catheter use with mortality, and a stepwise increase in mortality with duration of catheterization.

However, we did not identify any evidence that antimicrobial treatment of bacteriuria in persons with long-term indwelling catheters can reduce the risk of death. A prospective cohort study of prophylaxis to prevent ASB and UTI in patients with long-term indwelling catheters reported no benefits []. Studies also consistently report that treatment of subjects with ASB and chronic catheters is followed by rapid emergence of antimicrobial resistance in urinary strains [, ].

A prospective, randomized comparative trial [23] in residents of long-term care facilities compared 17 patients who received a day course of cephalexin monohydrate, repeated whenever susceptible bacteria were isolated courses , and 18 control patients who received no antimicrobials for bacteriuria. There were no differences between the groups in the incidence or prevalence of bacteriuria, number of bacterial strains isolated, incidence of febrile days, or incidence of catheter obstruction. For subjects who received the antimicrobial, fever occurred with similar frequency when receiving or not receiving cephalexin, and reinfection with cephalexin-resistant bacteria was more frequent.

In a recent randomized study of a bundle of interventions implemented with the goal to decrease screening and treatment of ASB in catheterized subjects, the intervention arm was associated with a substantial decrease in screening and treatment for ASB in long-term care patients, and no increase in symptomatic UTI was observed [34].

American Journal of Infectious Diseases · Science Publications

Whether there is a benefit of antimicrobial therapy for ASB while a catheter remains in situ is uncertain low-quality evidence , and there is high-quality evidence of harm with increased antimicrobial resistance. A positive urine culture in an asymptomatic subject with an indwelling catheter drives inappropriate antimicrobial treatment of ASB, so screening with urine cultures in catheterized patients or obtaining urine cultures for nonspecific symptoms should be discouraged. Further studies to determine which patients are at increased risk of bacteremia attributable to an indwelling catheter may inform clinical trials addressing the treatment of catheter-associated ASB for these high-risk populations.

Further studies, enrolling both medical and surgical patients, are needed to identify which patients, if any, benefit from antimicrobial prophylaxis or treatment of established ASB at the time of catheter removal. Preoperative ASB has been identified as a risk factor for postoperative complications, including deep and superficial surgical-site infections [—], and preoperative testing for pyuria and bacteriuria has been a relatively common practice in some settings for at least 30 years []. One major clinical concern is prosthetic infection developing in orthopedic patients.

We identified 3 studies that informed the recommendation for these patients [—] Figure 2. One clinical trial randomized patients with ASB undergoing total hip arthroplasty to antimicrobial therapy or no therapy []. There were 2 cohort studies—1 exclusive to orthopedic surgery [], and the other enrolling orthopedic, cardiac, and vascular surgery patients [].

The 3 studies combined screened preoperative patients for ASB, of which Many patients in these studies received preoperative antimicrobial prophylaxis of varying dose, duration, and spectrum of activity, based on institutional and provider practices. None of these studies reported the association between postoperative outcomes and use of standard or expanded perioperative prophylaxis active against the preoperative ASB organism, independent of the targeted ASB therapy. However, there is insufficient evidence to address whether the common strategy of expanding perioperative prophylaxis to include coverage of the ASB organism has any benefit.

The baseline risk of symptomatic UTI in patients who did not receive antimicrobial treatment for ASB was approximately 36 per , compared with per for surgical site infection and 27 per for prosthetic joint infection. There was very low certainty for an effect of treatment of ASB on all outcomes.

Most of the information came from observational studies at high risk for confounding and detection bias, and the CIs included both important benefit and harm. One reported the incidence of surgical site infections including prosthetic joint infections, 2 reported only prosthetic joint infections, and 2 reported the incidence of postoperative symptomatic UTI. Patients with orthopedic implant infections postoperatively had different pathogens isolated from the surgical infection compared to the preoperative urine [, ], suggesting a source other than the urine.

It is very uncertain whether antimicrobial treatment for ASB in patients undergoing nonurologic surgery, other than standard perioperative prophylaxis, has any important benefits. The magnitude of harm, which probably varies depending on the antimicrobial used, is very uncertain; however, there is high certainty that any antimicrobial increases the risk of harm. Screening for and treating ASB increases costs, and probably contributes to CDI, adverse drug effects, and antimicrobial resistance at an individual and health system level. The issue of whether perioperative antimicrobials should be adjusted to cover the urinary pathogen in patients undergoing orthopedic implants is not well addressed in the literature.

The panel did not want to make a recommendation for or against this common practice because the magnitudes of benefits and harms are so uncertain. Well-designed prospective, randomized trials that evaluate adjusting surgical prophylaxis regimens to ensure activity against ASB are needed. In addition, clinical trials evaluating screening and treatment of ASB in patients, other than those receiving orthopedic implants, are necessary. ASB is a well-established risk factor for development of febrile UTI after urological procedures, but the risk is highly dependent on the type of procedure performed [, ].

The risk for infectious complications is considered high in all procedures with a risk of breaching the mucosal lining eg, transurethral surgery of the prostate [TURP] or the bladder, ureteroscopy including lithotripsy, percutaneous stone surgery. For diagnostic, nontraumatic procedures, randomized studies of outpatient cystoscopy have generally been the standard for other, less frequent nontraumatic endoscopic procedures [].

The second randomized trial compared the efficacy of short started the day prior to operation and continued until the catheter was removed or more prolonged continued for 5 days after the catheter was removed courses of perioperative ciprofloxacin or no antimicrobial treatment in patients undergoing TURP []. ASB was eliminated postoperatively in There were no cases of postoperative bacteremia, and only 1 patient with postoperative upper UTI in each of the ciprofloxacin groups.

Four patients developed bacteremia and 4 patients had upper UTI in the control group 5. There were no episodes of bacteremia identified in patients who received appropriate antimicrobials 2—12 hours before operation, while 7 patients 6. No patient developed postoperative septicemia. Six studies [—] compared different perioperative ASB treatment regimens and durations. Two of these [, ] were published after the previous guideline. Two early RCTs compared the efficacy of perioperative antimicrobial treatment to methenamine hippurate treatment. Two 5. ASB resolved at 4—9 weeks postoperatively in In a trial [] of 42 patients with ASB undergoing TURP randomized to receive cefotaxime preoperatively and then daily for 5 days or methenamine hippurate from the day prior to operation for a total of 6 days, postoperative fever occurred in 1 of 22 4.

No cefotaxime patients and 2 methenamine patients had septicemia, but this difference was not statistically significant. Thus, these studies support perioperative antimicrobial treatment of ASB being superior to methenamine treatment. The accumulated elimination rates for the to day follow-up period were No patient had any clinical signs of upper UTI or septicemia. Two RCTs reported since the publication of the previous guideline assess the efficacy of single-dose compared to longer-course antimicrobial treatment of preoperative ASB [, ]. In 1 trial [], 31 patients were randomized to a single dose given 30—60 minutes before the surgical procedure and a second dose if a catheter was placed postoperatively, and 28 patients to antimicrobial treatment starting 3 days prior to and continuing for 15 days after surgery.

Urologic procedures included TURP, TURBT, double J insertion and exchange, cystostomy insertion, nephrostomy tube insertion or exchange, extracorporeal shock wave lithotripsy, and ureterorenoscopy. Dr Buckwold is now in private practice in San Antonio, Tex. Of ten acute symptomatic urinary tract infections, four were cured, three were not, and three cases could not be evaluated.

Two other women received trimethoprim for suppression of infection complicating stag-horn calculi. The conditions of both patients improved clinically but the urine remained infected. Eight women treated prophylactically with low-dose trimethoprim for recurrent urinary tract infection accumulated a total of 16 patient-years of prophylaxis. During treatment, the incidence of infection was 0.

Adverse reactions occurred in eight of 20 patients and administration of the drug had to be stopped in five cases. Trimethoprim alone is effective for the treatment and prophylaxis of urinary tract infections, but may cause a high incidence of adverse reactions in patients known to be sensitive to sulfonamides. Arch Intern Med. All Rights Reserved.

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