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Asymptomatic Bacteriuria
Asymptomatic Bacteriuria
Urine cultures for Diagnosis Of UTIs in young woman
Customary urine test is the dip stick and the mid-stream culture of voided
urine. Up to 77% of cystitis cases are cultured
More recently as little as 100 CFUs in a voided sample has been positively
correlated with coliform (such as E. coli) bladder infection
The problem with this cut off: Many labs will call 0 to 10,000 CFUs (<10⁴) as
a negative culture
……….
The way the urine test is done, diluting out
the urine 1000 times, there may be no
growth on the agar plates despite a bladder
infection being present
Voided Midstream Urine Culture and Acute Cystitis in Premenopausal Women
thomas M. Hooton, M.D., Pacita L. Roberts, M.S., Marsha E. Cox, B.S., and Ann E. Stapleton, M.D.
In contrast – 22% of mid- stream cultures grew enterococcus or Group B strep- at even 100,000 (10⁵
CFUs) – there was no correlation with bladder cultures- These bugs were not found in the corresponding
bladder culture, but E.coli was still cultured in the bladder (but not in the mid-stream culture) in 62% of these
cases !
III. In uncomplicated cases- obtaining cultures as a guide to therapy can be counter productive: either not
treating patients with actual infection, or treating patients for the wrong bacteria.
Question: Which of these options is the quickest, most
sensitive and cheapest way to diagnose a UTI?
Ask the patient “do you feel like you have a bladder infection- do
you have both a sense of urgency and burning when you
urinate?”
Do a dip stick and treat only if leukocytes or nitrite positive?
Send the urine for culture, wait 2 days, and treat the patient only if
>100,000/ml colonies
Diagnosis of Uncomplicated Cystitis
New Study- still >50% of Rxs are for Cipro, most of the time for >
than 3 days. Bactrim #2, nitro #3 , fosfomycin-no Rx
Evolving concepts in the beneficial role of asymptomatic bacteruria:
Very Common:
i. Young healthy women : 3 to 5%
i. Pregnant women: 2 to 9.5%
ii. Women aged 65-80 years: 18 to 43%
iii. Women > 80 years: up to 43%
iv. Men 65-80 years: 2 to 15%
Causes:
Obstructive uropathy, neuromuscular
disease, perineal soiling in dementia.
A new paradigm of asymptomatic bacteriuria (ABU)
Traditional teaching:
the presence of bacteriuria defines a population at risk,
therefore:
Eliminating the “asymptomatic UTI” (oxymoron) minimizes
the risk for a clinically symptomatic disease
Modern Teaching:
NO benefit to treatment (except in pregnancy and before
urologic procedure). Term changed to “asymptomatic
bacteriuria”
ABU in young women with history of recurrent UTI –is
this a precursor to symptomatic infection?
What role does this have in recurrent UTI’s? Many women get
follow-up urine studies and re-treatment after initial therapy for
UTI.
Many older patients get screening u/a’s and reflex cultures even
when they don’t have urgency and burning symptoms. They are then
treated for a “UTI”. This is a too common mistake…
“older patients should not be tested or treated for UTI unless they
have symptoms”
If you are treated for a true UTI: no follow-up test of cure should be
performed
Antibiotics:
have side-effects
can cause future problems like yeast infection and colitis
lead to drug resistant bacteria
are a waste of money
Urinary Tract Infection
Prostatitis
Symptoms of Urinary Tract Infection
Dysuria
Increased frequency
Hematuria
Fever
Nausea/Vomiting (pyelonephritis)
Flank pain (pyelonephritis)
Findings on Exam in UTI
Physical Exam:
CVA tenderness (pyelonephritis)
Urethral discharge (urethritis)
Tender prostate on DRE (prostatitis)
Labs: Urinalysis
+ leukocyte esterase
+ nitrites
More likely gram-negative rods
+ WBCs
+ RBCs
Culture in UTI
Positive Urine Culture = >105 CFU/mL
traditionally
Most common pathogen for cystitis,
prostatitis, pyelonephritis:
Escherichia coli
Staphylococcus saprophyticus
Proteus mirabilis
Klebsiella
Enterococcus
Most common pathogen for urethritis
Chlamydia trachomatis
Neisseria Gonorrhea
Lower Urinary Tract Infection -
Cystitis
Uncomplicated (Simple) cystitis
In healthy woman, with no signs of systemic
disease
Complicated cystitis
In men, or woman with comorbid medical
problems.
Recurrent cystitis
Uncomplicated (simple) Cystitis
Definition
Healthy adult woman (over age 12)
Non-pregnant
No fever, nausea, vomiting, flank pain
Diagnosis
Dipstick urinalysis (no culture or lab tests needed)
Treatment
Trimethroprim/Sulfamethoxazole for 3 days
May use fluoroquinolone (ciprofoxacin or levofloxacin) in
patient with sulfa allergy, areas with high rates of bactrim-
resistance
Risk factors:
Sexual intercourse
May recommend post-coital voiding or prophylactic antibiotic
use.
Complicated Cystitis
Definition
Females with comorbid medical conditions
All male patients
Indwelling foley catheters
Urosepsis/hospitalization
Diagnosis
Urinalysis, Urine culture
Further labs, if appropriate.
Treatment
Fluoroquinolone (or other broad spectrum antibiotic)
7-14 days of treatment (depending on severity)
May treat even longer (2-4 weeks) in males with UTI
Special cases of Complicated
cystitis
Indwelling foley catheter
Try to get rid of foley if possible!
Only treat patient when symptomatic (fever, dysuria)
Leukocytes on urinalysis
Patient’s with indwelling catheters are frequently colonized with
great deal of bacteria.
Should change foley before obtaining culture, if possible
Candiduria
Frequently occurs in patients with indwelling foley.
If grows in urine, try to get rid of foley!
Treat only if symptomatic.
If need to treat, give fluconazole (amphotericin if resistance)
Recurrent Cystitis