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Bacteriuria

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Bacteriuria
Other namesBacteruria
Multiple rod-shaped bacteria shown between the larger white blood cells at urinary microscopy from a person with urinary tract infection.
SpecialtyEmergency medicine, infectious disease
TypesAsymptomatic, symptomatic[1][2]
Diagnostic methodUrinalysis, urine culture[3]
Differential diagnosisContamination[1]
TreatmentBased on symptoms or risk factors[3][4]
FrequencyAsymptomatic: 3% (middle aged women), up to 50% (women in nursing homes)[5]
Symptomatic: up to 10% of women a year[6][7]

Bacteriuria is the presence of bacteria in urine.[1] Bacteriuria accompanied by symptoms is a urinary tract infection while that without is known as asymptomatic bacteriuria.[1][2] Diagnosis is by urinalysis or urine culture.[3] Escherichia coli is the most common bacterium found.[1] People without symptoms should generally not be tested for the condition.[3] Differential diagnosis include contamination.[1]

If symptoms are present treatment is generally with antibiotics.[3] Bacteriuria without symptoms generally does not require treatment.[4] Exceptions may include pregnant women, those who have had a recent kidney transplant, young children with significant vesicoureteral reflux, and those undergoing surgery of the urinary tract.[3][4]

Bacteriuria without symptoms is present in about 3% of otherwise healthy middle aged women.[5] In nursing homes rates are as high as 50% among women and 40% in men.[5] In those with a long term indwelling urinary catheter rates are 100%.[5] Up to 10% of women have a urinary tract infection in a given year and half of all women have at least one infection at some point in their lives.[6][7]

Signs and symptoms

Asymptomatic

Asymptomatic bacteriuria is bacteriuria without accompanying symptoms of a urinary tract infection. It is more common in women, in the elderly, in residents of long-term care facilities, and in people with diabetes, bladder catheters and spinal cord injuries. People with a long-term Foley catheter always show bacteriuria. Chronic asymptomatic bacteriuria occurs in as many as 50% of the population in long-term care.[8]

There is an association between asymptomatic bacteriuria in pregnant women with low birth weight, preterm delivery, and infection of the newborn.[9][10] However, most of these studies were graded as poor quality.[9] Bacteriuria in pregnancy also increases the risk of preeclampsia.[10]

Symptomatic

Main article: Urinary tract infection

Symptomatic bacteriuria is bacteriuria with the accompanying symptoms of a urinary tract infection (such as frequent urination, painful urination, fever, back pain) and includes pyelonephritis or cystitis. The most common cause of urinary tract infections is Escherichia coli.

Diagnosis

Testing for bacteriuria is usually performed in people with symptoms of a urinary tract infection. Certain populations which are not able to feel or express symptoms of an infection are also tested when showing nonspecific symptoms. For example, confusion or other changes in behaviour can be a sign of an infection in the elderly. Screening for asymptomatic bacteriuria in pregnancy is common routine in many countries, but controversial.

  • The gold standard for detecting bacteriuria is a bacterial culture which identifies the concentration of bacterial cells in the urine. The culture is usually combined with subsequent MALDI-TOF, which allows to identify the causal bacterial species, and antibiotic susceptibility testing. Urine culture is quantitative and very reliable, but takes at least one day to obtain a result. Therefore clinicians will often treat symptomatic bacteriuria based on the results of the urine dipstick test while waiting for the culture results.
  • Bacteriuria can usually be detected using a urine dipstick test. The nitrite test detects nitrate-reducing bacteria if growing in high numbers in urine. A negative dipstick test does not exclude bacteriuria, as not all bacteria which can colonise the urinary tract are nitrate-reducing. The leukocyte esterase test indirectly detects the presence of leukocytes (white blood cells) in urine which can be associated with a urinary tract infection. In elderly, the leukocyte esterase test is often positive even in the absence of an infection. The urine dipstick test is readily available and provides fast, but often unreliable results.
  • Microscopy can also be used to detect bacteriuria. It is rarely used in clinical routine, since it requires more time and equipment and does not allow reliable identification or quantification of the causal bacterial species.

Bacteriuria is assumed if a single bacterial species is isolated in a concentration greater than 100,000 colony forming units per millilitre of urine in clean-catch midstream urine specimens.[11] In urine samples obtained from women, there is a risk for bacterial contamination from the vaginal flora. Therefore, in research, usually a second specimen is analysed to confirm asymptomatic bacteriuria in women. For urine collected via bladder catheterization in men and women, a single urine specimen with greater than 100,000 colony forming units of a single species per millilitre is considered diagnostic.[11] The threshold for women displaying UTI symptoms can be as low as 100 colony forming units of a single species per millilitre. However, bacteria below a threshold of 10000 colony forming units per millilitre are usually reported as "no growth" by clinical laboratories.[12][13]

Using special techniques certain non-disease causing bacteria have also been found in the urine of healthy people.[14] These are part of the resident microbiota.[14]

Screening

Although controversial, many countries including the United States recommend a one time screening for bacteriuria during mid pregnancy.[15][16] The screening method is by urine culture.[16]

Screening non pregnant adults is recommended against by the United States Preventive Task Force.[16]

Treatment

The decision to treat bacteriuria depends on the presence of accompany symptoms and comorbidities.

Asymptomatic

Asymptomatic bacteriuria generally does not require treatment.[4] Exceptions include those undergoing surgery of the urinary tract, children with vesicoureteral reflux or others with structural abnormalities of the urinary tract.[4][17] In many countries, regional guidelines recommend treatment of pregnant women.[9]

There is no indication to treat asymptomatic bacteriuria in diabetics, renal transplant recipients, and in those with spinal cord injuries.[18]

The overuse of antibiotics to treat asymptomatic bacteriuria has many adverse effects[19] such as an increased risk of diarrhea, the spread of antimicrobial resistance, and infection due to Clostridium difficile.

Symptomatic

Symptomatic bacteriuria is synonymous with urinary tract infection and typically treated with antibiotics. Common choices include nitrofurantoin and trimethoprim/sulfamethoxazole.

Epidemiology

Rates of asymptomatic bacteriuria[5]
Group Prevalence (in %)
Healthy premenopausal women 1.0 to 5.0
Pregnant women 1.9 to 9.5
Postmenopausal women (50 to 70 years of age) 2.8 to 8.6
People with diabetes mellitus Women 9.0 to 27.0
Men 0.7 to 1.0
Older community-dwelling people Women (older than
70 years)		 > 15.0
Men 3.6 to 19.0
Older long-term care residents Women 25.0 to 50.0
Men 15.0 to 40.0
People with spinal cord injury Intermittent catheter 23.0 to 89.0
Sphincterotomy and
condom catheter		 57.0
People undergoing hemodialysis 28.0
People with an indwelling
urinary catheter		 Short-term 9.0 to 23.0
Long-term 100

References

  1. ^ a b c d e f Das, K. V. Krishna; Das, KV Krishna (2017). Textbook of Medicine: Two Volume Set. JP Medical Ltd. p. 1250. ISBN 9789386056108.
  2. ^ a b Sendi, P; Borens, O; Wahl, P; Clauss, M; Uçkay, I (2017). "Management of Asymptomatic Bacteriuria, Urinary Catheters and Symptomatic Urinary Tract Infections in Patients Undergoing Surgery for Joint Replacement: A Position Paper of the Expert Group". Journal of Bone and Joint Infection. 2 (3): 154–159. doi:10.7150/jbji.20425. PMC 5592375. PMID 28894690.
  3. ^ a b c d e f "Bacterial Urinary Tract Infections (UTIs)". Merck Manuals Professional Edition. May 2016. Retrieved 12 December 2017.
  4. ^ a b c d e Köves, B; Cai, T; Veeratterapillay, R; Pickard, R; Seisen, T; Lam, TB; Yuan, CY; Bruyere, F; Wagenlehner, F; Bartoletti, R; Geerlings, SE; Pilatz, A; Pradere, B; Hofmann, F; Bonkat, G; Wullt, B (25 July 2017). "Benefits and Harms of Treatment of Asymptomatic Bacteriuria: A Systematic Review and Meta-analysis by the European Association of Urology Urological Infection Guidelines Panel". European Urology. 72 (6): 865–868. doi:10.1016/j.eururo.2017.07.014. PMID 28754533.
  5. ^ a b c d e Colgan, R; Nicolle, LE; McGlone, A; Hooton, TM (15 September 2006). "Asymptomatic bacteriuria in adults". American Family Physician. 74 (6): 985–90. PMID 17002033.
  6. ^ a b Salvatore S, Salvatore S, Cattoni E, Siesto G, Serati M, Sorice P, Torella M (June 2011). "Urinary tract infections in women". European Journal of Obstetrics, Gynecology, and Reproductive Biology. 156 (2): 131–6. doi:10.1016/j.ejogrb.2011.01.028. PMID 21349630.
  7. ^ a b Nicolle LE (2008). "Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis". Urol Clin North Am. 35 (1): 1–12, v. doi:10.1016/j.ucl.2007.09.004. PMID 18061019.
  8. ^ AMDA – The Society for Post-Acute and Long-Term Care Medicine (February 2014), "Ten Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, AMDA – The Society for Post-Acute and Long-Term Care Medicine, retrieved 20 April 2015
  9. ^ a b c Smaill, Fiona M.; Vazquez, Juan C. (7 August 2015). "Antibiotics for asymptomatic bacteriuria in pregnancy". The Cochrane Database of Systematic Reviews (8): CD000490. doi:10.1002/14651858.CD000490.pub3. ISSN 1469-493X. PMID 26252501.
  10. ^ a b Szweda, Hanna; Jóźwik, Marcin (2016). "Urinary tract infections during pregnancy - an updated overview". Developmental Period Medicine. 20 (4): 263–272. ISSN 1428-345X. PMID 28216479.
  11. ^ a b Detweiler K, Mayers D, Fletcher SG (November 2015). "Bacteruria and Urinary Tract Infections in the Elderly". The Urologic Clinics of North America (Review). 42 (4): 561–8. doi:10.1016/j.ucl.2015.07.002. PMID 26475952.
  12. ^ Hooton, Thomas M. (15 March 2012). "Uncomplicated Urinary Tract Infection". New England Journal of Medicine. 366 (11): 1028–1037. doi:10.1056/NEJMcp1104429. ISSN 0028-4793. PMID 22417256.
  13. ^ Sam, Amir H.; James T.H. Teo (2010). Rapid Medicine. Wiley-Blackwell. ISBN 978-1-4051-8323-9.
  14. ^ a b "The human urinary microbiome and how it relates to urogynecology". Int Urogynecol J. 27 (9): 1307–12. 2016. doi:10.1007/s00192-016-2944-5. PMID 26811114. {{cite journal}}: Unknown parameter |authors= ignored (help)
  15. ^ Moore, Ainsley; Doull, Marion; Grad, Roland; Groulx, Stéphane; Pottie, Kevin; Tonelli, Marcello; Courage, Susan; Garcia, Alejandra Jaramillo; Thombs, Brett D. (8 July 2018). "Recommendations on screening for asymptomatic bacteriuria in pregnancy". Canadian Medical Association Journal. 190 (27): E823–E830. doi:10.1503/cmaj.171325. PMC 6041243. PMID 29986858.
  16. ^ a b c Owens, Douglas K.; Davidson, Karina W.; Krist, Alex H.; Barry, Michael J.; Cabana, Michael; Caughey, Aaron B.; Doubeni, Chyke A.; Epling, John W.; Kubik, Martha; Landefeld, C. Seth; Mangione, Carol M.; Pbert, Lori; Silverstein, Michael; Simon, Melissa A.; Tseng, Chien-Wen; Wong, John B. (24 September 2019). "Screening for Asymptomatic Bacteriuria in Adults". JAMA. 322 (12): 1188–1194. doi:10.1001/jama.2019.13069. PMID 31550038.
  17. ^ Ramos, Jorge A.; Salinas, Diego F.; Osorio, Johanna; Ruano-Ravina, Alberto (September 2016). "Antibiotic prophylaxis and its appropriate timing for urological surgical procedures in patients with asymptomatic bacteriuria: A systematic review". Arab Journal of Urology. 14 (3): 234–239. doi:10.1016/j.aju.2016.05.002. ISSN 2090-598X. PMC 4983160. PMID 27547467.
  18. ^ Nicolle, Lindsay E. (2014). "Urinary Tract Infections in Special Populations". Infectious Disease Clinics of North America. 28 (1): 91–104. doi:10.1016/j.idc.2013.09.006. PMID 24484577.
  19. ^ Zalmanovici Trestioreanu, A; Lador, A; Sauerbrun-Cutler, MT; Leibovici, L (8 April 2015). "Antibiotics for asymptomatic bacteriuria". The Cochrane Database of Systematic Reviews. 4: CD009534. doi:10.1002/14651858.CD009534.pub2. PMID 25851268.
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