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Harmful Effects of Asymptomatic Bacteriuria: Reducing Unnecessary Antibiotics

Learn why treating asymptomatic bacteriuria can be harmful and strategies to reduce unnecessary antibiotics, preventing antimicrobial resistance. Explore the risks and benefits to make informed decisions.

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Harmful Effects of Asymptomatic Bacteriuria: Reducing Unnecessary Antibiotics

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  1. Asymptomatic Bacteriuria (Frequently occurs; Frequently mistreated):Approach to reducing unnecessary antimicrobial therapy and thereby reducing Harm Thomas M File Jr. MD, MSc, MACP, FIDSA, FCCP Chair, Infectious Disease Division Summa Health System, Akron, Ohio; Professor of Internal Medicine, Chair ID Section Northeast Ohio Medical University Rootstown, Ohio

  2. Learning Objectives • List why treatment of asymptomatic bacteriuria can be harmful • List strategies to reduce unnecessary antibiotics for asymptomatic bacteriuria

  3. Height: 5’5” Weight: 140 lbs CrCl = 64 ml/min 84 yof resides at home. PMH includes: hypertension, osteoarthritis, diabetes, neuropathy, and dementia. Her daughter (primary caretaker) calls in your office and requests a prescription for trimethoprim-sulfamethoxazole for her mother’s worsening mentation as this helped her last time. Pt denies any fever, pain, or changes with urination habits. A urinalysis and urine culture are collected by the home care nurse via bed pan. UA reveals 5-10 WBC/HPF and moderate bacteria. Urine culture is pending. What is the most appropriate next step? • Prescribe trimethoprim-sulfamethoxazole 1 DS twice daily for 5 days • Prescribe ciprofloxacin 250 mg twice daily for 3 days • Do not treat until culture and sensitivity results are available • Do not treat, search for alternate causes of altered mentation

  4. Antimicrobial Stewardship Worksheet

  5. UTIs and Older Adults Detweiler K,et al. Urol Clin N Am 2015; 42: 561–568. Jump RLP, et al. J Am Geriatr Soc 2018; 66: 789-803. Crnich CJ,et al. J Am Geriatr Soc 2017; 65: 1661-3. Rowe TA, et al. Inf Dis Clin North Am Am 2014; 28: 75-89.

  6. Treatment of ASB in Nursing Home Patients Leads to Multi-drug Resistant Organisms • Cohort from 5 Nursing Homes in Connecticut • Findings: • Increasing episodes of observed bacteriuria among nursing home residents in this cohort are not associated with hospitalization for UTI or change in mental status, • but are associated with antibiotic utilization and occurrence of multi-drug resistant gram negative rods. • Restricting antibiotic prescriptions for bacteriuria should continue to be a guiding principle • Continued inappropriate utilization may increase hospital transfers and transmission of resistant organisms to the inpatient setting Das R, et al. Infect Control Hosp Epidemiol 2011 Jan; 32(1): 84–86.

  7. Bacteriuria in Individuals Who Become Delirious “No evidence beyond anecdote suggests that delirious patients who have asymptomatic bacteriuria do better with antibiotic treatment. For these patients, we believe clinicians should not ask whether there is a “real urinary tract infection,” but whether the patient is safer with antibiotic treatment or without it. Accepting asymptomatic bacteriuria as the cause of delirium, dubbing it “urinary tract infection,” and then giving antibiotics is dangerously complacent. McKenzie R et al. Am J Med. 2014

  8. Asymptomatic Bacteriuria • Patient with bacteria in the urine, but withoutclinical signs of a UTI • Women – two consecutive voided urine specimens with isolation of the same organism in counts of ≥ 105 cfu/mL • Men – a single voided urine specimen with isolation of a single organism in counts of ≥ 105 cfu/mL • Catheterized – a single catheterized specimen with isolation of a single organism in counts of ≥ 105 cfu/mL • Presence of pyuria (≥10 leukocytes/mm3 in UA) NOT SUFFICIENT/SPECIFIC for diagnosis of bacteriuria (or UTI) • Indications to treat: Pregnancy; Urological Procedures Boscia JA. Ann Intern Med 1989;110(5):404. Nicolle LE. Infect Dis Clin North Am 2012; 26(1): 13-27.

  9. Treatment of Asymptomatic Bacteriuria (ASB) in Young Women • Randomized Control Trial of women ages 18-40 with ASB • No therapy vs. antimicrobial therapy (based on culture results) • Result: • Recurrence: No therapy 13.1% • Recurrence: Therapy 46.8% (p < 0.0001) • Conclusion: • No benefit to treat ASB • ASB may play a protective role in preventing symptomatic recurrence • Don’t treat ASB Cai T, et al. Clin Infect Dis 2012 Sep;55(6):771-7.

  10. 2015 Cochrane Review: Antibiotics vs. No Treatment or Placebo for ASB • Randomized controlled trials or Quasi RCTs ( 9 studies with 1614 pts ) • Treatment vs. No Treatment, or Treatment vs. Placebo • Conclusion: • No difference in outcomes of development of symptomatic UTI, complications or death • Significantly higher adverse events in treatment group • No clinical benefit from treating ASB Trestioreanu ZA, et al. Cochrane Database Syst Rev. 2015 Apr 8;4:CD009534.

  11. Summary: UTI vs. ASB

  12. Importance of Normal Microbiome • Gut microbiome plays a role • Digestion • Metabolism • Immunity • Balanced, diverse microbiome contributes to better overall health • Specific biochemical functions of normal bacteria effect immune response • Antimicrobials cause Disruption of microbiome • Results in less diversity • Diminished Immunity TIME Health Spring 2018 Belkaid and Hand. Role of the microbiome in immunity and inflammation. Cell 2014; 157: 121

  13. Reducing Unnecessary Antimicrobials: Approaches • Education • ED algorithm and audit • Geriatrics and Home Nurses Grant • Remove UA and Cultures from order sets (delirium, falls) • UA reflex cultures • New IDSA Guidelines

  14. Asymptomatic Bacteriuria: Fact or Fiction? Adapted from: Massachusetts Coalition for the Prevention of Medical Errors http://www.macoalition.org/evaluation-and-treatment-uti-in-elderly.shtml

  15. Other Causes of Delirium JAMA. 2016;316:1775-1785. Crit Care Med 2014; 42:1899–1909. Crit Care Med 2014; 42:1480–1486. J Crit Care 2008; 23: 372-379. Crit Care 2008 : 12: S3 (doi:10.1185/cc6149). Arch Intern Med 2007; 167: 1629-1634. Circulation 2009; 119: 229-231. JAMA 1996; 275: 852-857.

  16. Summa Health Sample Preso

  17. Summa Health System Asymptomatic Bacteriuria vs. UTI Pathway

  18. From Jenkins TC et al. Clin Infect Dis 2018; 67: 1550-8

  19. Reflexive Urine Culture based on UA • Less Ucx being performed. • CA-UTI rates decreased 16

  20. Asymptomatic BacteriuriaFirst do NO HARM

  21. Case Question:A nurse from ECF calls about a 84 year old female who fell and appeared more confused. The nurse is requesting an order for an antimicrobial since her urine culture was obtained indicating 100,000 colonies of E. coli. What is best response?A. Prescribe fosfomycin since you are concerned for ESBL organisms B. Prescribe nitrofurantoin since her creatinine clearance is greater than 40 C. Order urinalysis D. If no symptoms of UTI avoid antimicrobial and search for alternative cause of confusion

  22. Assessment Question #1Which of the following are reasons why antimicrobial treatment of asymptomatic bacteriuria can  result in harm to patients? • Increase selection of resistant pathogens which are more likely to cause symptomatic infection • Unnecessary adverse effects such as CDI • Unnecessary Cost • Disturbance of normal microbiome • All above

  23. Assessment Question #2Which of the following strategies are effective to reduce unnecessary antibiotics for asymptomatic bacteriuria? • Reserve antimicrobial treatment to patients with asymptomatic bacteriuria who demonstrate a change in mental status • Education of patients, family members and healthcare providers as to the negative consequences • Screening of all patients from long term care facilities with voided urine culture • All of above

  24. Asymptomatic Bacteriuria (Frequently occurs; Frequently mistreated):Approach to reducing unnecessary antimicrobial therapy and thereby reducing Harm Thomas M File Jr. MD, MSc, MACP, FIDSA, FCCP Chair, Infectious Disease Division Summa Health System, Akron, Ohio; Professor of Internal Medicine, Chair ID Section Northeast Ohio Medical University Rootstown, Ohio

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