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. What is the most appropriate next step?
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
Height: 5’5”
Weight: 140 lbs
CrCl = 64 ml/min

4. Antimicrobial Stewardship Worksheet

5. UTIs and Older Adults
Responsible for 15.5% of ID hospitalizations in patients > 65 years old
Accounts for 5% of ER visits in patients > 65 years old
Most common infection diagnosed in patients living in long term facilities
Studies indicate that >50% of antibiotics used for UTI’s in older patients were unnecessary or inappropriate
Detweiler K,et al. Urol Clin N Am 2015; 42: 561–568.
Jump RLP, et al. J Am Geriatr Soc 2018; 66:
Crnich CJ,et al. J Am Geriatr Soc 2017; 65:
Rowe TA, et al. Inf Dis Clin North Am Am 2014; 28:

6. Das R, et al. Infect Control Hosp Epidemiol 2011 Jan; 32(1): 84–86.
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 without clinical 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):

9. Treatment of Asymptomatic Bacteriuria (ASB) in Young Women
Randomized Control Trial of women ages with ASB
No therapy vs. antimicrobial therapy (based on culture results)
Result:
Recurrence: No therapy 13.1%
Recurrence: Therapy 46.8% (p < )
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 Apr 8;4:CD

11. Summary: UTI vs. ASB UTI ASB + Pyuria Yes Possible + Culture Symptoms
dysuria, frequency, urgency, hematuria, incontinence, suprapubic pain, fever, chills, nausea, vomiting, costovertebral angle (CVA) tenderness, flank pain
None
Antibiotics Benefit
Antibiotics Cause Harm
Altered Mental Status Associated
Very unlikely (other cause almost always present)

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?
An abnormal urinalysis (UA) indicates a UTI
UA specimens are often contaminated in the elderly if not received by straight catheter
Even when done by catheter and culture is positive, most cases are ASB
UA should be ordered as a screening test
Order UA only when patient has UTI symptoms
An abnormal UA explains weakness, fatigue, change in mental status
Prevalence of ASB high in elderly patients
Seek other causes (dehydration, medication changes, constipation, sleep changes, signs of other infection)
Pyuria can differentiate ASB from UTI
Patients with ASB often have WBC in their urine
Cloudy or foul smelling urine is diagnostic of a UTI
These changes are also seen in ASB
Other causes include dehydration, certain medications, diet
Adapted from: Massachusetts Coalition for the Prevention of Medical Errors

15. Other Causes of Delirium
Opioids, Anticholinergics, Multiple Medications, Alcohol/Drug Withdrawal, Sedative/Hypnotics, Corticosteroids
Sleep Deprivation, Pain
Physical Restraints, Bladder catheter
Dehydration, Electrolyte abnormalities, Metabolic disturbances, Malnutrition
Stroke, Infections/Acute Infection, Hypoxia, Hypertension/Hypotension, Anemia, Surgery, ICU Stay
JAMA. 2016;316:
Crit Care Med 2014; 42:1899–1909.
Crit Care Med 2014; 42:1480–1486.
J Crit Care 2008; 23:
Crit Care 2008 : 12: S3 (doi: /cc6149).
Arch Intern Med 2007; 167:
Circulation 2009; 119:
JAMA 1996; 275:

18. Summa Health Sample Preso

19. Summa Health System Asymptomatic Bacteriuria vs. UTI Pathway

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

22. Reflexive Urine Culture based on UA
Effects of Reflexive Urine Cultures on Antibiotic use in Hospitalized patients. Petty et al. (Univ Chicago)
IDWeek 2015
Less Ucx being performed.
CA-UTI rates decreased 16

23. Asymptomatic Bacteriuria First do NO HARM

24. 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

25. Unnecessary adverse effects such as CDI Unnecessary Cost
Assessment Question #1 Which 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

26. Assessment Question #2 Which 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

27. 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