Urinary Tract Infection (UTI) Evaluation, Educational Guidance for Challenging Evaluations (AMS, Neurogenic Bladder, and CAUTI)

Criteria & Principles

The purpose of this urinary tract infection (UTI) evaluation guidance document is to aid in reducing CAUTI rates, reducing treatment of asymptomatic bacteriuria, and reducing C. difficile risk.

For more information regarding UTI treatment and antimicrobial selection, please refer to customID pages for cystitis, CAUTI, and pyelonephritis.  There is an informative page to answer many of your questions here.

Risks Associated with Treating Asymptomatic Bacteriuria (ASB)

What is ASB? Presence of bacteria in the urine irrespective of pyuria (ex: WBC >10) and without urinary symptoms.¹

How common is ASB? Occurs in >15% of women and men older than 70 years old and continues to increase after age 80. It is extremely common in spinal cord injuries including up to 89% with intermittent catheter use and 100% with long-term indwelling catheter.²

Who should be treated for ASB? Pregnant women and patients undergoing endourologic procedures due to fetal benefit and concern for translocation of bacteria during surgery, respectively. There is currently no consensus on the management of ASB in high-risk febrile neutropenia and patients within 1 month of kidney transplant.¹  

Harm of treating ASB: Consequences of treating ASB include increased risk for antibiotic resistance, adverse effects (8-fold increase for C. difficile infection), risk for future symptomatic UTIs, and healthcare costs without benefit in patient care outcomes.^3,4

NOTE: In 2023, 66% (43/65) of DUH patients who received antibiotics for a UTI indication and subsequently developed C. difficile were deemed to have been inappropriately treated for ASB

Diagnosis-Specific Information

Patient with Confusion 

Spinal Cord Injury/Neurogenic Bladder (including indwelling or clean intermittent or suprapubic catheter)

Patient with Indwelling Urinary Catheter

References

1. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 May 2;68(10):e83-e110
2. Luu T, Albarillo FS. Asymptomatic Bacteriuria: Prevalence, Diagnosis, Management, and Current Antimicrobial Stewardship Implementations. Am J Med. 2022 Aug;135(8):e236-e244.
3. Cai T, Mazzoli S, Mondaini N, et al. The Role of Asymptomatic Bacteriuria in Young Women with Recurrent Urinary Tract Infections: To Treat or Not to Treat?” Clin Infect Dis. 2015 Sept 15;55(6):e771-777
4. Rotjanapan P, Dosa D, Thomas KS. Potentially inappropriate treatment of urinary tract infections in two Rhode Island nursing homes. Arch Intern Med. 2011;171(5):438-443.
5. Mody L, Juthani-Mehta M. Urinary tract infections in older women: a clinical review. Jama 2014; 311(8): 844-54.
6. Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases 2011; 52(5): e103-e20.
7. Massa LM, Hoffman JM, Cardenas DD. Validity, accuracy, and predictive value of urinary tract infection signs and symptoms in individuals with spinal cord injury on intermittent catheterization. J Spinal Cord Med 2009; 32(5): 568-73.
8. Mullin KM, Kovacs CS, Fatica C, et al. A Multifaceted Approach to Reduction of Catheter-Associated Urinary Tract Infections in the Intensive Care Unit With an Emphasis on "Stewardship of Culturing". Infect Control Hosp Epidemiol 2017; 38(2): 186-8.
9. Fakas N, Souli M, Koratzanis G, Karageorgiou C, Giamarellou H, Kanellakopoulou K. Effects of antimicrobial prophylaxis on asymptomatic bacteriuria and predictors of failure in patients with multiple sclerosis. Journal of Chemotherapy 2010; 22(1): 36-43.
10. Andrews KL, Husmann DA. Bladder dysfunction and management in multiple sclerosis.  Mayo Clinic Proceedings; 1997: Elsevier; 1997. p. 1176-83.
11. Fitzgerald KC, Cassard LA, Fox SR, Probasco JC, Cassard SD, Mowry EM. The prevalence and utility of screening for urinary tract infection at the time of presumed multiple sclerosis relapse. Multiple Sclerosis and Related Disorders 2019; 35: 61-6.
12. Sebastian S, Stein LK, Dhamoon MS. Infection as a Stroke Trigger. Stroke 2019; 50(8): 2216-8.
13. Aizen E, Shifrin B, Shugaev I, Potasman I. Clinical and Microbiological Outcomes of Asymptomatic Bacteriuria in Elderly Stroke Patients. Isr Med Assoc J 2017; 19(3): 147-51.
14. Yan T, Liu C, Li Y, Xiao W, Li Y, Wang S. Prevalence and predictive factors of urinary tract infection among patients with stroke: A meta-analysis. Am J Infect Control 2018; 46(4): 402-9.
15. Bogason E, Morrison K, Zalatimo O, et al. Urinary Tract Infections in Hospitalized Ischemic Stroke Patients: Source and Impact on Outcome. Cureus 2017; 9(2): e1014.
16. Naveed O, Dorotan MK, Flynn B, Satz W, Jacobson M. Seizures in the ED: Significance of Asymptomatic Bacteriuria in Patients Presenting with Breakthrough Seizures (2722). Neurology 2020; 94(15 Supplement): 2722.