Please stop suspecting solely UTI when you see a confused elderly…….. ” IDSA say-so”

Infectious Diseases Society of America (IDSA) advises not to attack the sleeping bacteria in urine unnecessarily with antibiotics and force them to develop antimicrobial resistance or to give patients the blessings of clostridium difficile. We are talking about the antimicrobial stewardship program based on IDSA 2005 recommendations on asymptomatic bacteremia (ASB) management. It recommends for nontreatment of asymptomatic bacteriuria in patient population except for pregnant women and patients prior to undergoing invasive urologic procedures. Irrespective of the presence of pyuria and bacteriuria, if the patient has no local urinary symptoms suggestive of UTI, presence of bacteriuria itself is not a valid reason to initiate antimicrobial therapy. Now the committee updated guidelines by addressing population and situation specific questions in relation to the presence of ASB (Infectious Diseases Society of America (IDSA).  2019)

Takeaways from the IDSA recommendations 2005 and the 2019 update on management of asymptomatic bacteriuria (ASB)

Who do not need unnecessary urinary antibiotic for ASB?

The guidelines strongly recommend against screening and treating ASB in healthy non-pregnant women, pre and postmenopausal healthy women, community dwelling or long-term care facility residents who are functionally impaired, diabetic patients, renal transplant patients who had renal transplant surgery more than a month ago, non-renal solid organ transplant patients, patients with urinary catheter, patients going for elective non-urologic surgeries, and patients  living with implanted urologic devices.

For which patient population there is not enough scientific evidence to provide definite recommendations against antibiotic treatment for ASB?

When managing patients with high risk neutropenia and for patients with indwelling urinary catheters at the time of catheter removal, the committee is not recommending for or against screening and treating ASB. Antimicrobial prophylaxis at the time of catheter removal might prevent symptomatic UTI. In post spinal cord injury patients with voiding impairment even though the committee recommend against screening and treating ASB, the guidelines also advises to consider atypical presentation of UTI (Urinary tract infection) in these patient population.

Even if an older patient presents with cognitive impairment and bacteriuria but there are no local genitourinary symptoms or no signs of systemic infection the guideline recommend against using antibiotic treatment for UTI and the guideline recommends the practitioners to focus on the other possible causes of functional or cognitive impairment.  But if the patient has signs of sepsis or severe infection with bacteriuria even if there are no localizing urinary symptoms, the practitioners can use urinary broad-spectrum antibiotic

Who needs urinary antibiotic with ASB and for how long?

The treatment of ASB in pregnant women is 4-7 days of antibiotic rather than short duration of therapy, but aim at shortest effective dose.  If the patient is going for endoscopic urologic procedure obtain a urine culture before the procedure and do targeted short course (1 or 2 doses) antimicrobial therapy than empiric therapy. Initiate antibiotics 30- 60 minutes before the procedure.

If you want to read more about the IDSA recommendations please follow the link :

https://www.idsociety.org/globalassets/idsa/practice-guidelines/2019-asymptomatic-bacteriuria.pdf

DOI: 10.1093/cid/ciy1121