Screening for Asymptomatic Bacteriuria in Adults: Evidence for the U.S. Preventive Services Task Force Reaffirmation Recommendation Statement

Center for Primary Care, Prevention, and Clinical Partnerships, Agency for Healthcare Research and Quality, Rockville, Maryland 20850, USA.
Annals of internal medicine (Impact Factor: 17.81). 07/2008; 149(1):W20-4. DOI: 10.7326/0003-4819-149-1-200807010-00009-w1
Source: PubMed


Asymptomatic bacteriuria is common, and screening for this condition in pregnant women is a well-established, evidence-based standard of current medical practice. Screening other groups of adults has not been shown to improve outcomes.
To review new and substantial evidence on screening for asymptomatic bacteriuria, to support the work of the U.S. Preventive Services Task Force.
English-language studies of adults (age >18 years) indexed in PubMed and the Cochrane Library and published from 1 January 2002 through 30 April 2007.
For benefits of screening or treatment for screened populations, systematic reviews; meta-analyses; and randomized, controlled trials were included. For harms of screening, systematic reviews; meta-analyses; randomized, controlled trials; cohort studies; case-control studies; and case series of large multisite databases were included. Two reviewers independently reviewed titles, abstracts, and full articles for inclusion.
Two reviewers extracted data from studies on benefits of screening and treatment (including decreases in the incidence of adverse maternal and fetal outcomes, symptomatic urinary tract infections, hypertension, and renal function decline).
An updated Cochrane systematic review of 14 randomized, controlled trials of treatment supports screening for asymptomatic bacteriuria in pregnant women. A randomized, controlled trial and a prospective cohort study show that screening nonpregnant women with diabetes for asymptomatic bacteriuria is unlikely to produce benefits. No new evidence on screening men for asymptomatic bacteriuria or on harms of screening was found.
The focused search strategy may have missed some smaller studies on the benefits and harms of screening for asymptomatic bacteriuria.
The available evidence continues to support screening for asymptomatic bacteriuria in pregnant women, but not in other groups of adults.

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    • "For other organisms, counts ≥ 10 5 CFU mL À1 are treated according to the causal bacteria (Le et al., 2004; Schnarr & Smaill, 2008; Cormican et al., 2011; Allen et al., 2012). Screening and treatment reduce the risk of pyelonephritis and adverse obstetrical outcomes; however, the optimal duration of treatment is yet to be defined (Patterson & Andriole, 1997; Smaill, 2001; Lin & Fajardo, 2008; Schnarr & Smaill, 2008). "
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    ABSTRACT: Bacteriuria, or the presence of bacteria in urine, is associated with both asymptomatic, as well as symptomatic urinary tract infection and underpins much of the dynamic of microbial colonization of the urinary tract. The prevalence of bacteriuria in dissimilar patient groups such as healthy adults, institutionalized elderly, pregnant women, and immune-compromised patients varies widely. In addition, assessing the importance of 'significant bacteriuria' in infected individuals represents a diagnostic challenge, partly due to various causal microbes, and requires careful consideration of the distinct etiologies of bacteriuria in different populations and circumstances. Recent molecular discoveries have revealed how some bacterial traits can enable organisms to grow in human urine, which, as a fitness adaptation, is likely to influence the progression of bacteriuria in some individuals. In this review, we comprehensively analyze currently available data on the prevalence of causal organisms with a focus on asymptomatic bacteriuria in dissimilar populations. We evaluate recent advances in the molecular detection of bacteriuria from a diagnostic viewpoint, and briefly discuss the potential benefits and some of the challenges of these approaches. Overall, this review provides an update on the comparative prevalence and etiology of bacteriuria from both microbiological and clinical perspectives. This article is protected by copyright. All rights reserved.
    FEMS Microbiology Letters 06/2013; 346(1). DOI:10.1111/1574-6968.12204 · 2.12 Impact Factor
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    • "Asymptomatic bacteriuria (ASB) denotes bacterial colonization of the urogenital tract without subjective or systemic host responses. ASB screening and treatment are recommended only during pregnancy [1] and in the preoperative evaluation of men before urological procedures [2], circumstances where preemptive antibiotic administration decreases the risk of infectious complications [3]. Despite these recommendations, overuse of antibiotics for ASB is common and clearance of bacteriuria is often transient, leading to further treatment courses [4]. "
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    ABSTRACT: Background Escherichia coli is a common cause of asymptomatic and symptomatic bacteriuria in hospitalized patients. Asymptomatic bacteriuria (ASB) is frequently treated with antibiotics without a clear indication. Our goal was to determine patient and pathogen factors suggestive of ASB. Methods We conducted a 12-month prospective cohort study of adult inpatients with E. coli bacteriuria seen at a tertiary care hospital in St. Louis, Missouri, USA. Urine cultures were taken at the discretion of treating physicians. Bacterial isolates were tested for 14 putative virulence genes using high-throughput dot-blot hybridization. Results The median age of the 287 study patients was 65 (19–101) years; 78% were female. Seventy percent had community-acquired bacteriuria. One-hundred ten (38.3%) patients had ASB and 177 (61.7%) had symptomatic urinary tract infection (sUTI). Asymptomatic patients were more likely than symptomatic patients to have congestive heart failure (p = 0.03), a history of myocardial infarction (p = 0.01), chronic pulmonary disease (p = 0.045), peripheral vascular disease (p = 0.04), and dementia (p = 0.03). Patients with sUTI were more likely to be neutropenic at the time of bacteriuria (p = 0.046). Chronic pulmonary disease [OR 2.1 (95% CI 1.04, 4.1)] and dementia [OR 2.4 (95% CI 1.02, 5.8)] were independent predictors for asymptomatic bacteriuria. Absence of pyuria was not predictive of ASB. None of the individual virulence genes tested were associated with ASB nor was the total number of genes. Conclusions Asymptomatic E. coli bacteriuria in hospitalized patients was frequent and more common in patients with dementia and chronic pulmonary disease. Bacterial virulence factors could not discriminate symptomatic from asymptomatic bacteriurias. Asymptomatic E. coli bacteriuria cannot be predicted by virulence screening.
    BMC Infectious Diseases 05/2013; 13(1):213. DOI:10.1186/1471-2334-13-213 · 2.61 Impact Factor
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    • "In contrast, CA-ABU is marked by the absence of urinary-specific symptoms, and treatment with antibiotics does not reduce mortality, bacteremia, or subsequent risk of UTI [2]. Thus, both the Infectious Diseases Society of America (IDSA) and US Preventive Services Task Force discourage screening for, and treatment of, CA-ABU in most clinical settings [3]. Recent guidelines by IDSA provide excellent summaries of the evidence supporting these recommendations [1,2]. "
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    ABSTRACT: Background Overtreatment of catheter-associated bacteriuria is a quality and safety problem, despite the availability of evidence-based guidelines. Little is known about how guidelines-based knowledge is integrated into clinicians’ mental models for diagnosing catheter-associated urinary tract infection (CA-UTI). The objectives of this research were to better understand clinicians’ mental models for CA-UTI, and to develop and validate an algorithm to improve diagnostic accuracy for CA-UTI. Methods We conducted two phases of this research project. In phase one, 10 clinicians assessed and diagnosed four patient cases of catheter associated bacteriuria (n= 40 total cases). We assessed the clinical cues used when diagnosing these cases to determine if the mental models were IDSA guideline compliant. In phase two, we developed a diagnostic algorithm derived from the IDSA guidelines. IDSA guideline authors and non-expert clinicians evaluated the algorithm for content and face validity. In order to determine if diagnostic accuracy improved using the algorithm, we had experts and non-experts diagnose 71 cases of bacteriuria. Results Only 21 (53%) diagnoses made by clinicians without the algorithm were guidelines-concordant with fair inter-rater reliability between clinicians (Fleiss’ kappa = 0.35, 95% Confidence Intervals (CIs) = 0.21 and 0.50). Evidence suggests that clinicians’ mental models are inappropriately constructed in that clinicians endorsed guidelines-discordant cues as influential in their decision-making: pyuria, systemic leukocytosis, organism type and number, weakness, and elderly or frail patient. Using the algorithm, inter-rater reliability between the expert and each non-expert was substantial (Cohen’s kappa = 0.72, 95% CIs = 0.52 and 0.93 between the expert and non-expert #1 and 0.80, 95% CIs = 0.61 and 0.99 between the expert and non-expert #2). Conclusions Diagnostic errors occur when clinicians’ mental models for catheter-associated bacteriuria include cues that are guidelines-discordant for CA-UTI. The understanding we gained of clinicians’ mental models, especially diagnostic errors, and the algorithm developed to address these errors will inform interventions to improve the accuracy and reliability of CA-UTI diagnoses.
    BMC Medical Informatics and Decision Making 04/2013; 13(1):48. DOI:10.1186/1472-6947-13-48 · 1.83 Impact Factor
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