Urinalysis has Pyuria, Leucocyte Esterase—and is Growing Bacteria; Can You Resist the Urge to Treat?
The medical community has repeatedly been cautioned about the negative impact of unrestrained script-writing, particularly when it comes to antibiotics. Yet over and over again, stories surface about too hasty and too generous antibiotic dispensing. A notoriously egregious clinical example is in the treatment of asymptomatic bacteriuria. In 68% of diagnosed cases, patients are inappropriately prescribed antimicrobials. This very high percentage is concerning for (what should be) a very straightforward reason: If a person is without symptoms of a urinary tract infection (asymptomatic means that they are experiencing no frequency, dysuria, urgency, hematuria) the individual should not be screened (urinalysis and additional studies) unless pregnant or about to undergo a urologic procedure with mucosal disruption.1,2
These are the only 2 cohorts who benefit from antibiotic therapy for asymptomatic bacteriuria.
Furthermore, if asymptomatic patients are screened inappropriately and have bacteriuria and pyuria, they should not be treated with antibiotics. This month’s featured “Top Paper”1 begins with a patient who has neither of the indications for screening and is asymptomatic in regard to his urinary tract. He has pyuria and leucocyte esterase without symptoms. The patient was chosen wisely by the authors, since he is in his 80s and therapeutically anticoagulated with warfarin. Inappropriate antibiotic(s) administration exposes him to many risks, including bleeding because he is anticoagulated with a Vitamin K antagonist.
Here are the authors’ most salient points:
• Studies performed in nonpregnant women, the elderly, and institutionalized persons without catheters have not demonstrated any benefit of antibiotics in the setting of asymptomatic bacteriuria.
• Treatment of asymptomatic bacteriuria does not decrease the risk of symptomatic infections. In fact, the risk of a symptomatic infection in these folks is slight at most anyway.
• There is no association between asymptomatic carriage of bacteria and kidney function, malignancy, blood pressure, or mortality.
• Treating inappropriately with antibiotics increases the risk of resistant infections or Clostridium difficile later.
• One study suggested that asymptomatic bacteriuria in sexually active young women may be protective in that it decreases colonization by more virulent strains of bacteria.
• In a matter of weeks, I have seen multiple people without urinary tract symptoms treated with antibiotics for any of the following: pyuria, positive urine cultures (significant colonies or not), microscopic hematuria, or a positive leucocyte esterase. I also continue to witness simple, uncomplicated cystitis treated for a week to 10 days with antibiotics when guidelines recommend 3 days only! The costs in terms of money and complications should lead us to a change in this practice. It is high time we listen and learn.
Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.
References:
1. Weiskopf J, Scott S. Asymptomatic bacteriuria, what are you treating? JAMA Intern Med. 2015;175(3):344-345.
2. Lin K, and Fajardo K. US Preventive Services Task Force. Screening for asymptomatic bacteruria in adults: Evidence for the US preventive services task force reaffirmation recommendation statement. An Intern Med. 2008;149:W20-24.