Interpreting asymptomatic bacteriuria
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4780 (Published 04 August 2011) Cite this as: BMJ 2011;343:d4780
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If the bacteria are present in urinary tract without causing symptoms
(and with no pyuria) may perhaps mean that they are not harming the body in
any way and body is not reacting. An effort to treat them in children,
diabetics and patients with catheterization or in old age (with no
symptoms) will not only eradicate normal flora in the body viz., gut
flora, vaginal or oral flora (causing thrush, diarroea etc.), but probably
may make urinary tract vulnerable to other more harmful bacteria and may
result in emergence of resistant strains in most patients of asymptomatic
bacteriuria1. But question still remains that what to do in other
immunosuppresive states such as HIV/AIDS
Reference:
1. Harrison's Principle of Internal Medicine. 17th Edition. P. No.
1825.
Competing interests: No competing interests
Thank you for a nice overview of this very commonly encountered
clinical scenario.
Asymptomatic bacteruria is also very common in patients with various
urological conditions like benign prostatic hyperplasia, stone disease
etc. Very commonly attempts are made to eradicate infection in these
patients with various antibiotics which is unnecessary, harmful and many
times unsuccessful.
To convince non physician colleague about "no treatment" in this
setting is as difficult as convincing patients with this condition. Such
patients should only be treated if they are undergoing any surgical or
endoscopic intervention to prevent post op pyelonephritis.
Competing interests: No competing interests
I am grateful to the authors for providing a clear and comprehensive
article on interpreting asymptomatic bacteriuria.
A correction may be required in this article, however, as the authors
delineate that "Testing for and treating asymptomatic bacteriuria is of
established value in pregnant women as it reduces the risk of
pyelonephritis later in pregnancy by about 75%", although it is later
expressed that "Treatment of asymptomatic bacteriuria is not recommended
in pregnant women of any age because the condition is not associated with
adverse long term outcomes and because treatment does not result in
durable eradication of bacteriuria or improved clinical outcome." (line 7,
sentence 4, under heading of "Avoidance of testing", and subheading "Older
people") Perhaps, the authors really meant that that "Treatment of
asymptomatic bateriuria is not recommended in older/elderly women..." or
"Treatment of asymptomatic bateriuria is not recommended in non-pregnant
women of any age..."
Once again, thanks for a thorough article; it will certainly be
helpful to students preparing for exams and helping physicians practice
evidence based medicine.
Competing interests: No competing interests
Fosfomycin tromethamine for urinary tract infections
Dear Editor of the BMJ,
Mrs A., the clinical case presented in this article, was successfully
treated with nitrofurantoin.
All other fancy, modern and much more expensive antibiotics did not
work. Resistance is often encountered in common everyday clinical
scenarios, in many Countries. [4] [7] [8] [9] [10] [11] [12] [13] [16]
[18] [19] [20] [22] [24] [25] [26]
Together with fosfomycin tromethamine, nitrofurantoin constitutes
first line empirical antibiotic treatment for uncomplicated urinary tract
infections. [1] [2] [3] [9] [10] [12] [14] [17] [19]
I was surprised to read that fosfomycin tromethamine was neither
tested for susceptibility nor administered to Mrs A.
There exists an unexplained clinical exclusion for this effective,
well-tolerated, cheap, easily administered, not inducing high rates of
resistance, chemical compound. [4] [5] [6] [7] [8] [9] [11] [13] [15]
[16] [17] [21] [23] [24] [25]
Often, it is not even included in laboratory antibiotic resistance
tests. [3]
In many Countries supplies are very limited. In Greece it was
recently withdrawn from the market, probably because of low profit
marketing.
It is a pity to ignore and exclude such a useful chemical compound!
References
[1] Internist (Berl). 2011 Sep;52(9):1026-31.
Urinary tract infections.
H?rl WH.
Klinische Abteilung f?r Nephrologie und Dialyse, Medizinische
Universit?tsklinik III, W?hringer G?rtel 18-20, 1090, Wien, ?sterreich.
http://www.ncbi.nlm.nih.gov/pubmed/21850538
[2] Dtsch Arztebl Int. 2011 Jun;108(24):415-23. Epub 2011 Jun 17.
Uncomplicated urinary tract infections.
Wagenlehner FM, Hoyme U, Kaase M, F?nfst?ck R, Naber KG, Schmiemann G.
http://www.ncbi.nlm.nih.gov/pubmed/21776311
[3] Am J Ther. 2011 Jul 15.
Potential Role of Fosfomycin in the Treatment of Community-Acquired Lower
Urinary Tract Infections Caused by Extended-Spectrum ?-Lactamase-Producing
Escherichia coli.
Wilson DT, May DB.
1Department of Pharmacy, Campbell University College of Pharmacy and
Health Sciences, Buies Creek, NC; and 2Department of Pharmacy, Duke
University Hospital, Durham, NC.
http://www.ncbi.nlm.nih.gov/pubmed/21768870
[4] Infection. 2011 Aug;39(4):333-40. Epub 2011 Jun 25.
Extended-spectrum ?-lactamase-producing Gram-negative pathogens in
community-acquired urinary tract infections: an increasing challenge for
antimicrobial therapy.
Meier S, Weber R, Zbinden R, Ruef C, Hasse B.
Division of Infectious Diseases and Hospital Epidemiology, University
Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich,
Switzerland.
http://www.ncbi.nlm.nih.gov/pubmed/21706226
[5] Int J Gynaecol Obstet. 2011 Sep;114(3):229-33. Epub 2011 Jun 22.
Comparison of single-dose and multiple-dose antibiotics for lower urinary
tract infection in pregnancy.
Usta TA, Dogan O, Ates U, Yucel B, Onar Z, Kaya E.
Department of Obstetrics and Gynecology, Bagcilar Education and Research
Hospital, Istanbul, Turkey.
http://www.ncbi.nlm.nih.gov/pubmed/21696732
[6] Antimicrob Agents Chemother. 2011 Sep;55(9):4295-301. Epub 2011
Jun 13.
Antimicrobial susceptibilities of commonly encountered bacterial isolates
to fosfomycin determined by agar dilution and disk diffusion methods.
Lu CL, Liu CY, Huang YT, Liao CH, Teng LJ, Turnidge JD, Hsueh PR.
Departments of Laboratory Medicine and Internal Medicine, National Taiwan
University Hospital, No. 7, Chung-Shan South Road, Taipei 100, Taiwan.
http://www.ncbi.nlm.nih.gov/pubmed/21670185
[7] J Microbiol Immunol Infect. 2011 Jan 20.
Antimicrobial susceptibilities of urinary extended-spectrum beta-lactamase
-producing Escherichia coli and Klebsiella pneumoniae to fosfomycin and
nitrofurantoin in a teaching hospital in Taiwan.
Liu HY, Lin HC, Lin YC, Yu SH, Wu WH, Lee YJ.
Department of Internal Medicine, Taipei Medical University Hospital,
Taipei, Taiwan.
http://www.ncbi.nlm.nih.gov/pubmed/21524974
[8] Int J Antimicrob Agents. 2011 May;37(5):415-9. Epub 2011 Mar 22.
What remains against carbapenem-resistant Enterobacteriaceae? Evaluation
of chloramphenicol, ciprofloxacin, colistin,fosfomycin, minocycline,
nitrofurantoin, temocillin and tigecycline.
Livermore DM, Warner M, Mushtaq S, Doumith M, Zhang J, Woodford N.
Antibiotic Resistance Monitoring & Reference Laboratory, Health
Protection Agency Microbiology Services-Colindale, 61 Colindale Avenue,
London NW9 5EQ, UK.
http://www.ncbi.nlm.nih.gov/pubmed/21429716
[9] Urologe A. 2011 Feb;50(2):153-69.
National S3 guideline on uncomplicated urinary tract infection:
recommendations for treatment and management of uncomplicated community-
acquired bacterial urinary tract infections in adult patients.
Wagenlehner FM, Schmiemann G, Hoyme U, F?nfst?ck R, Hummers-Pradier E,
Kaase M, Kniehl E, Selbach I, Sester U, Vahlensieck W, Watermann D, Naber
KG.
Klinik und Poliklinik f?r Urologie, Kinderurologie und Andrologie,
Universit?tsklinikum Giessen und Marburg GmbH, Justus-Liebig-Universit?t
Giessen, Rudolf-Buchheim-Stra?e 7, 35385 Giessen, Deutschland.
http://www.ncbi.nlm.nih.gov/pubmed/21312083
[10] Curr Infect Dis Rep. 2010 Nov;12(6):455-64.
Treatment of resistant enterococcal urinary tract infections.
Swaminathan S, Alangaden GJ.
Division of Infectious Diseases, Wayne State University School of
Medicine, Detroit, MI, USA
http://www.ncbi.nlm.nih.gov/pubmed/21308555
[11] J Infect Chemother. 2011 Aug;17(4):575-8. Epub 2011 Feb 2.
In vitro susceptibility of enterococci strains isolated from urine samples
to fosfomycin and other antibiotics.
Butcu M, Akcay SS, Inan AS, Aksaray S, Engin DO, Calisici G.
Microbiology and Clinical Microbiology Laboratory, Haydarpasa Numune
Training and Research Hospital, Istanbul, Turkey.
http://www.ncbi.nlm.nih.gov/pubmed/21287226
[12] Aktuelle Urol. 2011 Jan;42(1):33-7. Epub 2011 Jan 25.
Uncomplicated urinary tract infection and treatment.
Wagenlehner FM, Vahlensieck W, Watermann D, Weidner W, Naber KG.
Klinik und Poliklinik f?r Urologie, Kinderurologie und Andrologie, Justus-
Liebig-Universit?t, Giessen.
http://www.ncbi.nlm.nih.gov/pubmed/21267803
[13] J Chemother. 2010 Oct;22(5):345-54.
Do different susceptibility breakpoints affect the selection of
antimicrobials for treatment of uncomplicated cystitis?
Schito GC, Gualco L, Naber KG, Botto H, Palou J, Mazzei T, Marchese A.
Institute of Microbiology, University of Genoa, Italy.
http://www.ncbi.nlm.nih.gov/pubmed/21123159
[14] Pharmacotherapy. 2010 Nov;30(11):1136-49.
Vancomycin-resistant enterococcal urinary tract infections.
Heintz BH, Halilovic J, Christensen CL.
Department of Clinical Pharmacy, University of California-San Francisco
School of Pharmacy, San Francisco, California 94143, USA.
http://www.ncbi.nlm.nih.gov/pubmed/20973687
[15] J Infect Chemother. 2011 Feb;17(1):80-6. Epub 2010 Aug 7.
Clinical effects of 2 days of treatment by fosfomycin calcium for acute
uncomplicated cystitis in women.
Matsumoto T, Muratani T, Nakahama C, Tomono K.
Department of Urology, School of Medicine, University of Occupational and
Environmental Health, Kitakyushu, Fukuoka, Japan.
http://www.ncbi.nlm.nih.gov/pubmed/20694571
[16] J Infect Chemother. 2010 Dec;16(6):424-30. Epub 2010 Jun 29.
A randomized comparative study of single-dose fosfomycin and 5-day
ciprofloxacin in female patients with uncomplicated lower urinary tract
infections.
Ceran N, Mert D, Kocdogan FY, Erdem I, Adalati R, Ozyurek S, Goktas P.
Infectious Diseases and Clinical Microbiology Clinics, Haydarpasa Numune
Training and Research Hospital, Istanbul, Turkey.
http://www.ncbi.nlm.nih.gov/pubmed/20585969
[17] Antimicrob Agents Chemother. 2010 Sep;54(9):4006-8. Epub 2010
Jun 28.
Oral treatment options for ambulatory patients with urinary tract
infections caused by extended-spectrum-beta-lactamase-producing
Escherichia coli.
Auer S, Wojna A, Hell M.
Department of Hospital Epidemiology and Infection Control, Salzburg
Medical University, Muellner Hauptstr. 48, Salzburg A-5020, Austria.
http://www.ncbi.nlm.nih.gov/pubmed/20585127
[18] Med Mal Infect. 2010 Oct;40(10):555-9. Epub 2010 Apr 22.
Susceptibility to antibiotics of Escherichia coli isolated from community-
acquired urinary tract infections.
Fabre R, M?rens A, Lefebvre F, Epifanoff G, Cerutti F, Pupin H, Tardif D,
Cavallo JD, Ternois I.
Label Bio, 36, rue du Neubourg 76500 Elbeuf, France.
http://www.ncbi.nlm.nih.gov/pubmed/20417046
[19] Rev Esp Quimioter. 2010 Mar;23(1):36-42.
Changes in the antimicrobial susceptibility of Escherichia coli isolates
from community diagnosed urinary tract infections during the period 2003-
2007. Multicentre study in Castilla la Mancha (Spain).
Tena D, Gonz?lez-Praetorius A, Gonz?lez JC, Heredero E, Illescas S, de
Baranda CS, Sese?a G.
Hospital Universitario de Guadalajara, C/ Donante de sangre s/ n, 19002
Guadalajara, Spain.
http://www.ncbi.nlm.nih.gov/pubmed/20232022
[20] Drugs. 2010 Feb 12;70(3):313-33. doi: 10.2165/11533040-
000000000-00000.
Infections with extended-spectrum beta-lactamase-producing
enterobacteriaceae: changing epidemiology and drug treatment choices.
Pitout JD.
Division of Microbiology, Calgary Laboratory Services, Calgary, Alberta,
Canada.
http://www.ncbi.nlm.nih.gov/pubmed/20166768
[21] J Ayub Med Coll Abbottabad. 2010 Jan-Mar;22(1):11-2.
Nosocomial uropathogens and their antibiotic sensitivity patterns in a
tertiary referral teaching hospital in Rawalpindi, Pakistan.
Khan BA, Saeed S, Akram A, Khan FB, Nasim A.
Department of Surgery, Foundation University Medical College, Rawalpindi,
Pakistan.
http://www.ncbi.nlm.nih.gov/pubmed/21409893
[22] Ann Clin Microbiol Antimicrob. 2009 Oct 24;8:27.
Empiric antibiotic therapy in acute uncomplicated urinary tract infections
and fluoroquinolone resistance: a prospective observational study.
Aypak C, Altunsoy A, D?zg?n N.
Department of Family Medicine, Ankara University, School of Medicine, Ibni
Sina Hospital 06100, Ankara, Turkey.
http://www.ncbi.nlm.nih.gov/pubmed/19852849
[23] Eur J Clin Microbiol Infect Dis. 2009 Dec;28(12):1457-64. Epub
2009 Sep 20.
Fosfomycin in a single dose versus a 7-day course of amoxicillin-
clavulanate for the treatment of asymptomatic bacteriuria during
pregnancy.
Estebanez A, Pascual R, Gil V, Ortiz F, Santib??ez M, P?rez Barba C.
Villena Health Centre, San Francisco, 1, Villena, 03400 Alicante, Spain.
http://www.ncbi.nlm.nih.gov/pubmed/19768649
[24] Eur J Clin Microbiol Infect Dis. 2009 Nov;28(11):1399-403. Epub
2009 Jul 29.
Antimicrobial non-susceptibility of cervico-vaginal and rectal Escherichia
coli isolates is associated with phylogeny and plasmid carriage.
Hilbert DW, Paulish TE, Mordechai E, Adelson ME, Gygax SE, Trama JP.
Research and Development, Medical Diagnostic Laboratories LLC, Hamilton,
NJ 08016, USA.
http://www.ncbi.nlm.nih.gov/pubmed/19639348
[25] Int J Antimicrob Agents. 2009 Nov;34(5):407-13. Epub 2009 Jun
7.
The ARESC study: an international survey on the antimicrobial resistance
of pathogens involved in uncomplicated urinarytract infections.
Schito GC, Naber KG, Botto H, Palou J, Mazzei T, Gualco L, Marchese A.
Sezione di Microbiologia del DISCMIT, University of Genoa, Genoa, Italy.
http://www.ncbi.nlm.nih.gov/pubmed/19505803
[26] J Chemother. 2008 Dec;20(6):721-7.
Antimicrobial resistance among uropathogens responsible for community-
acquired urinary tract infections in an Italian community.
Miragliotta G, Di Pierro MN, Miragliotta L, Mosca A.
Section of Microbiology, Department of Clinica Medica, Immunologia,
Malattie Infettive, University of Bari, Italy.
http://www.ncbi.nlm.nih.gov/pubmed/19129070
Competing interests: No competing interests