Asymptomatic Bacteriuria

Which of the following two patients with asymptomatic bacteria, or abbreviated ABS, should receive antimicrobial therapy?

A. An 84‑year‑old woman who is a resident of a long‑term care facility with dementia, no new urinary symptoms, her urine is positive for nitrites, leukocytes, and culture reveals 100,000 colony forming units per ml of E. coli.

B. A 70‑year‑old man with an indwelling Foley catheter, no new urinary symptoms. His urine appears cloudy and foul‑smelling. His culture is 100,000 CFU of mixed flora.

C. A 30‑year‑old woman who is 10 weeks pregnant, no urinary symptoms, culture reveals 100,000 CFU per ml of E. coli.

D. A 72‑year‑old man scheduled for a transurethral prostate resection, a TURP, next week, no urinary symptoms. His culture reveals 100,000 CFU per ml of E. coli.

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Transcript

Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.

Margaret Fitzgerald: Which of the following two patients with asymptomatic bacteria or abbreviated ABS should receive antimicrobial therapy? 

A. An 84-year-old woman who is a resident of a long-term care facility with dementia, no new urinary symptoms. Her urine is positive for nitrites, leukocytes, and culture reveals 100,000 colony forming units per ml of E.coli.

B. A 70-year-old man with an indwelling foley catheter, no new urinary symptoms. His urine appears cloudy and foul smelling. His culture is 100,000 CFU of mixed flora.

C. A 30-year-old woman who is 10 weeks pregnant, no urinary symptoms. Culture reveals 100,000 CFU of per ml of E.coli.

D. A 72-year-old man scheduled for a transurethral prostate resection, a TURP, next week, no urinary symptoms. His culture reveals 100,000 CFU per ml of E.coli. 

And the correct answers are C, the 30-year-old woman who's 10 weeks pregnant, and D, the 72-year-old man who scheduled for a TURP next week. 

Where should we start with this question? First, we figure out what kind of a question it is. We're presented with four patient case studies and being asked who should be treated. This is a plan/intervention question. 

A bit of background information. ABS or asymptomatic bacteria is the presence of bacteria in the urine at significant levels without signs and symptoms of UTI. Of course, the UTI symptoms that we would typically note in cystitis and urethritis are absent and the patient denies dysuria frequency urinary urgency, suprapubic pain, flank pain or fever attributable to the UTI. While there are no UTI signs and symptoms in any of the patients presented to us, nonetheless, urine culture is positive. And you'll notice in some of these case studies there are WBC's and often nitrites in the urine which typically make us think of UTI. And you might say then if these people do not have UTI like symptoms, why was a urine analysis and a urine culture done? Well, in older adults, this often happens is that there is a reflex urine culture done. A person has a urinalysis done for another reason there's some WBC's some nitrites in the urine and even though the person has not does not have any UTI like symptoms reflexively the lab will then send it over for culture and so that's how we can end up with urine cultures like this in a person who's asymptomatic 

Who is most likely to have ABS? This condition is most often found in older adults, particularly older women, residents of long-term care facilities, individuals with an indwelling urinary catheter, and people with spinal cord injuries or other form of neurogenic bladder. Having diabetes also appears to increase the risk of developing ABS. The condition is often found during pregnancy as well and this is due in part to the normative anatomic changes that occur in the urinary tract during pregnancy. Indeed, part of routine prenatal care includes a check for asymptomatic bacteria at least once during the gestation. In this question, we have four clinical scenarios. All these folks are asymptomatic, right? But all four of them have bacteria growing in their urine. A person with a more classic UTI, of course, would have symptoms. And in that case, we would have a UTI and treatment should proceed. 

With that information in mind, let's take another look at the question. Which of the following two patients with ABS should receive antimicrobial therapy? 

A. An 84-year-old woman who is a long-term care resident with dementia and no new urinary symptoms. Urine is positive for nitrites and leukocytes. And the culture reveals 100 uh 100,000 CFU per ml of E.coli. This answer is incorrect. You might say yes, but this is a person with cognitive alterations. Good point. But this is major neurocognitive disorder or dementia and not delirium. As you know, UTI are a common contributor to the development of temporary changes in cognition such as delirium. But we're told this person has dementia. Implied there is the neurocognitive changes have been longstanding.

B. A 70-year-old man with an indwelling Foley catheter. No urinary symptoms. His urine appears cloudy and foul smelling. And the culture reveals 100,000 CFU per ml of mixed flora. I suspect you know this is incorrect from your RN experience in acute care because most of you have had some acute care experience. People with indwelling catheters tend to get bladder colonization of bacteria within days of the Foley going in. It's usually mixed flora. And what this tells me is any culture that comes back as mixed flora, it's a urinary tract contaminant or a contaminated specimen. While treating with an antibiotic is certainly tempting, what this simply leads to is increased risk for resistant pathogens without any improvement in clinical outcomes. And I would say the exact same thing for the patient in answer A. 

C. A 30-year-old woman 10 weeks pregnant, no urinary symptoms, culture 100,000 CFU per ml of E. coli. This is of course one of the correct answers. Pregnancy is one of the few times when ABS is treated. The reason for this is the anatomic changes in the urinary tract. These are physiologic changes not pathologic and they are present to allow for increased circulating volume. This can result in extra reflux of urine into the renal pelvis and subsequent risk for pyloritis which can be quite dangerous during pregnancy. Untreated ABS during pregnancy can lead to increased risk for a low birthweight baby and increased risk for preterm birth. Treating this condition mitigates the risks. As I mentioned, this is the reason that during pregnancy, a urinalysis with a urine culture and sensitivity is done at least once to screen for ABS. If ABS is present, the frequency of urine culture and sensitivity during the pregnancy increases and further surveillance is warranted. 

D. A 72-year-old man scheduled for a trans urethral prostate resection, a TURP, next week, no urinary symptoms, and he has 100,000 CFU per ml of E.coli. This is of course the second of the correct answers. ABS is typically treated before there is any urinary tract surgery done. This reduces the risk of surgical complication in urosepsis.

Key takeaway ABS is a commonly encountered clinical condition. Knowing when to treat is as important as knowing when not to treat.

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