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Florian M. E. Wagenlehner, Kurt G. Naber, Editorial Commentary: Asymptomatic Bacteriuria—Shift of Paradigm, Clinical Infectious Diseases, Volume 55, Issue 6, 15 September 2012, Pages 778–780, https://doi.org/10.1093/cid/cis541
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(See the Major Article by Cai et al, on pages 771–7.)
Initial studies on quantitative urine cultures obtained from large numbers of patients have established so-called significant (true) bacteriuria at a threshold of ≥105 colony-forming units per milliliter [1]. Because asymptomatic bacteriuria (ABU) has been found with particular frequency in populations more likely to develop pyelonephritis (ie, individuals with diabetes mellitus, pregnancy, obstructive uropathy, past history of instrumentation of the urinary tract), a strong relationship between bacteriuria and pyelonephritis was assumed. This was consolidated by the observation that in pregnancy elimination of ABU decreases the risk for a symptomatic infection [2]. Although bacteriuria is present in a relatively asymptomatic population, it is virtually always necessary for the development of symptomatic disease. Therefore, it was assumed that the presence of bacteriuria defines a population at risk and the elimination of bacteriuria minimizes the risk for a clinically symptomatic disease [2]. The discrepancy between the frequency of pyelonephritis found in autopsies and that diagnosed during life in only about one-fifth of the cases was explained by a high incidence of clinically atypical or inapparent infections [3]. At that time bacteriuria was considered dangerous in any case, because bacteriuria detected at a significant quantity, even if asymptomatic, was associated with a substantially increased risk of pyelonephritis and premature delivery.
