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James R Johnson, Asymptomatic Bacteriuria, Clinical Infectious Diseases, Volume 66, Issue 11, 1 June 2018, Pages 1816–1817, https://doi.org/10.1093/cid/cix1146
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To the Editor—Spivak et al [1] conclude correctly that, among veterans, asymptomatic bacteriuria (ASB) is commonly misdiagnosed as “urinary tract infection” (UTI) and treated unnecessarily, to the patient’s detriment. However, limitations in the definitions these authors used may undercut their important message and lead providers to disregard their findings.
Specifically, the study’s stated diagnostic criteria for cystitis, pyelonephritis, and ASB were nonstandard and inconsistent with the cited references. For cystitis, the authors required the presence of pyuria, which was not mentioned in the Infectious Diseases Society of America (IDSA) treatment guidelines from 1999 (in which bladder symptoms and a positive urine culture sufficed) or 2011 (which implicitly accepted the 1999 diagnostic criteria) [2, 3]. Acute cystitis clearly occurs without pyuria in some women [4]. For pyelonephritis, the authors required flank pain and/or tenderness plus fever, whereas the 1999 IDSA guidelines accepted flank pain (and/or tenderness) and/or fever. Fever is not a universally accepted criterion for pyelonephritis [5, 6]. Moreover, ASB presumably could be diagnosed based on a single urine sample, whereas for voided samples from women the IDSA ASB guidelines require a confirmatory culture [7], which is rarely done in clinical practice so was probably done in few of the study subjects, if any [1].
Consequently, many of the subjects whom the authors classified as having ASB, and therefore as not qualifying for antimicrobial therapy, had ≥1 symptom and/or physical finding suggestive of cystitis or pyelonephritis, per IDSA guidelines, or of urosepsis. Most clinicians would be reluctant to ignore such manifestations, and perhaps appropriately so. Indeed, the clinical trials underlying the IDSA ASB guidelines, which convincingly showed no benefit from treating ASB, involved asymptomatic individuals identified through prospective urine screening programs [7], not by urine cultures that providers ordered as part of routine clinical care, potentially in response to unexplained clinical manifestations—as occurred for many of the present study subjects [1].
It would be of interest to know what proportion of subjects had none of the manifestations listed by Spivak et al [1, table 2], including systemic inflammatory response syndrome criteria, and so were truly asymptomatic. It also would help to know how many had only the nonspecific, noninflammatory manifestations in that listing (ie, altered mental status, malaise, nausea, and lethargy). Such ambiguous manifestations, together with bacteriuria (with or without pyuria), would qualify them for the recently proposed label bacteriuria/pyuria of clinically undetermined significance (BPCUS) [8]. These 2 clinical entities—bacteriuria that is truly asymptomatic and BPCUS—represent the “low-hanging fruit” for which UTI-related antimicrobial stewardship efforts are most appropriate.
I fear that attempts to convince providers that bacteriuria is actually just ASB even when it is accompanied by localizing UTI symptoms and/or otherwise unexplained manifestations of systemic inflammatory response syndrome, and that such patients should not be treated, are doomed to failure; they also threaten the credibility of stewardship efforts and may even harm patients. Providers unquestionably tend to cast too broad a net in diagnosing and treating “UTI” [9], but we must avoid going reactively to the opposite extreme by casting too narrow a net.
Notes
Disclaimer. The opinions expressed here are strictly those of the author and not of his institution or the Department of Veterans Affairs.
Financial support. This work was supported in part by the Office of Research and Development, Department of Veterans Affairs.
Potential conflicts of interest. J. R. J. has received research grants and/or consultancies from Allergan, Crucell/Janssen, ICET, Merck, Tetraphase, and The Medicines Company and is a coinventor on patent applications for tests to detect specific Eschericha coli strains. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
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