![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Infectious Diseases Society of America guidelines for the diagnosis and
treatment of asymptomatic bacteriuria in adults.

#### BIBLIOGRAPHIC SOURCE(S)

Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM.
Infectious Diseases Society of America guidelines for the diagnosis and
treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005
Mar 1;40(5):643-54. \[118 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15714408)

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse (NGC)**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [July 08, 2008, Fluoroquinolones (ciprofloxacin, norfloxacin,
    ofloxacin, levofloxacin, moxifloxacin,
    gemifloxacin)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Fluoroquinolone):
    A BOXED WARNING and Medication Guide are to be added to the
    prescribing information to strengthen existing warnings about the
    increased risk of developing tendinitis and tendon rupture in
    patients taking fluoroquinolones for systemic use.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Asymptomatic bacteriuria

**Note**: Recommendations are relevant only for the treatment of
asymptomatic bacteriuria and do not address prophylaxis for prevention
of symptomatic or asymptomatic urinary infection.

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Geriatrics\
Infectious Diseases\
Internal Medicine\
Obstetrics and Gynecology\
Urology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide recommendations for diagnosis and treatment of asymptomatic
bacteriuria in adult populations \>18 years of age

#### TARGET POPULATION

Adult patients \>18 years of age with asymptomatic bacteriuria

Special populations considered include:

-   Premenopausal, nonpregnant women

-   Pregnant women

-   Diabetic women

-   Older persons residing in the community

-   Elderly institutionalized subjects

-   Subjects with spinal cord injuries

-   Patients with indwelling urethral catheters (both short-term and
    long-term catheters considered)

-   Patients undergoing urologic interventions

-   Immunocompromised patients and organ transplant patients

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Screening**

1.  Screening of special populations for asymptomatic bacteriuria

2.  Collection of urine specimens to minimize contamination

3.  Urine culture

**Treatment**

1.  Nitrofurantoin

2.  Sulfonamides

3.  Mandelamine

4.  Ampicillin

5.  Nalidixic acid

6.  Tetracycline

7.  Cefaclor

8.  Trimethoprim

9.  Norfloxacin

10. Cephalexin

#### MAJOR OUTCOMES CONSIDERED

-   Symptomatic urinary infection

-   Bacteremia with sepsis

-   Worsening functional status

-   Progression to chronic kidney disease or hypertension

-   Development of urinary tract cancer

-   Decreased duration of survival

-   Subsequent antimicrobial resistance

-   Adverse drug effects

-   Cost factors

-   Mortality

-   Progression to diabetic complications (i.e., nephropathy)

-   Incidence of fever

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**Literature Review**

The recommendations in this guideline were developed after a review of
studies published in English. These were identified through a search of
the PubMed database supplemented by review of references of relevant
papers to identify additional reports, particularly early studies not
accessed through the PubMed search. In addition, experts in urinary
infection were asked to identify any additional trials not accessed
through review. Clinical studies include prospective, randomized
clinical trials; prospective cohort studies; case-control studies; and
other descriptive studies. When appropriate, the methodological rigor of
studies was evaluated using accepted criteria (e.g., the CONSORT
statement). Studies were excluded if the study population was not
adequately characterized to assess generalizability, if procedures for
patient follow-up or exclusions may have introduced sufficient bias to
limit the credibility of observations, or if there were insufficient
numbers of patients enrolled to support valid statistical analysis.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Quality of Evidence**

I.  Evidence from [\>]{.underline}1 properly randomized, controlled
    trial

II. Evidence from [\>]{.underline}1 well-designed clinical trial,
    without randomization; from cohort or case-controlled analytic
    studies (preferably from \>1 center); from multiple time-series; or
    from dramatic results from uncontrolled experiments

III. Evidence from opinions of respected authorities, based on clinical
     experience, descriptive studies, or reports of expert committees

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Strength of Recommendation**

A.  Good evidence to support a recommendation for use; should always be
    offered

B.  Moderate evidence to support a recommendation for use; should
    generally be offered

C.  Poor evidence to support a recommendation; optional

D.  Moderate evidence to support a recommendation against use; should
    generally not be offered

E.  Good evidence to support a recommendation against use; should never
    be offered

#### COST ANALYSIS

**Pregnant Women**

An American cost evaluation from the viewpoint of the outcome of
pyelonephritis concluded that a single screening culture in the first
trimester was cost-effective if the prevalence of bacteriuria was \>2%
and the risk of pyelonephritis in bacteriuric women was \>13%.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Respected peers - those who are not members of the guideline panel but
who are experts in the same field - reviewed the guidelines for
scientific validity. These outside reviewers are acknowledged at the end
of the original guideline document. Guidelines were also reviewed by the
Infectious Diseases Society of America (IDSA) Practice Guidelines
Committee for content and format. The guideline group submitted its
final draft to the Practice Guidelines Committee for approval. After
approval was grated, the draft was forwarded to the IDSA Governing
Council for final approval and then to *Clinical Infectious Diseases*
for publication.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The strength of recommendation (A-E) and quality of evidence (I-III) are
defined at the end of the \"Major Recommendations\" field.

**Note**: Recommendations are relevant only for the treatment of
asymptomatic bacteriuria and do not address prophylaxis or prevention of
symptomatic or asymptomatic urinary infection.

1.  The diagnosis of asymptomatic bacteriuria should be based on results
    of culture of a urine specimen collected in a manner that minimizes
    contamination (**A-II**).

    -   For asymptomatic women, bacteriuria is defined as 2 consecutive
        voided urine specimens with isolation of the same bacterial
        strain in quantitative counts [\>]{.underline}10^5^ colony
        forming units (cfu)/mL (**B-II**).

    -   A single, clean-catch voided urine specimen with 1 bacterial
        species isolated in a quantitative count [\>]{.underline}10^5^
        cfu/mL identifies bacteriuria in men (**BIII**).

    -   A single catheterized urine specimen with 1 bacterial species
        isolated in a quantitative count [\>]{.underline}10^2^ cfu/mL
        identifies bacteriuria in women or men (**A-II**).

2.  Pyuria accompanying asymptomatic bacteriuria is not an indication
    for antimicrobial treatment (**A-II**).

3.  Pregnant women should be screened for bacteriuria by urine culture
    at least once in early pregnancy, and they should be treated if the
    results are positive (**A-I**).

    -   The duration of antimicrobial therapy should be 3-7 days
        (**A-II**).

    -   Periodic screening for recurrent bacteriuria should be
        undertaken following therapy (**A-III**).

    -   No recommendation can be made for or against repeated screening
        of culture-negative women in later pregnancy.

4.  Screening for and treatment of asymptomatic bacteriuria before
    transurethral resection of the prostate is recommended (**A-I**).

    -   An assessment for the presence of bacteriuria should be
        obtained, so that results will be available to direct
        antimicrobial therapy prior to the procedure (**A-III**).

    -   Antimicrobial therapy should be initiated shortly before the
        procedure (**A-II**).

    -   Antimicrobial therapy should not be continued after the
        procedure, unless an indwelling catheter remains in place
        (**B-II**).

5.  Screening for and treatment of asymptomatic bacteriuria is
    recommended before other urologic procedures for which mucosal
    bleeding is anticipated (**A-III**).

6.  Screening for or treatment of asymptomatic bacteriuria is not
    recommended for the following persons.

    -   Premenopausal, nonpregnant women (**A-I**)

    -   Diabetic women (**A-I**)

    -   Older persons living in the community (**A-II**)

    -   Elderly, institutionalized subjects (**A-I**)

    -   Persons with spinal cord injury (**A-II**)

    -   Catheterized patients while the catheter remains in situ
        (**A-I**)

7.  Antimicrobial treatment of asymptomatic women with catheter-acquired
    bacteriuria that persists 48 hours after indwelling catheter removal
    may be considered (B-I).

8.  No recommendation can be made for screening for or treatment of
    asymptomatic bacteriuria in renal transplant or other solid organ
    transplant recipients (**C-III**).

**[Definitions]{.underline}**:

**Quality of Evidence**

I.  Evidence from [\>]{.underline}1 properly randomized, controlled
    trial

II. Evidence from [\>]{.underline}1 well-designed clinical trial,
    without randomization; from cohort or case-controlled analytic
    studies (preferably from \>1 center); from multiple time-series; or
    from dramatic results from uncontrolled experiments

III. Evidence from opinions of respected authorities, based on clinical
     experience, descriptive studies, or reports of expert committees

**Strength of Recommendation**

A.  Good evidence to support a recommendation for use; should always be
    offered

B.  Moderate evidence to support a recommendation for use; should
    generally be offered

C.  Poor evidence to support a recommendation; optional

D.  Moderate evidence to support a recommendation against use; should
    generally not be offered

E.  Good evidence to support a recommendation against use; should never
    be offered

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for most
recommendations (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate diagnosis and treatment of asymptomatic bacteriuria in
adults

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline is not meant to replace clinical judgment.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM.
Infectious Diseases Society of America guidelines for the diagnosis and
treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005
Mar 1;40(5):643-54. \[118 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15714408)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005 Mar 1

#### GUIDELINE DEVELOPER(S)

Infectious Diseases Society of America - Medical Specialty Society

#### SOURCE(S) OF FUNDING

Infectious Diseases Society of America (IDSA)

#### GUIDELINE COMMITTEE

Infectious Diseases Society of America (IDSA) Practice Guidelines
Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Lindsay E. Nicolle, University of Manitoba, Winnipeg, Canada;
Suzanne Bradley, University of Michigan, Ann Arbor; Richard Colgan,
University of Maryland, Baltimore; James C. Rice, University of Texas,
Galveston; Anthony Schaeffer, Northwestern University, Chicago,
Illinois; Thomas M. Hooton, University of Washington, Seattle

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

**Potential conflicts of interest**. L.E.N. has received research
funding from Ortho-McNeil. R.C. has received research funding from
Ortho-McNeil and has served on the speakers\' bureau for Bayer. A.S. has
been a consultant for Ortho-McNeil, Proctor & Gamble, Gerson Lehrman
Group, Urologix, DepoMed, Schwarz BioSciences GmbH, and SynerMed
Communications. T.M.H. has been a consultant for Bayer and served on the
speakers\' bureau for Aventis, Bayer, Merck, and Pfizer.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Infectious Disease Society of
America (IDSA) Web
site](http://www.journals.uchicago.edu/cgi-bin/resolve?CID35309).

Print copies: Available from Infectious Diseases Society of America,
1300 Wilson Boulevard, Suite 300, Arlington, VA 22209.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Kish MA. Guide to development of practice guidelines. Clin Infect
    Dis 2001 Mar 15;32(6):851-4.

Electronic copies: Available from the [Clinical Infectious Diseases
Journal Web
site](http://www.journals.uchicago.edu/doi/full/10.1086/319366).

Print copies: Available from Infectious Diseases Society of America,
1300 Wilson Boulevard, Suite 300, Arlington, VA 22209.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on April 6, 2005. This summary was
updated by ECRI Institute on July 28, 2008 following the U.S. Food and
Drug Administration advisory on fluoroquinolone antimicrobial drugs.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which may be
subject to the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008