A 74 Year Old Woman With Asymptomatic Bacteriuria

A 74-year-old woman is in your office for a complete physical. On further questioning, she has mentions having had stress urinary incontinence for a number of years, which is unchanged. She reports no fevers, hematuria, dysuria, flank pain, or other symptoms.
You obtain a urinalysis which shows 10–20WBC/hpf and is nitrite positive on dipstick. A culture of the urine shows 100,000 cfu/mL of E. coli.

How should you treat this patient?

A) Trimethoprim-sulfamethoxazole DS 1 tab PO BID for 10 days.
B) Erythromycin 500 mg PO q 6 hours for 14 days.
C) Ampicillin 250 mg PO q 6 hours for 10 days.
D) Ceftriaxone 1 g IM every day for 3 days.
E) With courtesy and respect, but not with antibiotics.

Answer And Discussion:


The correct answer is “E.”
A positive urine culture in an asymptomatic patient (e.g., asymptomatic bacteriuria) should not be treated with antibiotics.
Asymptomatic bacteriuria is a very common finding, especially in elderly females, persons with indwelling catheters, and institutionalized persons. Treatment does not reduce the incidence of symptomatic infection. Treatment also does not reduce mortality in
frail elderly patients, and does not improve chronic urinary incontinence symptoms. Persistent asymptomatic bacteriuria does not result in renal insufficiency or the development of hypertension.

Exceptions For Treatment:Treat asymptomatic bacteriuria in the following patients:

• those with urinary tract obstruction (functional or anatomic),
• nephrolithiasis, 
• pregnancy, 
• planned urinary instrumentation, and 
• children with grade V vesicoureteral reflux only (it is not helpful in grades I–IV reflux).

Other Pathologic Causes Of Pyuria: 

Not all pyuria is from UTI. Other pathologic causes of pyuria include: 

• vaginitis (infectious and atrophic), 
• urethritis (Chlamydia trachomatis, Neisseria gonorrhoeae), and 
• genital herpes infections.