2.  9 million doctor visits/year!  Customary urine test is the dip stick and the mid-stream culture of voided urine. Up to 77% of cystitis cases are cultured  Traditionally- >100,000 (10⁵)CFUs was called diagnostic of either UTI (bladder infection present) or asymptomatic bacteruria.  More recently as little as 100 CFUs in a voided sample has been positively correlated with coliform (such as E. coli) bladder infection  The problem with this cut off: Many labs will call 0 to 10,000 CFUs (<10⁴) as a negative culture

3. The way the urine test is done, diluting out the urine 1000 times, there may be no growth on the agar plates despite a bladder infection being present

4. What does the results of the urine culture tell you ? 202 paired samples of mid stream collected urine cultures and catheterized bladder cultures in young woman who had symptoms of uncomplicated cystitis, no features of pyelonephritis 70% of bladder cultures positive 78% of voided mid-stream cultures positive As few as 10 CFUs of mid-stream cultures of E. coli or Klebsiella pneumoniae– highly correlated with a true bladder infection ( 93% PPV). In contrast – 22% of mid- stream cultures grew enterococcus or Group B strep- at even 100,000 (10⁵ CFUs) – there was no correlation with bladder cultures- These bugs were not found in the corresponding bladder culture, but E.coli was still cultured in the bladder (but not in the mid-stream culture) in 62% of these cases ! Take Home Message: I. a young woman with classic cystitis symptoms can have a documented bladder infection, but her midstream urine culture can still be a false negative test ( too few CFUs to be detected on standard urine cultures) II. Positive mid-stream cultures for enterococcus and Group B strep are most likely contaminants III. In uncomplicated cases- obtaining cultures as a guide to therapy can be counter productive: either not treating patients with actual infection, or treating patients for the wrong bacteria.

5.  Ask the patient “do you feel like you have a bladder infection- do you have both a sense of urgency and burnig when you urinate?”  Do a dip stick and treat only if leukocytes or nitrite positive?  Send the urine for culture, wait 2 days, and treat the patient only if >100,000/ml colonies

6.  Symptoms only: +dysuria, +frequency, no discharge or irritation:***90% chance of cystitis***  Dipstick: leukocyte esterase + and/or nitrite + only 75% sensitive, so symptoms more important even if dip is negative  Culture:10⁵ (100,000) bacterial CFU- traditional criterion of UTI- 50% sensitive -will miss up to half of cases of UTI – counts of 100 to 10,000 colonies – all at levels that may be called as “no growth” by micro lab. Least sensitive diagnostic test

7.  **Rarely progresses to severe disease even if untreated: goal is to ameliorate symptoms  In selecting therapy, efficacy as well as “ecologic collateral damage” (selecting for antibiotic resistant bacteria, C. difficile colitis) should be considered equally- fluoroquinolones should be avoided, except in pyelonephritis  Nitrofurantoin, Septra, fosfomycin are therefore first line agents  New Study- still >50% of Rxs are for Cipro, most of the time for > than 3 days. Septra #2, nitro #3, fosfomycin-no Rx

9.  Definition: presence of bacteria >100,000 cfu/ml in urine of an individual without signs or symptoms of UTI.  This definition is independent of the presence or absence of pyuria, odor, cloudy urine

10.  Very Common: i. Young healthy women : 3 to 5% i. Pregnant women: 2 to 9.5% ii. Women aged 65-80 years: 18 to 43% iii. Women > 80 years: up to 43% iv. Men 65-80 years: 2 to 15%  Causes: Obstructive uropathy, neuromuscular disease, perineal soiling in dementia, etc

11.  Traditional teaching: the presence of bacteriuria defines a population at risk, therefore: Eliminating the “asymptomatic UTI” (oxymoron) minimizes the risk for a clinically symptomatic disease Modern Teaching:  NO benefit to treatment (except in pregnancy and before urologic procedure). Term changed to “asymptomatic bacteriuria”

12.  3 to 5% of young women have ABU  What role does this have in recurrent UTI’s? Many women get follow-up urine studies and re-treatment after initial therapy for UTI.  Study in Clinical Inf. Disease -9/15/2012: 673 healthy non-pregnant woman followed after first UTI for one year.- all were treated again at any time if had symptomatic UTIs. urine cultures were also obtained at 3, 6 and 12 months-if positive but if patient asymptomatic only half were treated, other half were not

13.  Results after one year of observation: Those treated for ABU- 46.8% had a symptomatic UTI later during the year Those not treated for ABU- only 13.1% had another UTI! Conclusion: The paradoxical result was increased incidence of symptomatic UTIs in patients given antimicrobials for asymptomatic bacteruria!

14.  Bacterial interference- the inability of pathogenic bacteria to set up a bladder infection due to blockage by commensal bacteria colonizing the bladder- was disrupted by the treatment of ABU. Conclusion :The human microbiome is a potent defense mechanism against superinfecting pathogenic bacteria. Applies to the bladder, as well as the GI tract and other sites.

15.  Antibiotic treatment of ASB does not reduce frequency of symptomatic UTI  Treatment of ASB in diabetes does not reduce adverse outcomes, improve glucose control, or reduce symptomatic UTIs  It does lead to untreatable drug resistant bacteria, c.diff,etc  Only exceptions are pregnancy where asymptomatic bacteriuria is associated with pyelonephritis, growth retardation, neonatal death… and patients undergoing urologic procedures (such as prostate bx)

16.  Many older patients get screening u/a’s and reflex cultures even when they don’t have urgency and burning symptoms. They are then treated for a “UTI”. This is a too common mistake…  “older patients should not be tested or treated for UTI unless they have symptoms”  If you are treated for a true UTI: no follow-up test of cure should be performed  Antibiotics: have side-effects can cause future problems like yeast infection and colitis lead to drug resistant bacteria are a waste of money

17.  Think twice before ordering a urine culture- go by symptoms and signs. Only culture in possible pyelonephritis, unclear diagnosis, complicated cases or treatment failure  Consider Macrodantin or Septra as first line therapy, quinolones if they are ill  Mid-stream culture results with enterococcus and GBS can be deceiving – rarely cause of UTI. Most likely still E. coli  If the patient is asymptomatic –if it ain’t broke, don’t fix it!