UTI

Should we treat asymptomatic candiduria?

FA Manian MD, MPH, Leave a comment

This is a common scenario among our hospitalized patients with indwelling catheters, prior antibiotic therapy or diabetes mellitus who seem to have no clinical signs of infection. Fortunately, candidemia from urinary sources appears uncommon to rare, with up to nearly ½ of patients clearing their candiduria with removal of the indwelling catheter alone (1). The Infectious Diseases Society of America guidelines do not recommended treatment of asymptomatic candiduria unless the patient belongs to a group at high risk of dissemination, such as severely immunosuppressed or neutropenic patients, infants with low birth weight, and patients who will undergo urologic manipulation (2).  Supporting such recommendation is a retrospective long-term follow-up of patients with candiduria demonstrating no significant improvement in rates of recurrences of candiduria or candidemia with treatment (3).  Fluconazole is usually considered the first-line agent of choice when treatment is indicated.  

1. Kauffman CA. Candiduria. Clin Infect Dis 2005;41:S371-6.

2. Pappas PG, Kauffman CA, Andes D, et al. Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 48:503–35.

3. Revankar SG, Hasan MS, Revankar VS, et al. Long-term follow-up of patients with candiduria. Eur J Clin Microbiol Infect Dis 2011;30:137-140.

Should we treat asymptomatic candiduria?

How do I interpret an elevated serum C-reactive protein (CRP) and normal erythrocyte sedimentation rate (ESR) or vice-versa?

FA Manian MD, MPH, , , , , , , , , , , , Leave a comment

Discordance between serum CRP and ESR is not uncommon (1,2). This phenomenon may be due to a variety of factors including the fact that the kinetics of these two tests is quite different, as discussed in another P4P Post.

In a study of CRP/ESR discordance (defined as results differing by 2 or 3 quartiles) in adults, a high CRP/low ESR profile was more likely to be associated with  urinary, GI, blood stream, and pulmonary infections, myocardial infarction, and venous thromboembolism and less likely to be associated with bone and joint infections (1).

In the same study, a high ESR/low CRP was associated with connective tissue diseases, such as systemic lupus erythematosus and strokes (1).

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References

1. Feldman M, Aziz B, Kang GN, et al. C-reactive protein and erythrocyte sedimentation rate discordance: frequency and causes in adults. Translational Research 2013;161:37-43. https://www.ncbi.nlm.nih.gov/pubmed/22921838

2. Colombet I, Pouchot J, Kronz V. Agreement between erythrocyte sedimentation rate and C-reactive protein in hospital practice. Am J Med 2010;123:864.e7-863.e13.https://www.ncbi.nlm.nih.gov/pubmed/20800157

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers, Mass General Hospital, Harvard Medical School or its affiliated institutions. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

How do I interpret an elevated serum C-reactive protein (CRP) and normal erythrocyte sedimentation rate (ESR) or vice-versa?

When should I consider treating my hospitalized patients with asymptomatic bacteruria (ASB)?

FA Manian MD, MPH, , , , Leave a comment

The great majority of hospitalized patients with ASB do not need treatment with antibiotics.

In fact, there are only a couple of conditions for which treatment of ASB is indicated:  pregnant women (due to risk of pyelonephritis and low-birth infants/pre-term delivery) and before  GU instrumentation, such as transurethral resection of the prostate or other GU procedures for which mucosal bleeding is anticipated (1).  

So for the great majority of our hospitalized patients, including the elderly, diabetic women, institutionalized residents of long-term facilities, and spinal cord injury patients treatment of ASB is not indicated.  Even in the case of renal transplant patients, supportive evidence for the  use of prophylactic antibiotics in ASB is so far lacking (2).  

The estimated prevalence of ASB varies widely in the population,  with rates of 15-20% among community-dwelling women > 70 yrs of age, and 5-10% for men>65 yrs for community-dwelling men. In long-term care facility residents, 25-50% of women, 15-40% of men, and 100% of those with chronic indwelling catheters have ASB (3).  

So keep these rates in mind before attributing patient’s symptoms to ASB (ie, patient’s presentation may have nothing to do with urine findings).  It’s also worth emphasizing that pyuria accompanying ASB is not an indication for treatment.

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References

1. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54.  https://academic.oup.com/cid/article/40/5/643/363229

2. Coussement J, Abramowicz D. Should we treat asymptomatic bacteriuria after renal transplantation? Nephrol Dial Transplant 2013;0:1-3. https://academic.oup.com/ndt/article/29/2/260/1913512

3. Nicolle LE. Asymptomatic bacteriuria in older adults. Geriatrics & Aging 2003;6:24-28. https://www.healthplexus.net/files/content/2003/October/0609bacteriuria.pdf

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers, Mass General Hospital, Harvard Medical School or its affiliated institutions. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

When should I consider treating my hospitalized patients with asymptomatic bacteruria (ASB)?