Do Kids With Asymptomatic Bacteriuria Warrant Surveillance Cultures?
The recommendation: Avoid the use of surveillance cultures for the screening and treatment of asymptomatic bacteriuria.
The rationale: There is minimal evidence that surveillance urine cultures or treatment of asymptomatic bacteriuria are beneficial. Surveillance cultures are costly and produce both false-positive and false-negative results. And in those asymptomatic children with positive cultures, treatment is not recommended because it increases exposure to antibiotics, which is a risk factor for subsequent infections with a resistant organism. This also results in the overall use of antibiotics in the community and may lead to unnecessary imaging.
Medscape spoke with Linda M. Dairiki Shortliffe, MD, the Stanley McCormick Memorial Professor and Chair of Urology Emerita in the Department of Pediatric Urology at Stanford.
Medscape: This recommendation speaks to continuing surveillance cultures in a child who has already been identified as having bacteriuria. But perhaps you could take a step back. What are some of the reasons for obtaining a urine culture in an asymptomatic child in the first place? How much of a problem is this practice?
Dr. Shortliffe: I would preface my answer by emphasizing that this recommendation is speaking about children who have normal urinary tracts. There is a group of patients who may be asymptomatic because they have a neurogenic bladder or bladder without normal lining -- meaning they lack normal nerve input into the bladder and may not feel a urinary tract infection (UTI). This recommendation does not refer to those children. The reason for discouraging surveillance cultures in children with asymptomatic bacteriuria is that the organisms that cause symptomatic and asymptomatic bacteriuria are usually different and less likely to cause problems. Asymptomatic children do not have the routine signs of UTI such as painful urination or fever. However, there are children with signs atypical of UTI for whom a urine culture is warranted -- for example, a child who is having new episodes of incontinence or more irritative bladder symptoms. The incontinence may or may not be related to the bacteriuria, but it is worth evaluating and treating even though afebrile incontinence is not necessarily a sign of a UTI in a young child. Incontinence even once a week or sudden incontinence at night has been related to bacteriuria. Treating the bacteriuria may improve or stop the incontinence. One caution when obtaining a culture in that situation: Cultures in a girl or a boy who is uncircumcised may be contaminated, so how the specimen is obtained and interpretation of the specimen are important. Is this true for bacteriuria? I would not catheterize a child for that kind of evaluation necessarily unless the initial obtained culture was suspicious.
This recommendation does not apply to children with hydronephrosis, neurogenic bladder, vesicoureteral reflux (VUR), or major genitourinary abnormalities, although I don't recommend routine surveillance cultures in VUR either. In the past, children with VUR would have been on prophylaxis, but more and more of them are no longer on prophylaxis. If they are asymptomatic, my practice is that I don't get surveillance cultures on them.
Medscape: Presuming the child with incontinence and bacteriuria regains continence after treatment, would there be any reason to continue surveillance cultures?
Dr. Shortliffe: No.
Medscape: Is there anything else about this particular recommendation that you wish to emphasize for primary care providers?
Dr. Shortliffe: When applying this recommendation, you have to redefine asymptomatic. Sometimes what has been called asymptomatic bacteriuria is actually symptomatic depending on the age of the child. Toilet-trained children or children in the process of toilet training may be a problematic group. They have a few accidents and a little dysuria. Sometimes practitioners or parents will ignore these symptoms and consider them asymptomatic because it occurred in the process of toilet training. I would urge clinicians to be attuned to the fact that some behaviors and symptoms that we ordinarily think of as routine may actually be symptoms and to raise the bar of suspicion in these children.
from Medscape