2. Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment (A-II).
IDSA Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults
Pyuria is present with asymptomatic bacteriuria in*:
32% of young women
90% of elderly institutionalized patients
90% of hemodialysis patients
30-75% of bacteriuric patients with short-term catheters in place
50-100% of individuals with long-term indwelling catheters in place
*see above link for appropriate references
Does a fever (unidentified source) with no dysuria, frequency, urgency, or suprapubic pain in a patient with bacteriuria/pyuria count as symtomatic bacteriuria and require treatment for UTI?
The IDSA guidelines for uncomplicated cystitis excluded studies where >2% had fever and/or flank pain, asymptomatic bacteriuria, and men.
In my opinion, a patient with fever (unidentified source) who has asymptomatic bacteriuria/pyuria should be evaluated for possible "acute nonobstructive pyelonephritis" or "complicated urinary tract infection" which require treatment. The patient should also be evaluated for other causes of fever and if the cause cannot be elucidated, should be worked up for fever of unknown origin.
Non-infectious causes of fever include malignancies, connective tissue diseases, and drugs. Treating a patient with asymptomatic pyuria with fever for possible cystitis/pyelonephritis may prevent the timely work-up of other causes.
Connective tissue diseases that have been reported to cause FUO include Adult Still's disease, giant cell arteritis, polyarteritis nodosa, Takayasu's arteritis, Wegener's granulomatosis, and mixed cryoglobulinemia.
Malignancies that can present as FUO include lymphoma, leukemia, renal cell carcinoma, and hepatocellular carcinoma.
Drugs that can cause fever include antimicrobials, H1 & H2 antihistamines, antiepileptic drugs, Iodides, NSAIDs, antihypertensives (hydralazine / methyldopa), antiarrhythmics (quinidine / procainamide), antithyroids, digoxin, aminoglycosides, and contaminants in injected cocaine or heroin such as quinine.
Rare causes include factitious fever, disordered heat homeostasis from hypothalamic dysfunction following stroke or anoxic brain injury, abnormal heat dissipation (from skin conditions like ichthyosis), or excessive production from hyperthyroidism. Another cause that should present with other sequelae is alcoholic hepatitis. Rare infections such as Q fever, leptospirosis, psittacosis, tularemia, and melioidosis can cause fever.
an example, 80 y/o nursing home resident with severe dementia comes in with fever 100.5F and has a white count, is admitted to find the source of fever, UA is positive for UTI.
pt is demented at baseline cannot reliably give h/o dysuria/frequency/urgency. This patient invariably will be treated for the UTI with levoquin and will be admitted to the hospital.
With all the guidelines for treatment we still make exceptions when it comes to practical application.
A work up for FUO is rarely done unless fever fails to resolve with antipyretics.
Guidelines are meant to be guidelines.
In the IDSA recommendation, they noted that elderly women in long term care facilities have a prevalence of asymptomatic bacteriuria of about 25-50%.
The case you present is a commonly encountered siutation in the community hospital setting. However, the IDSA gave a recommendation of grade A-1 (the highest recommendation) because treatment was not associated with increased survival but was associated with increased adverse effects and infection with resistant organisms. In one study, there was a non-significant increase in mortality 18% v 39% (p=.11, @ 12m) for no treatment vs treatment, respectively (re: NEJM 1986; 314: 1152 / Am J Med 1987; 83: 27). In a 2006 study, the use of any fluoroquinolone was associated with CDAD, with a matched OR 4.71 (2.19-10.12, p less than 0.001, re: Arch Int Med 2006; 166: 2518).
A paper in this month's NEJM, the 6 month mortality rate for elderly, demented patients, with a febrile episode was 44.5% (re: NEJM 2009; 361: 1529).
In 1989, a case report spoke of the possible risk of C. diff colitis and fluoroquinolones. They reported one reported case in 3.5 million patients treated with ofloxacin and 2 cases in 8861 patients treated with ciprofloxacin (Am J Med 1989; 87: 479). In 2004, a study showed that the incidence of proven CDAD (c. diff. associated diarrhea) with levofloxacin use was 1% (CDI 2004; 39: 602). In addition, fluoroquinolone use has resulted in the emergence of a hypervirulent NAP1/BI/027 strain (NEJM 2005; 353: 2433).