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Asymptomatic bacteriuria in adults

������: Thomas Fekete, MD
������� ������: Stephen B Calderwood, MD
������ ������: Allyson Bloom, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jul 2023.

This topic last updated: May 31, 2023.

INTRODUCTION

The term asymptomatic bacteriuria refers to isolation of bacteria in an appropriately collected urine
specimen from an individual without symptoms of urinary tract infection (UTI). Asymptomatic
bacteriuria is common, but most patients with asymptomatic bacteriuria have no adverse
consequences and derive no benefit from antibiotic therapy. With few exceptions, nonpregnant
patients should not be screened or treated for asymptomatic bacteriuria.

The rationale for not screening or treating asymptomatic bacteriuria in the general population is
discussed in this topic.

Asymptomatic bacteriuria in the few patient populations that may warrant screening and treatment
is discussed in detail elsewhere. These populations include:

● Pregnant persons. (See "Urinary tract infections and asymptomatic bacteriuria in pregnancy".)

● Patients undergoing urologic procedures in which mucosal bleeding is anticipated. (See

"Prostate biopsy", section on 'Preparation' and "Placement and management of indwelling
ureteral stents", section on 'Preparation' and "Surgical treatment of benign prostatic
hyperplasia (BPH)", section on 'Antibiotic prophylaxis'.)

● Patients who recently received a renal transplant. (See "Urinary tract infection in kidney
transplant recipients", section on 'Monitoring for asymptomatic bacteriuria'.)
CLINICAL DEFINITIONS

Asymptomatic bacteriuria is defined as isolation of a specified quantitative count of bacteria in an

appropriately collected urine specimen from an individual without symptoms of urinary tract
infection (UTI).

Bacteriuria threshold — Quantitative thresholds have been established to distinguish bladder

bacteriuria from urethral contamination. The definitions of bacteriuria are slightly different for
voided clean-catch specimens and catheterized specimens.

Voided clean-catch specimens — The threshold for asymptomatic bacteriuria from a clean-catch
voided urine specimen is isolation of a single organism in quantitative counts ≥105 colony-forming
units (CFU)/mL [1]. For females, a second specimen should be obtained (preferably within two
weeks) to confirm growth of the same organism over the same quantitative threshold. For males, a
single urine specimen meeting the criteria is sufficient for making the diagnosis.

● Rationale for the count threshold – The high quantitative threshold is intended to increase
the likelihood that bacteriuria reflects bladder bacteriuria rather than urethral, vaginal, or
fecal contamination. Early studies had indicated that most asymptomatic patients with
bacterial counts ≥105 CFU/mL from voided urine had corresponding bacteriuria on a specimen
obtained through straight catheterization, but only a minority of those with lower counts did
[2]. Similarly, patients with bacterial counts ≥105 CFU/mL from a voided specimen are more
likely to have a repeat culture with the same organism growth compared with patients with
lower counts.

● Rationale for repeat specimen collection for females – For females, a confirmatory
specimen is recommended to improve specificity for persistent bacteriuria, as bacteriuria can
represent contamination and can also be transient. Two consecutive voided specimens are
needed to predict bladder bacteriuria with the same degree of accuracy as a single urine
specimen obtained through a catheter. In studies of voided and catheterized urine specimens
from asymptomatic females, a bacterial count of ≥105 CFU/mL from a catheterized specimen
was confirmed by a repeat catheterized specimen in >95 percent of cases, whereas a count
≥105 CFU/mL from a voided urine specimen was confirmed in a second voided specimen in
only 80 percent of cases [2-6]. Two consecutive positive cultures from a voided specimen
predicted a third positive culture with 95 percent confidence. Studies in healthy young
females suggest that most episodes of bacteriuria in females are transient and not detected
on repeat specimens [7,8]. As an example, in a study of 104 healthy premenopausal females
with recurrent UTI who prospectively collected daily voided urine for culture and urinalysis, 45
experienced at least one episode of asymptomatic bacteriuria ≥105 CFU/mL with a
 uropathogen over a 90-day follow-up period; however, bacteriuria was seldom detected for
more than two days in a row (eg, in only 9 of 43 episodes of E. coli bacteriuria), and only one
participant had bacteriuria for more than five days in a row [8].

● Rationale for a single specimen for males – There are fewer data on microbiologic criteria
for diagnosis of asymptomatic bacteriuria in males, but the diagnostic threshold is less
stringent in them in part because external contamination during voiding is an unlikely cause
of significant bacteriuria. The most rigorous report informing the threshold is a study of 59
asymptomatic males with the incidental finding of ≥105 CFU/mL of an Enterobacteriaceae; this
finding was reproducible with repeat culture one week later in 98 percent of cases [9]. (See
"Acute simple cystitis in adult males".)

The definition of a positive urine culture in the setting of symptoms of cystitis or complicated UTI is
distinct and discussed in detail elsewhere. (See "Sampling and evaluation of voided urine in the
diagnosis of urinary tract infection in adults", section on 'Definition of a positive culture'.)

Catheterized specimens — The threshold for asymptomatic bacteriuria from a catheterized urine
specimen is isolation of a single organism in quantitative counts ≥105 CFU/mL [10]. The sample
does not have to be repeated for confirmation.

Specimens collected through straight catheterization (or a newly placed catheter) are less likely to
have urethral contamination than voided specimens, but the significance of positive cultures in
asymptomatic catheterized adults is unclear. Patients with long-term indwelling catheters often
have low-level bacteriuria, often with multiple organisms, which often reflects colonization of the
catheter. In such patients, the threshold for significant bacteriuria in asymptomatic patients is
higher than in those with symptoms, to increase specificity and reduce overuse of antimicrobials
[10]. There have been no comparisons of culture yields from urethral catheterized specimens and
suprapubic aspiration specimens. (See "Catheter-associated urinary tract infection in adults",
section on 'Definitions'.)

Definition of asymptomatic — Asymptomatic bacteriuria refers to patients who have no

symptoms specifically referable to a UTI (eg, dysuria, urinary frequency or urgency, suprapubic pain
in patients with simple cystitis and fevers with cystitis symptoms, flank pain, or costovertebral angle
tenderness in patients with acute complicated UTI). The clinical presentation and diagnosis of UTI is
discussed in detail elsewhere. (See "Acute simple cystitis in females", section on 'Diagnostic
approach' and "Acute simple cystitis in adult males", section on 'Diagnostic approach' and "Acute
complicated urinary tract infection (including pyelonephritis) in adults", section on 'Diagnostic
approach'.)

This distinction is important, since many people, particularly older patients, are diagnosed with UTI
when they present with nonspecific symptoms (such as delirium, behavioral changes, failure to
thrive, falls, etc) and bacteriuria, when in fact there is some alternate cause of their nonspecific
symptoms, and they actually have asymptomatic bacteriuria. In the absence of fever, local or
systemic symptoms, or signs of infection, clinicians should have a high threshold before using such
nonspecific symptoms to diagnose a UTI. The pitfalls of diagnosing UTI in older adults are
discussed in detail elsewhere. (See "Approach to infection in the older adult", section on 'Urinary
tract infection'.)

By contrast, in some patients with severe neurogenic bladder, such as those with spinal cord injury,
UTI often presents without typical urinary symptoms. In such cases, fevers, malaise, increased
spasticity, and autonomic dysreflexia may be the only manifestations of UTI [1,11]. When such
patients present with such symptoms in the absence of alternate potential causes, it is reasonable
to attribute them to UTI when bacteriuria is present. (See "Chronic complications of spinal cord
injury and disease", section on 'Urinary tract infection'.)

Irrelevance of pyuria — Although most patients with symptomatic UTI have pyuria (≥10
leukocytes/microL of uncentrifuged urine), it is not a surrogate marker for bacteriuria or UTI and
frequently occurs in their absence [7,12,13]. This was illustrated in a study of urine samples from
asymptomatic older females; 60 percent of samples with pyuria had no bacteriuria [12]. Similarly, in
another study of healthy premenopausal females who underwent daily collection of voided urine,
the predictive value of pyuria for asymptomatic bacteriuria with E. coli was 4 to 8 percent,
depending on the pyuria threshold [8].

Conversely, asymptomatic bacteriuria is frequently accompanied by pyuria, which does not indicate
a symptomatic UTI that warrants therapy. As an example, the prevalence of pyuria in patients with
diabetes mellitus and asymptomatic bacteriuria is almost 80 percent [14].

EPIDEMIOLOGY

Females — The prevalence of asymptomatic bacteriuria among healthy females increases with
advancing age, from about 1 percent among schoolgirls to >20 percent among those over 80 years
of age residing in the community [7,15,16]. It correlates with sexual activity; as an example,
prevalence is greater among premenopausal married women than nuns of the same age (4.6
versus 0.7 percent, respectively) [17]. Pregnant and nonpregnant females have a similar prevalence
(2 to 7 percent) [16]. In young healthy women, asymptomatic bacteriuria is transient; it rarely lasts
longer than a few weeks.

Prevalence among females with diabetes mellitus is 8 to 14 percent and is usually correlated with
duration and presence of long-term complications of diabetes, rather than with metabolic
parameters of diabetes control [14].
Males — Asymptomatic bacteriuria is rare among healthy young males [18]. Among males older
than 75 years residing in the community, prevalence is 6 to 15 percent [16]. Males with diabetes
mellitus do not appear to have a higher prevalence of bacteriuria than those without [19].

PATHOPHYSIOLOGY

The absence of symptoms in patients with asymptomatic bacteriuria could reflect characteristics
specific to the pathogen, the host, or both.

Pathogen factors — The microbiology of asymptomatic bacteriuria is similar to that of cystitis and
pyelonephritis, although some strains capable of producing asymptomatic bacteriuria may have
subtle adaptations that facilitate pathogenesis. For example, attachment of bacteria via fimbrial
adhesins is thought to be important for the establishment and persistence of symptomatic
infection. Some bacterial strains with reduced capability for fimbriae expression appear to have the
capacity for relatively rapid growth that thus allows them to cause asymptomatic bacteriuria [20].

Alternatively, strains implicated in asymptomatic bacteriuria may be less virulent and, therefore,
may not necessarily be true pathogens [21-25]. For example, E. coli strains recovered from spinal
cord injury patients with asymptomatic bacteriuria demonstrate diminished capacity for red blood
cell hemagglutination and hemolysis compared with strains implicated in symptomatic urinary tract
infections [23,24]. Even if they persist, such strains are unlikely to progress to serious infection.
Based on this notion, some investigators have suggested that colonization with "uroprotective"
strains of E. coli may be protective against infection with more invasive uropathogens [26]. (See
"Bacterial adherence and other virulence factors for urinary tract infection" and 'Adverse effects of
antibiotics' below.)

Host factors — The absence of symptoms in patients with asymptomatic bacteriuria could also
reflect differences in the host response [27,28]. A study of children with asymptomatic bacteriuria
demonstrated lower levels of neutrophil toll-like receptor 4 (TLR4) expression compared with age-
matched controls [27]. In mice, TLR4 controls the mucosal response to E. coli, and inactivation of
TLR4 can lead to a carrier state that resembles asymptomatic bacteriuria [28]. (See "Toll-like
receptors: Roles in disease and therapy".)

Bladder microbiome — While routine cultures of urine collected via suprapubic aspiration or
straight catheterization are usually sterile in healthy, asymptomatic persons, more sensitive
detection methods have identified a normal bladder-associated microbiome [29]. As with other
mucosal surfaces, the flora of the bladder consists of various species of bacteria and varies by the
individual. In females, there is some overlap between the vaginal and bladder flora. Study of the
bladder microbiome is in its infancy, and its relevance to human health remains to be determined.
RATIONALE FOR NOT TREATING

In general, we suggest not screening for nor treating asymptomatic bacteriuria. There are a few
exceptions in whom screening and treatment are warranted; these include pregnant persons,
patients undergoing urologic intervention, and recent renal transplant recipients.

The presence of pyuria on a urinalysis does not alter our suggestion to avoid screening for or
treating asymptomatic bacteriuria in most individuals; in someone who is asymptomatic, pyuria is
not indicative of a urinary tract infection (UTI). (See 'Irrelevance of pyuria' above.)

Our recommendations are consistent with those from the Infectious Diseases Society of America
(IDSA) and the US Preventive Services Task Force [1,30]. The IDSA guidelines also cover
asymptomatic bacteriuria in children, which is discussed elsewhere. (See "Urinary tract infections in
infants and children older than one month: Clinical features and diagnosis", section on 'Differential
diagnosis'.)

Benign natural history — Although asymptomatic bacteriuria has been associated with
subsequent UTI in some patient populations (as discussed below), asymptomatic bacteriuria is not
associated with long-term adverse effects, such as chronic kidney disease or mortality [15,31,32]. As
an example, in a study of over 600 females with diabetes mellitus, asymptomatic bacteriuria was
not independently associated with declines in renal function or hypertension after a six-year follow-
up [32].

The benign outcome of asymptomatic bacteriuria, at least in healthy young females, may be
because of its transient nature [7,8]. (See 'Voided clean-catch specimens' above.)

Lack of treatment benefit

Nonpregnant adults — There is no role for routine screening for or treating asymptomatic
bacteriuria in the general, nonpregnant population [1,30]. Although asymptomatic bacteriuria is
associated with subsequent UTI in some studies [7], treatment does not appear to reduce the
frequency of symptomatic infection or prevent other adverse outcomes [15,33-38]. Uncommon
exceptions are discussed elsewhere. (See 'Select indications to screen/treat' below.)

Several trials have failed to find a clear benefit of treating asymptomatic bacteriuria [33,36,37]. In a
meta-analysis of nine trials that included females and males from outpatient, geriatric, and nursing
home settings, treatment of asymptomatic bacteriuria had no statistically significant effect on the
incidence of symptomatic UTI (risk ratio [RR] 1.11, 95% CI 0.51-2.43), complications (RR 0.78, 95% CI
0.35-1.74), or death (RR 0.99, 95% CI 0.70-1.41) compared with no treatment or placebo [33].
Although antibiotics initially sterilize the urine in almost all patients, bacteriuria recurs in
approximately one-half of treated patients and can spontaneously resolve in untreated patients,
such that the prevalence is similar between treated and untreated individuals at one year [34].

Even many individuals with immunocompromising conditions do not appear to be at greater risk of
adverse outcomes from untreated asymptomatic bacteriuria. In a study of 260 females with
rheumatologic disease, of whom 94 percent were taking an immunosuppressive agent,
asymptomatic bacteriuria was identified in 9 percent [39]. After a median of 12 months of follow-
up, the rates of symptomatic UTI among those with and without asymptomatic bacteriuria at
baseline were not statistically different (17 versus 12 percent), and no woman with asymptomatic
bacteriuria developed sepsis or pyelonephritis requiring hospitalization. Data are more limited for
other immunocompromised populations, but there is no clear evidence to support screening or
treatment of asymptomatic bacteriuria in such patients.

Older patients — There is no role for screening for or treatment of asymptomatic bacteriuria
among older adults, either in the community or in health care facilities [1].

Asymptomatic bacteriuria is common in such patients, with reported rates of 6 to 16 percent in

females in the community, 25 to 54 percent of females in skilled nursing facilities, and rates at
about half of those among males [40,41]. Nevertheless, asymptomatic bacteriuria is not associated
with an increased risk of adverse outcomes in such patients [40,42-46]. Furthermore, antimicrobial
treatment has not been shown to be of benefit in such patients [47,48]. (See 'Nonpregnant adults'
above.)

As an example, in a randomized trial of 50 older females residing in a skilled nursing facility who
had asymptomatic bacteriuria, treatment of all episodes of bacteriuria did not decrease urogenital
morbidity or mortality over the course of a year compared with treatment for only symptomatic UTI
[48]. In another randomized trial of 191 nursing home residents with incontinence and bacteriuria,
eradicating bacteriuria had no short-term effects on the severity of chronic urinary incontinence
[47]. In addition, bacteriuria tended to recur after therapy, with emergence of antibiotic resistance
[48]. (See "Medical care in skilled nursing facilities (SNFs) in the United States", section on
'Asymptomatic bacteriuria'.)

Patients with diabetes mellitus — There is no role for screening for asymptomatic bacteriuria in
patients with diabetes mellitus. However, screening for microalbuminuria is routine in such
patients, and the presence of pyuria on urinalysis may result in a reflexed urine culture that leads to
the incidental discovery of asymptomatic bacteriuria. If it is identified, we suggest not treating
asymptomatic bacteriuria in such patients. Although diabetes mellitus is associated with
asymptomatic bacteriuria in females, which in turn is associated with subsequent UTI, including
severe UTI, available evidence suggests that treating asymptomatic bacteriuria in patients with
diabetes mellitus does not improve outcomes.

Overall, diabetes mellitus is associated with an approximate three- to fourfold increase in the risk of
asymptomatic bacteriuria in females, from 6 percent to 18 to 26 percent [14,49,50]. In one study,
increased risk occurred mainly in females using insulin and those with a duration of disease longer
than 10 years [51]. In particular, patients with advanced or severe disease as determined by end-
organ damage or elevated levels of glycosylated hemoglobin reportedly have a higher incidence of
asymptomatic bacteriuria [14].

As in the general population, asymptomatic bacteriuria is associated with subsequent UTI in

patients with diabetes mellitus [52-54]. In a cohort of females with type 2 diabetes mellitus, those
with asymptomatic bacteriuria at baseline had a higher risk of UTI over the subsequent 18 months
(34 versus 19 percent) [53,55]. Overall, however, most symptomatic UTIs in this cohort occurred
among females who had negative baseline urine cultures. Similarly, in a prospective study of 496
adults with diabetes mellitus, asymptomatic bacteriuria was associated with an approximate
fourfold increased risk of hospitalization for acute complicated UTI associated with sepsis [54].

Nevertheless, multiple studies have found that antibiotic therapy of asymptomatic bacteriuria is
associated with no reduction in symptomatic infection and a high rate of recurrent bacteriuria once
antibiotics are discontinued [56,57]. The best data come from a trial in which 105 females with
diabetes mellitus and asymptomatic bacteriuria were randomly assigned to 14 days of antibiotics
or placebo [56]. At four weeks after the end of therapy, a greater proportion of patients in the
antibiotic group cleared the bacteriuria (80 versus 22 percent with placebo). However, after this
initial follow-up period, the group assignment was revealed, and patients were followed for a mean
of 27 months; bacteriuria was assessed at three-month intervals, and patients who originally
received antibiotics were treated during subsequent episodes. Over this long-term follow-up,
patients in the antibiotic group had nearly five times the number of antibiotic days compared with
the placebo group, but there were no differences between the groups in UTI incidence (including
pyelonephritis), hospitalization for UTI, or timing of UTI onset.

Other studies have suggested that the rate of recurrence of asymptomatic bacteriuria in patients
with diabetes mellitus is approximately 50 to 80 percent despite effective therapy (over follow-up
ranging from one to several years) [57,58].

Patients undergoing nonurologic surgery — There is no role for screening for or treatment of
asymptomatic bacteriuria among patients undergoing nonurologic surgery, including joint
arthroplasty [1]. (See 'Joint arthroplasty' below.)

In a retrospective study of 489 males who had urine cultures performed prior to undergoing
orthopedic, cardiothoracic, or vascular procedures, bacteriuria was uncommon (11 percent of
patients) [59]. Preoperative bacteriuria was not associated with an increased risk of surgical site
infection. Furthermore, the incidence of subsequent UTI was not decreased with antibiotic therapy
for bacteriuria (3 of 43 untreated versus 2 of 11 treated patients).
 Joint arthroplasty — We suggest not routinely performing urinalysis or culture in patients
without urinary symptoms prior to or following joint arthroplasty. If a patient is found to have
perioperative bacteriuria in the confirmed absence of urinary symptoms, we recommend not
treating with antibiotics. Although there are no data from large trials to inform this issue [60], there
is no evidence of a clear association between joint infections and bacteriuria, and the typical
pathogen profiles of these infections are very different.

Most observational studies do not demonstrate a clear association between perioperative

bacteriuria and subsequent development of prosthetic joint infection. In a prospective, multicenter
study of nearly 2500 patients undergoing total hip or knee arthroplasty, screening identified
asymptomatic bacteriuria (≥105 colony-forming units (CFU)/mL in the absence of signs or
symptoms of UTI) in 12 percent [61-64]. In the year following surgery, there were 43 prosthetic joint
infections (1.7 percent). Although patients with preoperative asymptomatic bacteriuria were more
likely to have a prosthetic joint infection than those without (4.3 versus 1.4 percent infection rate,
odds ratio 3.23, 95% CI 1.67-6.27), treatment of the bacteriuria, which was at the discretion of the
clinician, was not associated with a decreased risk of infection. Moreover, the organisms isolated
from the urine were not the same as those from the surgical site infection in any patient with
asymptomatic bacteriuria. These results complement those of other large observational studies
that did not demonstrate an association between bacteriuria or symptomatic UTI and prosthetic
joint infection and also noted that organisms isolated from the urine are not the same as those
causing surgical site infections [61,64]. Other small studies evaluating patients with asymptomatic
preoperative bacteriuria who proceeded to surgery (with preoperative or postoperative antibiotic
therapy) failed to find any instances of subsequent joint infections attributable to the urinary
pathogens [65,66].

Some studies have suggested an association between postoperative UTI and prosthetic joint
infections, but these are mainly limited to small case reports [67-69]. In one large retrospective
study, post-arthroplasty UTI was independently associated with a subsequent surgical site infection
[70]. However, the criteria for UTI diagnosis used in the study were not specified, and there was no
evaluation of a microbiologic link between the uropathogens and those causing the joint infections.

Some experts have advocated screening and treatment for asymptomatic bacteriuria in patients
undergoing joint arthroplasty because of the biological plausibility of subsequent surgical site
infection and the relative ease of treatment [71]. We believe that further data are warranted before
such a recommendation can be made. The very low infection risk of total joint arthroplasty, the
disparity of flora between bacteriuria and surgical site infection, and the delays as well as the small
but real risks related to screening and treating bacteriuria do not support universal screening. (See
'Adverse effects of antibiotics' below.)

In contrast, evaluation and treatment are indicated in pre- and postoperative patients who have
symptomatic UTI. (See "Acute simple cystitis in adult males", section on 'Treatment' and "Acute
complicated urinary tract infection (including pyelonephritis) in adults", section on 'Management'
and "Acute simple cystitis in females".)

Patients with indwelling bladder catheters — There is no role for screening for or treatment of
asymptomatic bacteriuria among patients with indwelling bladder catheters [1]. Bacteriuria is
extremely common among patients with indwelling catheters, and treatment does not improve
patient outcomes.

All patients with an indwelling catheter in place long enough ultimately develop bacteriuria, which
has been estimated to occur at a rate of approximately 3 to 10 percent per day of catheterization
[72,73]. This bacteriuria is mostly asymptomatic. As an example, in a study of nearly 1500 newly
catheterized patients, 235 developed bacteriuria over the course of one to two weeks, but more
than 90 percent of cases were asymptomatic [74]. Among patients with a chronic indwelling
catheter, bacteriuria is associated with a higher risk of complicated UTI than in the absence of a
catheter.

Nevertheless, several trials have failed to demonstrate any benefit to treatment of asymptomatic
bacteriuria in catheterized patients [75,76]. As an example, in a trial of patients in the intensive care
unit (ICU) with an indwelling catheter in place for >48 hours and asymptomatic bacteriuria, a short
course of antibiotics and replacement of the catheter did not reduce the rate of UTI with sepsis,
duration of ICU stay, or incidence of subsequent positive urine cultures [76]. Similarly, in a trial of
patients with long-term indwelling catheters, a course of cephalexin given whenever bacteriuria
was identified did not reduce the rate of febrile episodes, incidence of bacteriuria, or catheter
malfunctioning [75]. Studies of programs aimed at reducing treatment of asymptomatic bacteriuria
in chronically catheterized patients have not identified any increase in UTI-related adverse effects
[77].

Patients with spinal cord injury — Determining whether bacteriuria reflects asymptomatic
bacteriuria or UTI in patients with spinal cord injury or severe neurogenic bladder can be difficult
because they may have atypical manifestations of UTI (see 'Definition of asymptomatic' above). In
the absence of potential symptoms of UTI, there is no role for screening or treating bacteriuria in
such patients [1].

Although patients with spinal cord injury have a high prevalence of asymptomatic bacteriuria,
bacteriuria tends to recur early after therapy or prophylaxis [78,79]. Many patients with spinal cord
injury have indwelling catheters, among whom treatment for asymptomatic bacteriuria does not
confer a clinical benefit; data in such patients without indwelling catheters are more limited. (See
'Patients with indwelling bladder catheters' above.)

Nevertheless, avoiding unnecessary antibiotic therapy is a particular priority in these patients, as

they have a high rate of symptomatic UTI, and excessive antibiotic exposure increases the risk of
drug-resistant uropathogens, which complicate UTI treatment. (See 'Adverse effects of antibiotics'
below.)

Adverse effects of antibiotics — Beyond the potential direct adverse effects of antibiotics (eg,
toxicity or intolerance, risk of Clostridioides difficile colitis), overuse of antibiotics is well known to
drive antibiotic resistance at both the individual and the community or institutional level (see
"Antimicrobial stewardship in hospital settings", section on 'Adverse effects of antimicrobial use').
Eliminating treatment of asymptomatic bacteriuria has been identified as an important target of
efforts to reduce unnecessary antibiotic administration [1,80]. There is also some evidence that
treating asymptomatic bacteriuria could increase the risk of subsequent UTI.

Evidence from a number of studies supports the potential risks of antibiotic use in asymptomatic
bacteriuria. In a meta-analysis of nine trials evaluating treatment for asymptomatic bacteriuria,
antibiotics increased the incidence of any adverse event (RR 3.77, 95% CI 1.40 to 10.15) [33]. Other
studies have found that treatment of asymptomatic bacteriuria is associated with emergence of
antibiotic resistance in subsequently isolated uropathogens [48,81]. As an example, in one study,
treatment of asymptomatic bacteriuria was associated with higher rates of resistance to
amoxicillin-clavulanate (25 versus 4 percent), trimethoprim-sulfamethoxazole (34 versus 12
percent), and ciprofloxacin (44 versus 19 percent) among subsequent E. coli urinary isolates [81].

Furthermore, in a trial of healthy, premenopausal, nonpregnant females with asymptomatic

bacteriuria, a greater proportion of the participants randomly assigned to receive antibiotic
treatment for the bacteriuria experienced a subsequent symptomatic UTI over the following year
compared with the females who did not receive antibiotics [50]. Confidence in the results from this
trial is limited by the lack of blinding and a placebo control, and the unexpected pathogen profile
(with E. coli accounting for only a third of cases). Nevertheless, if these findings are confirmed by
additional studies, they support the concept that asymptomatic bacterial colonization can protect
against superinfection with more virulent strains and should not be treated [82]. (See
'Pathophysiology' above.)

SELECT INDICATIONS TO SCREEN/TREAT

Pregnancy — Asymptomatic bacteriuria during pregnancy has been associated with adverse
pregnancy outcomes. Screening for asymptomatic bacteriuria is warranted for pregnant persons
[1,83]. This is discussed in detail separately. (See "Urinary tract infections and asymptomatic
bacteriuria in pregnancy", section on 'Asymptomatic bacteriuria'.)

Patients undergoing urologic intervention — Screening for and treatment of asymptomatic

bacteriuria are warranted for patients undergoing urologic procedures in which mucosal bleeding
is anticipated [1,83]. Untreated bacteriuria is associated with infectious complications following
urologic interventions, with a higher risk associated with procedures that disturb mucosal integrity
(such as transurethral prostate interventions, percutaneous stone surgery). In trials of patients with
asymptomatic bacteriuria undergoing transurethral resection of the prostate, antibiotic treatment
reduced the risk of postoperative complicated urinary tract infection and bacteremia [84,85].
Antibiotic prophylaxis prior to urologic procedures is discussed elsewhere. (See "Prostate biopsy",
section on 'Preparation' and "Placement and management of indwelling ureteral stents", section on
'Preparation' and "Surgical treatment of benign prostatic hyperplasia (BPH)", section on 'Antibiotic
prophylaxis'.)

Renal transplant recipients — Some experts screen for and treat asymptomatic bacteriuria in the
first few months following transplantation. This is discussed in detail elsewhere. (See "Urinary tract
infection in kidney transplant recipients", section on 'Monitoring for asymptomatic bacteriuria' and
"Urinary tract infection in kidney transplant recipients", section on 'Early ureteral stent removal'.)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Urinary tract infections in adults"
and "Society guideline links: Asymptomatic bacteriuria in adults".)

INFORMATION FOR PATIENTS

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The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
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who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Asymptomatic bacteriuria (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Asymptomatic bacteriuria is defined as isolation of a specified quantitative count of bacteria in

an appropriately collected urine specimen from an individual without symptoms or signs of
urinary tract infection (UTI). (See 'Clinical definitions' above.)

● The threshold for asymptomatic bacteriuria from a clean-catch voided or catheterized urine
specimen is isolation of a single organism in quantitative counts ≥105 colony-forming units
(CFU)/mL. For females providing a voided specimen, a second specimen should be obtained
(preferably within two weeks) to confirm growth of the same organism over the same
quantitative threshold. A single specimen is sufficient for a voided urine from males or for
urine obtained through catheterization. (See 'Bacteriuria threshold' above.)

● Asymptomatic bacteriuria refers to patients who have no symptoms specifically referable to a

UTI (eg, dysuria, urinary frequency or urgency, suprapubic pain in patients with simple cystitis
and fevers with cystitis symptoms, flank pain, or costovertebral angle tenderness in patients
with acute complicated UTI). In the absence of fever or systemic signs of infection, clinicians
should have a high threshold before using nonspecific symptoms (such as delirium,
behavioral changes, failure to thrive) to diagnose a UTI. (See 'Definition of asymptomatic'
above.)

● Pyuria is not a surrogate marker for bacteriuria. Additionally, in the setting of bacteriuria,
pyuria is not an indication of a symptomatic UTI that warrants therapy. (See 'Irrelevance of
pyuria' above.)

● Asymptomatic bacteriuria is common, particularly in females. Although noncatheterized

patients with asymptomatic bacteriuria have a higher risk for subsequent symptomatic UTI,
bacteriuria itself is not associated with long-term adverse effects. Furthermore, for most
patients, there is no evidence that antibiotic treatment of asymptomatic bacteriuria reduces
the frequency of symptomatic infection or infection-related adverse effects. (See 'Rationale for
not treating' above.)

● In addition to the direct adverse effects of antibiotics, antibiotic treatment of asymptomatic

bacteriuria is associated with emergent drug resistance in uropathogens, making treatment
of subsequent symptomatic UTIs more complicated. There is also some evidence that treating
asymptomatic bacteriuria could increase the risk of subsequent UTI. (See 'Adverse effects of
antibiotics' above.)

● There is no role for routine screening the general, nonpregnant population for asymptomatic
bacteriuria. For most nonpregnant patients who are found to have asymptomatic bacteriuria,
 we recommend not treating with antibiotics (Grade 1B). This also applies to older patients,
patients with diabetes mellitus, patients with an indwelling bladder catheter, and patients
undergoing nonurologic surgery. (See 'Lack of treatment benefit' above.)

● There are a few exceptions to this approach. Pregnancy, urologic procedures that are
expected to result in mucosal bleeding, and recent renal transplantation are indications to
screen for and treat asymptomatic bacteriuria. These indications are discussed in detail
elsewhere. (See "Urinary tract infections and asymptomatic bacteriuria in pregnancy", section
on 'Asymptomatic bacteriuria' and "Surgical treatment of benign prostatic hyperplasia (BPH)",
section on 'Antibiotic prophylaxis' and "Urinary tract infection in kidney transplant recipients",
section on 'Monitoring for asymptomatic bacteriuria'.)

ACKNOWLEDGMENT

The UpToDate editorial staff acknowledges Thomas M Hooton, MD, who contributed to earlier
versions of this topic review.

Use of UpToDate is subject to the Terms of Use.

REFERENCES

1. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of
Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin
Infect Dis 2019; 68:e83.

2. KASS EH. Asymptomatic infections of the urinary tract. Trans Assoc Am Physicians 1956; 69:56.

3. Kass EH. The role of asymptomatic bacteriuria in the pathogenesis of pyelonephritis. In: Biolog
y of Pyelonephritis, Quinn EL, Kass EH (Eds), Little, Brown, Boston 1960. p.399.

4. Norden CW, Kass EH. Bacteriuria of pregnancy--a critical appraisal. Annu Rev Med 1968; 19:431.

5. KASS EH. Bacteriuria and the diagnosis of infections of the urinary tract; with observations on
the use of methionine as a urinary antiseptic. AMA Arch Intern Med 1957; 100:709.

6. MONZON OT, ORY EM, DOBSON HL, et al. A comparison of bacterial counts of the urine
obtained by needle aspiration of the bladder, catheterization and midstream-voided methods.
N Engl J Med 1958; 259:764.

7. Hooton TM, Scholes D, Stapleton AE, et al. A prospective study of asymptomatic bacteriuria in
sexually active young women. N Engl J Med 2000; 343:992.

8. Hooton TM, Roberts PL, Stapleton AE. Asymptomatic Bacteriuria and Pyuria in Premenopausal
Women. Clin Infect Dis 2021; 72:1332.
 9. Gleckman R, Esposito A, Crowley M, Natsios GA. Reliability of a single urine culture in
establishing diagnosis of asymptomatic bacteriuria in adult males. J Clin Microbiol 1979; 9:596.

10. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-
associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from
the Infectious Diseases Society of America. Clin Infect Dis 2010; 50:625.

11. Goetz LL, Cardenas DD, Kennelly M, et al. International Spinal Cord Injury Urinary Tract
Infection Basic Data Set. Spinal Cord 2013; 51:700.

12. Boscia JA, Abrutyn E, Levison ME, et al. Pyuria and asymptomatic bacteriuria in elderly
ambulatory women. Ann Intern Med 1989; 110:404.

13. Stamm WE. Measurement of pyuria and its relation to bacteriuria. Am J Med 1983; 75:53.

14. Zhanel GG, Nicolle LE, Harding GK. Prevalence of asymptomatic bacteriuria and associated
host factors in women with diabetes mellitus. The Manitoba Diabetic Urinary Infection Study
Group. Clin Infect Dis 1995; 21:316.

15. Bengtsson C, Bengtsson U, Björkelund C, et al. Bacteriuria in a population sample of women:

24-year follow-up study. Results from the prospective population-based study of women in
Gothenburg, Sweden. Scand J Urol Nephrol 1998; 32:284.

16. Nicolle LE. Asymptomatic bacteriuria: when to screen and when to treat. Infect Dis Clin North
Am 2003; 17:367.

17. Kunin CM, McCormack RC. An epidemiologic study of bacteriuria and blood pressure among
nuns and working women. N Engl J Med 1968; 278:635.

18. Lipsky BA. Urinary tract infections in men. Epidemiology, pathophysiology, diagnosis, and
treatment. Ann Intern Med 1989; 110:138.

19. Zhanel GG, Harding GK, Nicolle LE. Asymptomatic bacteriuria in patients with diabetes
mellitus. Rev Infect Dis 1991; 13:150.

20. Roos V, Nielsen EM, Klemm P. Asymptomatic bacteriuria Escherichia coli strains: adhesins,
growth and competition. FEMS Microbiol Lett 2006; 262:22.

21. Hanson LA. Prognostic indicators in childhood urinary infections. Kidney Int 1982; 21:659.

22. Roos V, Schembri MA, Ulett GC, Klemm P. Asymptomatic bacteriuria Escherichia coli strain
83972 carries mutations in the foc locus and is unable to express F1C fimbriae. Microbiology
2006; 152:1799.

23. Hull RA, Rudy DC, Wieser IE, Donovan WH. Virulence factors of Escherichia coli isolates from
patients with symptomatic and asymptomatic bacteriuria and neuropathic bladders due to
spinal cord and brain injuries. J Clin Microbiol 1998; 36:115.
24. Hull RA, Rudy DC, Donovan WH, et al. Virulence properties of Escherichia coli 83972, a
prototype strain associated with asymptomatic bacteriuria. Infect Immun 1999; 67:429.

25. Plos K, Carter T, Hull S, et al. Frequency and organization of pap homologous DNA in relation to
clinical origin of uropathogenic Escherichia coli. J Infect Dis 1990; 161:518.

26. Klemm P, Hancock V, Schembri MA. Mellowing out: adaptation to commensalism by Escherichia
coli asymptomatic bacteriuria strain 83972. Infect Immun 2007; 75:3688.

27. Ragnarsdóttir B, Samuelsson M, Gustafsson MC, et al. Reduced toll-like receptor 4 expression
in children with asymptomatic bacteriuria. J Infect Dis 2007; 196:475.

28. Fischer H, Yamamoto M, Akira S, et al. Mechanism of pathogen-specific TLR4 activation in the
mucosa: fimbriae, recognition receptors and adaptor protein selection. Eur J Immunol 2006;
36:267.

29. Thomas-White K, Forster SC, Kumar N, et al. Culturing of female bladder bacteria reveals an
interconnected urogenital microbiota. Nat Commun 2018; 9:1557.

30. US Preventive Services Task Force, Owens DK, Davidson KW, et al. Screening for Asymptomatic
Bacteriuria in Adults: US Preventive Services Task Force Recommendation Statement. JAMA
2019; 322:1188.

31. Tencer J. Asymptomatic bacteriuria--a long-term study. Scand J Urol Nephrol 1988; 22:31.

32. Meiland R, Geerlings SE, Stolk RP, et al. Asymptomatic bacteriuria in women with diabetes
mellitus: effect on renal function after 6 years of follow-up. Arch Intern Med 2006; 166:2222.

33. Zalmanovici Trestioreanu A, Lador A, Sauerbrun-Cutler MT, Leibovici L. Antibiotics for

asymptomatic bacteriuria. Cochrane Database Syst Rev 2015; 4:CD009534.

34. Asscher AW, Sussman M, Waters WE, et al. Asymptomatic significant bacteriuria in the non-
pregnant woman. II. Response to treatment and follow-up. Br Med J 1969; 1:804.

35. Henderson JT, Webber EM, Bean SI. Screening for Asymptomatic Bacteriuria in Adults: Updated
Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019;
322:1195.

36. Dull RB, Friedman SK, Risoldi ZM, et al. Antimicrobial treatment of asymptomatic bacteriuria in
noncatheterized adults: a systematic review. Pharmacotherapy 2014; 34:941.

37. Köves B, Cai T, Veeratterapillay R, et al. Benefits and Harms of Treatment of Asymptomatic
Bacteriuria: A Systematic Review and Meta-analysis by the European Association of Urology
Urological Infection Guidelines Panel. Eur Urol 2017; 72:865.

38. Petty LA, Vaughn VM, Flanders SA, et al. Risk Factors and Outcomes Associated With Treatment
of Asymptomatic Bacteriuria in Hospitalized Patients. JAMA Intern Med 2019; 179:1519.

39. Georgiadou SP, Gamaletsou MN, Mpanaka I, et al. Asymptomatic bacteriuria in women with
autoimmune rheumatic disease: prevalence, risk factors, and clinical significance. Clin Infect
 Dis 2015; 60:868.

40. Nicolle LE. Asymptomatic bacteriuria in the elderly. Infect Dis Clin North Am 1997; 11:647.

41. Juthani-Mehta M. Asymptomatic bacteriuria and urinary tract infection in older adults. Clin
Geriatr Med 2007; 23:585.

42. Boscia JA, Kobasa WD, Knight RA, et al. Therapy vs no therapy for bacteriuria in elderly
ambulatory nonhospitalized women. JAMA 1987; 257:1067.

43. Nordenstam GR, Brandberg CA, Odén AS, et al. Bacteriuria and mortality in an elderly
population. N Engl J Med 1986; 314:1152.

44. Wood CA, Abrutyn E. Urinary tract infection in older adults. Clin Geriatr Med 1998; 14:267.

45. Abrutyn E, Mossey J, Berlin JA, et al. Does asymptomatic bacteriuria predict mortality and does
antimicrobial treatment reduce mortality in elderly ambulatory women? Ann Intern Med 1994;
120:827.

46. Abrutyn E, Berlin J, Mossey J, et al. Does treatment of asymptomatic bacteriuria in older
ambulatory women reduce subsequent symptoms of urinary tract infection? J Am Geriatr Soc
1996; 44:293.

47. Ouslander JG, Schapira M, Schnelle JF, et al. Does eradicating bacteriuria affect the severity of
chronic urinary incontinence in nursing home residents? Ann Intern Med 1995; 122:749.

48. Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no
therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med 1987; 83:27.

49. Sharkey TP, Root HF. Infection of the urinary tract in diabetes. JAMA 1935; 104:2231.

50. Cai T, Mazzoli S, Mondaini N, et al. The role of asymptomatic bacteriuria in young women with
recurrent urinary tract infections: to treat or not to treat? Clin Infect Dis 2012; 55:771.

51. Boyko EJ, Fihn SD, Scholes D, et al. Risk of urinary tract infection and asymptomatic bacteriuria
among diabetic and nondiabetic postmenopausal women. Am J Epidemiol 2005; 161:557.

52. Geerlings SE, Stolk RP, Camps MJ, et al. Risk factors for symptomatic urinary tract infection in
women with diabetes. Diabetes Care 2000; 23:1737.

53. Geerlings SE, Stolk RP, Camps MJ, et al. Consequences of asymptomatic bacteriuria in women
with diabetes mellitus. Arch Intern Med 2001; 161:1421.

54. Karunajeewa H, McGechie D, Stuccio G, et al. Asymptomatic bacteriuria as a predictor of

subsequent hospitalisation with urinary tract infection in diabetic adults: The Fremantle
Diabetes Study. Diabetologia 2005; 48:1288.

55. Geerlings SE, Stolk RP, Camps MJ, et al. Asymptomatic bacteriuria may be considered a
complication in women with diabetes. Diabetes Mellitus Women Asymptomatic Bacteriuria
Utrecht Study Group. Diabetes Care 2000; 23:744.
56. Harding GK, Zhanel GG, Nicolle LE, et al. Antimicrobial treatment in diabetic women with
asymptomatic bacteriuria. N Engl J Med 2002; 347:1576.

57. Forland M, Thomas V, Shelokov A. Urinary tract infections in patients with diabetes mellitus.
Studies on antibody coating of bacteria. JAMA 1977; 238:1924.

58. Forland M, Thomas VL. The treatment of urinary tract infections in women with diabetes
mellitus. Diabetes Care 1985; 8:499.

59. Drekonja DM, Zarmbinski B, Johnson JR. Preoperative urine cultures at a veterans affairs
medical center. JAMA Intern Med 2013; 173:71.

60. Rajamanickam A, Noor S, Usmani A. Should an asymptomatic patient with an abnormal

urinalysis (bacteriuria or pyuria) be treated with antibiotics prior to major joint replacement
surgery? Cleve Clin J Med 2007; 74 Suppl 1:S17.

61. Koulouvaris P, Sculco P, Finerty E, et al. Relationship between perioperative urinary tract
infection and deep infection after joint arthroplasty. Clin Orthop Relat Res 2009; 467:1859.

62. Bozic KJ, Lau E, Kurtz S, et al. Patient-related risk factors for postoperative mortality and
periprosthetic joint infection in medicare patients undergoing TKA. Clin Orthop Relat Res 2012;
470:130.

63. Sousa R, Muñoz-Mahamud E, Quayle J, et al. Is asymptomatic bacteriuria a risk factor for
prosthetic joint infection? Clin Infect Dis 2014; 59:41.

64. Lamb MJ, Baillie L, Pajak D, et al. Elimination of Screening Urine Cultures Prior to Elective Joint
Arthroplasty. Clin Infect Dis 2017; 64:806.

65. Glynn MK, Sheehan JM. The significance of asymptomatic bacteriuria in patients undergoing
hip/knee arthroplasty. Clin Orthop Relat Res 1984; :151.

66. Ritter MA, Fechtman RW. Urinary tract sequelae: possible influence on joint infections following
total joint replacement. Orthopedics 1987; 10:467.

67. Cruess RL, Bickel WS, vonKessler KL. Infections in total hips secondary to a primary source
elsewhere. Clin Orthop Relat Res 1975; :99.

68. D'Ambrosia RD, Shoji H, Heater R. Secondarily infected total joint replacements by
hematogenous spread. J Bone Joint Surg Am 1976; 58:450.

69. Hall AJ. Late infection about a total knee prosthesis. Report of a case secondary to urinary tract
infection. J Bone Joint Surg Br 1974; 56:144.

70. Pulido L, Ghanem E, Joshi A, et al. Periprosthetic joint infection: the incidence, timing, and
predisposing factors. Clin Orthop Relat Res 2008; 466:1710.

71. David TS, Vrahas MS. Perioperative lower urinary tract infections and deep sepsis in patients
undergoing total joint arthroplasty. J Am Acad Orthop Surg 2000; 8:66.
72. Warren JW, Platt R, Thomas RJ, et al. Antibiotic irrigation and catheter-associated urinary-tract
infections. N Engl J Med 1978; 299:570.

73. Haley RW, Hooton TM, Culver DH, et al. Nosocomial infections in U.S. hospitals, 1975-1976:
estimated frequency by selected characteristics of patients. Am J Med 1981; 70:947.

74. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic: a
prospective study of 1,497 catheterized patients. Arch Intern Med 2000; 160:678.

75. Warren JW, Anthony WC, Hoopes JM, Muncie HL Jr. Cephalexin for susceptible bacteriuria in
afebrile, long-term catheterized patients. JAMA 1982; 248:454.

76. Leone M, Perrin AS, Granier I, et al. A randomized trial of catheter change and short course of
antibiotics for asymptomatic bacteriuria in catheterized ICU patients. Intensive Care Med 2007;
33:726.

77. Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an Antimicrobial Stewardship
Approach for Urinary Catheter-Associated Asymptomatic Bacteriuria. JAMA Intern Med 2015;
175:1120.

78. Waites KB, Canupp KC, DeVivo MJ. Eradication of urinary tract infection following spinal cord
injury. Paraplegia 1993; 31:645.

79. Kuhlemeier KV, Stover SL, Lloyd LK. Prophylactic antibacterial therapy for preventing urinary
tract infections in spinal cord injury patients. J Urol 1985; 134:514.

80. Ten things physicians and patients should question. Choosing Wisely: an initiative of the ABIM
Foundation. 2013. http://www.choosingwisely.org/doctor-patient-lists/american-geriatrics-soci
ety/. (Accessed on April 07, 2019).

81. Cai T, Nesi G, Mazzoli S, et al. Asymptomatic bacteriuria treatment is associated with a higher
prevalence of antibiotic resistant strains in women with urinary tract infections. Clin Infect Dis
2015; 61:1655.

82. Wagenlehner FM, Naber KG. Editorial commentary: asymptomatic bacteriuria--shift of

paradigm. Clin Infect Dis 2012; 55:778.

83. Lin K, Fajardo K, U.S. Preventive Services Task Force. Screening for asymptomatic bacteriuria in
adults: evidence for the U.S. Preventive Services Task Force reaffirmation recommendation
statement. Ann Intern Med 2008; 149:W20.

84. Grabe M, Forsgren A, Hellsten S. The effect of a short antibiotic course in transurethral
prostatic resection. Scand J Urol Nephrol 1984; 18:37.

85. Grabe M, Forsgren A, Björk T, Hellsten S. Controlled trial of a short and a prolonged course
with ciprofloxacin in patients undergoing transurethral prostatic surgery. Eur J Clin Microbiol
1987; 6:11.
Topic 8061 Version 34.0

Contributor Disclosures
Thomas Fekete, MD No relevant financial relationship(s) with ineligible companies to disclose. Stephen B
Calderwood, MD Consultant/Advisory Boards: Day Zero Diagnostics [Whole genome sequencing for microbial
identification and determination of antimicrobial susceptibility]. All of the relevant financial relationships listed
have been mitigated. Allyson Bloom, MD No relevant financial relationship(s) with ineligible companies to
disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
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