Screening for and treating asymptomatic bacteriuria not useful in women with diabetes

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Q&A

Screening for and treating asymptomatic bacteriuria not useful in women with diabetes

J Fam Pract. 2003 February;52(2):94-117

By

Robert G. DeYoung, PharmD, BCPS

Steve Ashmead, MD

BACKGROUND: Should we screen for and treat asymptomatic bacteriuria in women with diabetes mellitus? Women with diabetes mellitus have more frequent and often more severe UTIs when compared with their nondiabetic peers. Moreover, these same women are 3 times more likely to exhibit asymptomatic bacteriuria. In an attempt to prevent the morbidity associated with UTIs in these patients, some experts recommend screening for and treatment of bacteriuria in diabetic women.
POPULATION STUDIED: The investigators recruited adult women with diabetes (approximately 80% had Type 2) referred to endocrinology clinics at 2 tertiary-care teaching hospitals. Eligible women had to have demonstrated bacteriuria (at least 10⁵ colony-forming units of an organism per mL) on 2 consecutive urine cultures over a 2-week period while remaining asymptomatic. The placebo and antibiotic treatment groups were similar in baseline characteristics, including age (mean 57.0 and 53.7 years, respectively) and recent blood glucose control (mean A1C 13.2% and 12.7%, respectively). Comparable percentages of women in each group were sexually active and had a history of UTI.
STUDY DESIGN AND VALIDITY: From an initial screening group of 1900 women, 108 who met the inclusion criteria were randomized, using concealed allocation, into this double-blind trial. After the initial 6 weeks of the study, the blinding of the participants and the study coordinators was discontinued for the remainder of the follow-up (up to 36 months). Patients randomized to antimicrobial treatment received trimethoprimsulfamethoxazole 160 mg/800 mg (TMP/SMX, Bactrim DS) orally twice a day for 14 days. Patients allergic to TMP/SMX or who had resistant organisms on culture received ciprofloxacin (Cipro) 250 mg orally 2 times a day. A planned treatment arm of 3 days of therapy was discontinued after the first 6 patients randomized to it had an early relapse. Active treatment patients with symptomatic UTI or reinfections were managed using longer courses of therapy and/or low-dose antimicrobial prophylaxis. Therapy was credited with a bacteriologic cure if a pretherapy isolate had not recurred after 4 weeks.
OUTCOMES MEASURED: The investigators assessed the time to the first episode of a symptomatic UTI and its frequency as primary outcomes. Secondary outcomes were many, including: hospital admission for a UTI or other causes; patient’s response to the first course of antibiotics; the number of days of antibiotic therapy; occurrence of new episodes of asymptomatic bacteriuria; and adverse effects of antibiotic therapy.
RESULTS: Antimicrobial therapy provided no benefit compared with placebo in terms of time to first symptomatic UTI or number of infections per 1000 days. Likewise, hospitalization for UTI or other causes did not change because of therapy. The antimicrobial therapy group actually received 5 times the number of days of antibiotics compared with the control group—a difference that was completely attributable to the attempted eradication of asymptomatic bacteriuria. Not surprisingly, placebo and treatment arms did differ in days of antibiotic therapy per 1000 days of follow-up (33.7 vs 158.2; P<.001) and adverse effects from antibiotic therapy (3 vs 10 women; P=.05; number needed to harm=8).

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Screening for and treating asymptomatic bacteriuria not useful in women with diabetes

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