CME INDIA Case Presentation by Dr. Pratik Savaj, DNB(Medicine) FID, FNB Infectious Diseases, Infectious diseases specialist, IDCC Hospital Surat, Gujrat, India.

A Lesson in Antibiotic Stewardship.

CME INDIA Case Study

Asymptomatic pyuria, the presence of white blood cells in urine without accompanying symptoms of urinary tract infection, can often perplex clinicians. In this case report, authors delve into a fascinating patient encounter that sheds light on the importance of antibiotic stewardship and challenges prevailing assumptions regarding the management of pyuria.

How Presented?

• 68-year-old male patient.
• Past history of diabetes mellitus and bilateral kidney stones.
• His urine culture revealed multi-drug resistant Pseudomonas infection, prompting a referral for stronger antibiotic treatment.
• However, detailed history-taking revealed a surprising finding: the patient had been experiencing recurrent asymptomatic pyuria for the past 20 years.

Insights and Discoveries:

• Upon further investigation, it became apparent that the patient had never experienced fever or burning during urination, rendering the need for antibiotics questionable.
• This led to explore the root causes behind persistent pyuria and the development of multi-drug resistance.

Implications for Antibiotic Use:

• Analysing the patient’s culture reports, it was discovered that Pseudomonas, initially susceptible to various drugs, had become resistant over time.
• The culprit? Inappropriate and excessive use of antibiotics.
• This alarming trend emphasizes the urgent need for improved antibiotic stewardship practices.

Quick Take-Aways

• Asymptomatic pyuria, even when associated with renal colic, does not necessitate antibiotic treatment.
• Inappropriate antibiotic use can lead to the emergence of multi-drug resistant organisms, compromising future treatment options.
• Healthcare providers must be vigilant in prescribing antibiotics and educate patients about the risks of unnecessary antibiotic usage.

Unveiling the Biofilm Connection:

• In this case, the persistent pyuria was attributed to the formation of biofilm around the kidney stones. Pseudomonas and Candida, known biofilm-forming organisms, contributed to the recurrent presence of white blood cells in the urine.

CME INDIA Learning Points

(By Dr. Pratik Savaj)

• This intriguing case serves as a reminder of the importance of re-evaluating our practices in managing asymptomatic pyuria.
• Antibiotic stewardship is paramount, and healthcare providers should resist the temptation to administer antibiotics without sound clinical indications.
• By doing so, we can mitigate the emergence of multi-drug resistance, optimize patient care, and safeguard the effectiveness of antimicrobial therapies.

CME INDIA Tail Piece

IDSA has established specific criteria for diagnosing asymptomatic bacteriuria:

Asymptomatic bacteriuria is diagnosed through urine culture, which can be obtained using a properly collected clean-catch specimen or a catheterized specimen. The Infectious Diseases Society of America (IDSA) has established specific criteria for diagnosing asymptomatic bacteriuria:

1. Midstream clean catch urine specimen:
   • For women, two consecutive specimens showing isolation of the same bacteria species with at least 100,000 colony-forming units (CFUs) per ml of urine.
   • For men, a single specimen showing isolation of one bacteria species with at least 100,000 CFUs per ml of urine.
2. Catheterized specimen:
   • For both women and men, a single specimen showing isolation of one bacteria species with at least 100 CFUs per ml of urine.

Urine dipstick test for leukocyte is not specific for asymptomatic bacteriuria

• Although a urine dipstick test for leukocyte esterase can reliably indicate the presence of pyuria (an increased number of white blood cells in the urine), it is not specific for asymptomatic bacteriuria.
• Pyuria can also occur due to other inflammatory disorders of the genitourinary tract. The urinary dipstick test for nitrites is of limited usefulness because some organisms do not produce nitrites, there may be a delay between specimen collection and testing, and there may not have been enough time since the last voiding for detectable levels of nitrites to be produced.
• However, combining the dipstick tests for leukocyte esterase and nitrites can increase the specificity for diagnosing asymptomatic bacteriuria compared to using either test alone. Urinalysis with microscopic examination for bacteria is a useful qualitative method for identifying bacteriuria, although it does not provide quantitative information.

What is “Antibiotic stewardship?”

• To ensure efficient utilization of healthcare resources, it is crucial to exercise caution and avoid unnecessary medical examinations and interventions.
• “Antibiotic stewardship” refers to the responsible use of antibiotics, aiming to enhance patient outcomes, combat microbial resistance, and reduce the spread of infections caused by drug-resistant organisms.
• Therefore, adopting a rational and evidence-based approach to the assessment and management of asymptomatic bacteriuria is imperative.
• Routine ordering of urinalysis, urine culture, and sensitivity tests for every hospitalized patient is not warranted unless there is a clinical indication suggesting a symptomatic or hidden urinary tract infection.
• Moreover, in the case of a 70-year-old female patient who is admitted for an unrelated condition and does not exhibit any urinary symptoms, it is common for the clean-catch urine culture to yield an increase in Escherichia coli growth to levels exceeding 100,000 CFU/ml.
• However, it is important to resist the temptation to initiate treatment based solely on these culture results. Treating such cases is unnecessary and may potentially lead to harm.

Book Recommendation

Casebook on Dengue Fever https://amzn.eu/d/bz6RB7E (Available on Amazon)

Further Reading:

1. Glen P, Prashar A, Hawary A. Sterile pyuria: a practical management guide. Br J Gen Pract. 2016 Mar;66(644):e225-7. doi: 10.3399/bjgp16X684217. PMID: 26917663; PMCID: PMC4758505.
2. Kwon YE, Oh D, Kim MJ, Choi HM.  Prevalence and Clinical Characteristics of Asymptomatic Pyuria in Chronic Kidney Disease.  Ann Lab Med 2020;40:238-244.  https://doi.org/10.3343/alm.2020.40.3.238
3. Kulchavenya E. Editorial Comment to Role of increasing leukocyturia for detecting the transition from asymptomatic bacteriuria to symptomatic infection in women with recurrent urinary tract infections: A new tool for improving antibiotic stewardship. Int J Urol. 2018 Sep;25(9):806-807.
4. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America.Published CID, 3/21/2019 .Clinical Infectious Diseases, ciy1121, https://doi.org/10.1093/cid/ciy1121

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