Not all Urinary Bacteria are Bad!
ASYMPTOMATIC URINARY TRACT INFECTIONS
Bacteria are present in, on, and around the entire human body. There is a normal bacterial flora present on the skin, in the mouth, in the GI tract, and in the vaginal canal as well. This normal flora keeps virulent bacteria under control and co-exists well with bodily and organ functions.
It should not be surprising then that articles have now demonstrated that there is normal bacterial flora present in the lower urinary tract.
This is not to imply that the urine culture that contains three or more organisms on a voided urine specimen is true urinary tract colonization but rather a contaminated specimen. (Please see link of prior Primary Care Update “What Men Have Over Women” in urine collections.)
The incidents of asymptomatic bacteriuria in pre-menopausal women is 5%, in elderly men and
women 20%, and in long-term care facilities up to 50%. E. coli is the most common asymptomatic bacteria detected.
Recent studies have been performed that show different strains of E. coli with different degrees of virulence. The virulence or lack thereof appears to be related to the lipopolysaccharides that are released by the E. coli and other strains.
Some lipopolysaccharides appear to actually stimulate pain and an inflammatory response when released by the E. coli. On the other hand, some lipopolysaccharides actually inhibit or minimize any pain or inflammatory response.
The speculation is that the patients that are asymptomatic with E. coli or other urinary tract pathogens, truly are not in need of treatment. In fact, treating them may and can lead to: 1. Resistant organisms and, 2. More virulent organisms.
For over the last 5 to 10 years, I have numerous patients (in excess of over 100) who have a chronic positive urinary culture but absolutely no symptoms. On occasion, when I have attempted to eradicate the bacteria, the culture turns negative but subsequently returns to its positive state, in some cases, with a resistant organism.
What does this mean for a primary care physician? Obtaining a urinalysis that reveals evidence of either nitrates or white blood cells, certainly should lead to a urine culture. However, treatment of an asymptomatic, especially elderly patient, with antibiotics is probably unnecessary. It is not unreasonable to consider a minimum urologic evaluation including a bladder scan for residual urine and possibly imaging of the upper tract with an ultrasound to insure that there is no evidence of obstruction or stone formation.
None of the above is to imply that symptomatic patients should not be treated.
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