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The Journal of Maternal-Fetal and Neonatal Medicine, May 2009; 22(5): 423427

Asymptomatic bacteriuria during pregnancy


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EYAL SHEINER1, EFRAT MAZOR-DREY2, & AMALIA LEVY3


1
Faculty of Health Sciences, The Department of Obstetrics and Gynecology, Soroka University Medical Center, Beer-Sheva,
Israel, 2Faculty of Health Sciences, Internal Medicine, Soroka University Medical Center, Beer-Sheva, Israel, and 3Faculty of
Health Sciences, Epidemiology and Health Services Evaluation, Ben Gurion University of the Negev, Beer-Sheva, Israel

(Received 10 May 2008; accepted 21 July 2008)

Abstract
Objective. The present study was aimed to test the association between asymptomatic bacteriuria during pregnancy, among
patients in whom antibiotic treatment was recommended, and perinatal outcome. Our study was also designed to
characterize common bacteria and risk factors associated with asymptomatic bacteriuria during pregnancy.
Methods. A retrospective population-based study comparing all singleton pregnancies of women with and asymptomatic
bacteriuria was conducted. Patients with urinary tract infection were excluded from the analysis. Multiple logistic regression
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model was used to control for confounders.


Results. Out of 199,093 deliveries, 2.5% (n 4890) were in patients with asymptomatic bacteriuria. E. coli was the most
common pathogen associated with asymptomatic bacteriuria, representing 78.6% of the cultures with specified growth.
Patients with asymptomatic bacteriuria were more likely to deliver preterm (PTD, 13.3% vs. 7.6%, odd ratio (OR) 1.9, 95%
confidence interval CI 1.72.0; P 5 0.001) and deliver low birth-weight neonates (52500 g, 13.3% vs. 7.9%, OR 1.8; 95%
CI 1.62.0; P 5 0.001). Asymptomatic bacteriuria was independently associated with PTD (adjusted OR 1.6; 95% CI 1.5
1.7; P 5 0.001), fertility treatments, hypertensive disorders, recurrent abortions, diabetes mellitus, intrauterine growth
restriction, polyhydramnion and oligohydramnion, premature rupture of membranes and labour induction, in a multivariable
analysis with backwards elimination. Perinatal mortality rates (1.5% vs. 1.4%; P 0.707) as well as low 5 min Apgar scores
(0.8% vs. 0.6%; P 0.065) were comparable between the groups.
Conclusion. Asymptomatic bacteriuria is an independent risk factor for preterm delivery.

Keywords: Asymptomatic bacteriuria, preterm delivery, low birth-weight, caesarean delivery, pregnancy

significantly reduced the risk of LBW (relative risk


Introduction
RR 0.56; 95% confidence interval CI 0.43, 0.73)
Asymptomatic bacteriuria, defines as true bacteriuria [2]. Accordingly, screening for and treatment of
in the absence of symptoms of acute urinary tract asymptomatic bacteriuria during pregnancy has
infection (UTI), complicates 210% of pregnancies become a standard of care [1,2].
[13]. During pregnancy, asymptomatic bacteriuria The present population-based study was aimed to
is not considered benign, because pregnancy induces test the association between asymptomatic bacter-
stasis and accordingly increases the risk for pyelone- iuria during pregnancy, among patients in whom
phritis [2,4,5]. Controversy exists regarding the antibiotic treatment was recommended, and perina-
association between asymptomatic bacteriuria during tal outcomes. Our study was also aimed to char-
pregnancy and adverse perinatal outcome, including acterize common bacteria and risk factors associated
preterm deliveries and low-birthweight (LBW) [2,6]. with asymptomatic bacteriuria during pregnancy.
However, meta-analysis of cohort studies showed
that untreated asymptomatic bacteriuria during
Materials and methods
pregnancy significantly increased rates of LBW and
preterm delivery [7]. Moreover, analysis of rando- A retrospective population-based study comparing
mised clinical trials showed that antibiotic treatment all singleton pregnancies of women with and

Correspondence: Eyal Sheiner, MD, PhD, Department of Obstetrics and Gynecology, Soroka University Medical Center, P.O Box 151, Beer-Sheva, Israel.
Tel: 972-8-6400774. Fax: 972-8-6275338. E-mail: sheiner@bgu.ac.il
ISSN 1476-7058 print/ISSN 1476-4954 online 2009 Informa Healthcare USA, Inc.
DOI: 10.1080/14767050802360783
424 E. Sheiner et al.

asymptomatic bacteriuria was conducted. Patients Results


with UTI (n 4742) were excluded from the
analysis. Deliveries occurred during the years Out of 199,093 deliveries, 2.5% (n 4890) were in
19882007 at the Soroka University Medical Center. patients with asymptomatic bacteriuria. E. coli was
This is the sole hospital in the Negev, the southern the most common pathogen associated with asymp-
part of Israel, serving the entire obstetrical popula- tomatic bacteriuria, representing 78.6% of the
tion in this region. cultures with specified growth (Table I). Patients
Asymptomatic bacteriuria was defined as labora- with asymptomatic bacteriuria were more likely to
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tory positive urine culture (based on the detection of deliver preterm (OR 1.9, 95% CI 1.72.0;
more than 100,000 bacteria/ml in a single voided P 5 0.001; Table II).
midstream urine), in the absence of specific symp- Obstetric risk factors complications and outcomes
toms of acute UTI [2,5,8]. National health services of patients with and without asymptomatic bacter-
in Israel provide comprehensive perinatal care for all iuria are presented in Table III. Patients with
women, and urine cultures are performed as part of asymptomatic bacteriuria had higher rates of fertility
the routine prenatal care, starting during the first treatments, hypertensive disorders, recurrent
appointment, basically around 12 weeks gestation. abortions, diabetes mellitus (either gestational or
These patients with positive urine culture were pre-gestational), IUGR, polyhydramnion and oligo-
prescribed antibiotic treatment. Data were collected hydramnion, PROM and labour induction as
from the computerised perinatal database that compared to patients without asymptomatic bacter-
consists of information recorded directly after iuria. Also, these patients had higher rates of CD,
delivery by an obstetrician. Only four skilled medical vacuum extractions and complications such as
secretaries examine the information routinely before chorioamnionitis, pyelonephritis, calculus of kidney
entering it into the database. Coding is done after
assessing the medical prenatal care records as well as
Table I. Bacterial growth in specimens of asymptomatic women
the routine hospital documents. These procedures (asymptomatic bacteriuria; n 4890).
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assure maximal completeness and accuracy of the


database. Characteristics n (%)
The following clinical characteristics were eval-
Escherichia coli 2882 (58.9)
uated: maternal age, parity, gestational age and Proteus 413 (8.4)
specifically preterm delivery (PTD 5 37 weeks). Streptococcus A 4 (0.1)
The following obstetrical risk factors were exam- Streptococcus B 196 (4.0)
ined: fertility treatments, hypertensive disorders, Streptococcus (unspecified) 108 (2.2)
Staphylococcus aureus 23 (0.5)
gestational and pregestational diabetes mellitus,
Staphylococcus (unspecified) 45 (0.9)
recurrent abortions, premature rupture of mem- Pseudomonas 66 (1.5)
branes (PROM) and intra-uterine growth restric- Pneumococcus 5 (0.1)
tion (IUGR). The following labour characteristics Other (unspecified growth) 1223 (25.1)
and perinatal outcomes were assessed: placental
Data are expressed as means + standard deviation (SD), or
abruption, polyhydramnion and oligohydramnion, numbers and percentages. Few cultures had more than one
labour induction, vacuum extraction, forceps bacteria.
delivery, caesarean delivery (CD), post-partum
haemorrhage (PPH), chorioamnionitis, pyelone-
phritis, hydroureter, calculus of kidney and Table II. Clinical characteristics of women with and without
asymptomatic bacteriuria.
hospitalisation days. The following neonatal out-
comes were recorded: gender, Apgar score at 1 Asymptomatic Comparison
and 5 min less than 7, birthweight and specifically bacteriuria group
LBW (52500 g) and perinatal mortality. The local Characteristics (n 4890) (n 194,203) P
ethics institutional review board approved the Maternal age 28.4 + 6.0 28.5 + 6.0 0.130
study. (years + SD)
Statistical analysis was performed with the SPSS Gestational age at 38.7 + 2.5 39.2 + 2.1 50.001
package (SPSS 15 version, Chicago, IL). Statistical delivery
significance was calculated using the chi square test (weeks + SD)
for differences in qualitative variables and ANOVA Gestational age
for differences in continuous variables. Stratified 537 13.3% 7.6%
3742 83.6% 87.7%
analysis was performed using a multivariable logistic
42 3.2% 4.7% 50.001
regression model. Odds ratios (OR) and their 95%
CI were computed. P 5 0.05 was considered statis- Data are expressed as means + standard deviation (SD), or
tically significant. numbers and percentages.
Asymptomatic bacteriuria during pregnancy 425

and hydroureter, as well as prolonged hospitalisations Discussion


as compared to women without asymptomatic
bacteriuria. The present population-based study is one of the
Table IV presents neonatal outcome and compli- largest studies investigating pregnancy outcome of
cations of the two groups. Patients with asympto- patients with asymptomatic bacteriuria. The major
matic bacteriuria had higher rates of 1 min Apgar finding of our study is that even among patients who
scores less than 7, and LBW as compared to were given antimicrobial treatment, asymptomatic
parturients without asymptomatic bacteriuria. bacteriuria is independently associated with PTD
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Perinatal mortality rate was comparable between (adjusted OR 1.6; 95% CI 1.51.7; P 5 0.001),
the groups. and accordingly with LBW (52500 g, OR 1.8;
Asymptomatic bacteriuria was independently as- 95% CI 1.62.0; P 5 0.001). Asymptomatic bacter-
sociated with PTD, fertility treatments, hypertensive iuria is linked to a wide variety of complications
disorders, recurrent abortions, diabetes mellitus, suggesting that it might be a marker for the intensity
IUGR, polyhydramnion and oligohydramnion, of prenatal care and the complications that influence
PROM and labour induction, in a multivariable that intensity.
analysis with backwards elimination (Table V). The Because asymptomatic bacteriuria, by definition,
model controlled for the year of delivery, to control is lacking any symptoms, compliance might be
for ascertainment bias. low. Unfortunately, we do not have information

Table III. Obstetric risk factors, complications and outcomes of patients with and without asymptomatic bacteriuria.

Asymptomatic Comparison group


Characteristics bacteriuria (n 4890) (n 194,203) OR 95% CI P

Fertility treatments 2.8% 1.7% 1.7 1.42.0 50.001


Hypertensive disorders 9.4% 5.6% 1.7 1.61.9 50.001
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Diabetes mellitus 11.0% 6.0% 1.9 1.82.1 50.001


Recurrent abortions 6.3% 5.1% 1.3 1.11.4 50.001
IUGR 4.0% 2.0% 2.1 1.82.4 50.001
Polyhydramnion 5.3% 3.8% 1.4 1.21.6 50.001
Oligohydramnion 3.7% 2.3% 1.7 1.41.9 50.001
PROM 8.8% 6.5% 1.4 1.21.5 50.001
Placental abruption 1.1% 0.7% 1.6 1.22.0 0.001
Labor induction 35.8% 26.2% 1.6 1.51.7 50.001
Meconium-stained amniotic fluid 15.6% 16.3% 1.0 0.91.01 0.210
Caesarean delivery 20.3% 12.4% 1.8 1.71.9 50.001
Vacuum extraction 3.8% 2.8% 1.4 1.21.6 50.001
Forceps delivery 0.1% 0.1% 1.0 0.42.8 0.910
Post-partum hemorrhage 0.5% 0.5% 0.9 0.61.4 0.707
Chorioamnionitis 1.7% 0.8% 2.2 1.82.7 50.001
Pyelonephritis 0.1% 0.0% 52.9 11.8236.8 50.001
Calculus of kidney 0.3% 0.1% 4.2 2.47.2 50.001
Hydroureter 8.8% 6.5% 1.4 1.21.5 5.001
Hospitalisation days (days + SD) 4.4 + 4 3.5 + 3 50.001

IUGR, intra-uterine growth restriction; PROM, premature rupture of membranes. Data are presented as percentages, odds ratios (OR),
95% confidence intervals (CI) and P-values for statistical significance.

Table IV. Neonatal outcome of patients with and without asymptomatic bacteriuria.

Asymptomatic Comparison group


Characteristics bacteriuria (n 4890) (n 194,203) OR 95% CI P

Gender
Male 51.3% 51.3%
Female 48.7% 48.7% 1.0 0.91.1 0.931
Apgar 1 min 5 7 5.1% 4.1% 1.0 0.91.1 50.001
Apgar 5 min 5 7 0.8% 0.6% 1.3 0.981.9 0.065
Birth weight (mean + SD) 3100 + 617 3190 + 544 50.001
LBW (weight 52.5 kg) 13.3% 7.9% 1.8 1.62.0 50.001
Perinatal mortality 1.5% 1.4% 1.0 0.81.3 0.707

Data are presented as percentages, odds ratios (OR), 95% confidence intervals (CI) and P-values for statistical significance.
426 E. Sheiner et al.

Table V. Multiple logistic regression model, with backward were noted between the groups regarding lower
elimination, of factors associated with asymptomatic bacteriuria. 5 min Apgar scores and perinatal mortality despite
Characteristics Odds ratio 95% CI P higher rates of PTD.
Similar to all other studies [2,5,8,14], the major
Diabetes mellitus 1.8 1.61.9 50.001 pathogen isolated from about 80% of the urine
Preterm delivery (537 week) 1.6 1.51.7 50.001
cultures was E. coli. In our study, it involved 78.6%
IUGR 1.6 1.31.5 50.001
Hypertensive disorders 1.3 1.11.6 50.001 of the cultures with specified growth. The E. coli is
Fertility treatments 1.3 2.83.1 50.001 considered uropathogenic due to a number of
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Labour induction 1.3 1.21.4 50.001 virulence factors specific for colonisation and inva-
Polyhydramnios 1.3 1.11.5 50.001 sion of the urinary epithelium, such as the P-fimbria
Oligohydramnios 1.2 1.11.4 0.023
and S-fimbria adhesions [5]. Likewise, the associa-
Recurrent abortions 1.1 1.011.3 0.046
PROM 1.1 1.011.2 0.031 tion between diabetes mellitus and asymptomatic
Year of delivery (years) 1.08 1.071.09 50.001 bacteriuria is well-established [4,15].
In conclusion, asymptomatic bacteriuria is an
IUGR, intrauterine growth restriction; PROM, premature rupture independent risk factor for preterm delivery,
of membranes; CI, confidence interval. Data are expressed as odds
ratio, 95% confidence interval and P-values for statistical
although treatment recommendation. Further pro-
significance. The initial model included placental abruption as spective studies should investigate compliance for
well. treatment of asymptomatic bacteriuria and compare
outcome of patients who were actually treated to
these with partial or no treatment. Patients should be
regarding actual treatment and compliance. Thus, consulted regarding the significance of asymptomatic
the high rates of PTD might be attributed to sub- bacteriuria to improve compliance for antimicrobial
optimal treatment. Treatment is basically given to treatment.
prevent UTI and other complications, such as
pyelonephritis [4]. Pyelonephritis is a serious Declaration of interest: The authors report no
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complication leading to severe morbidity, including conflicts of interest. The authors alone are respon-
multi-system derangement from endotoximia and sible for the content and writing of the paper.
sepsis [5,9,10]. A cost evaluation study reported
that screening for pyelonephritis is appropriate
when the prevalence of asymptomatic bacteriuria References
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