Correspondence

Treatment of Asymptomatic Bacteriuria in Diabetic Women

N Engl J Med 2003; 348:957-958March 6, 2003

Article

To the Editor:

Harding et al. (Nov. 14 issue)1 conclude that treatment of asymptomatic bacteriuria in women with diabetes does not appear to reduce complications and that screening and treatment are therefore not needed. However, Table 3 of their article shows that the women in the placebo group received significantly more antibiotics for symptomatic urinary tract infections than the women in the antimicrobial-therapy group. In addition, in our opinion, it is the effect of asymptomatic bacteriuria on renal function, and not symptomatic urinary tract infection, that is the most important variable. In citing our study,2 Harding et al. do not mention that we reported that women with type 1 diabetes and asymptomatic bacteriuria had a tendency toward a decline in renal function over a short follow-up period. Since type 1 and type 2 diabetes are considered different diseases, separate analyses are warranted. In the study by Harding et al., all the patients were analyzed together, and only 21 (20 percent) had type 1 diabetes.

The conclusion of this interesting study should be that it is difficult to keep these patients free of bacteriuria. Furthermore, we believe it is premature to conclude that screening and treatment of asymptomatic bacteriuria in diabetic women are not needed. We are awaiting the results of our five-year follow-up study of nearly 200 women with type 1 diabetes, in which renal-function decline is the primary outcome variable.

Suzanne E. Geerlings, M.D., Ph.D.
Vrije Universiteit Medical Center, 1007 MB Amsterdam, the Netherlands
se.geerlings@vumc.nl

Ruby Meiland, M.D.
Andy I.M. Hoepelman, M.D., Ph.D.
University Medical Center Utrecht, 3508 GA Utrecht, the Netherlands

2 References

1. 1

   Harding GKM, Zhanel GG, Nicolle LE, Cheang M. Antimicrobial treatment in diabetic women with asymptomatic bacteriuria. N Engl J Med 2002;347:1576-1583
   Full Text | Web of Science | Medline

2. 2

   Geerlings SE, Stolk RP, Camps MJL, et al. Consequences of asymptomatic bacteriuria in women with diabetes mellitus. Arch Intern Med 2001;161:1421-1427
   CrossRef | Web of Science | Medline

Author/Editor Response

Geerlings et al. suggest that the results of our study may not support the conclusion that treatment of asymptomatic bacteriuria in diabetic women had no benefit. The number of days an antibiotic was used for symptomatic urinary tract infection was 30 percent greater in the placebo group than in the antimicrobial-therapy group, and the number of days an antibiotic was used for all non–urinary tract infections was 20 percent higher in the placebo group. However, the rate of the primary outcome variable, symptomatic urinary tract infection, was similar in the two groups, and the total number of days of antibiotic use in the antimicrobial-therapy group was five times that in the placebo group. Considering all outcomes, then, we believe that the conclusion that there is no benefit of screening for and treatment of bacteriuria seems appropriate.

We observed no differences between the two groups in serum creatinine levels or the progression to renal failure. Our analysis also did not identify differences between women with type 1 diabetes and those with type 2 diabetes, although there were relatively few subjects with type 1 diabetes. Geerlings et al. reported no association between asymptomatic bacteriuria and a decline in renal function among women with type 2 diabetes at 18 months.1 There was a tendency for women with type 1 diabetes and asymptomatic bacteriuria to have a greater increase in the serum creatinine level than women with type 2 diabetes, but this difference was not significant. In another prospective cohort study, which had 14 years of follow-up, there was no difference in renal-function decline between diabetic patients with bacteriuria and those without it.2 Further longitudinal study of renal function in women with asymptomatic or symptomatic urinary tract infection will be of interest. However, even if observed, an association between bacteriuria and a decline in renal function may not be causal. The additional question of whether antimicrobial treatment could limit such a decline would also need to be addressed.

Lindsay E. Nicolle, M.D.
Godfrey K.M. Harding, M.D.
George G. Zhanel, Ph.D.
University of Manitoba, Winnipeg, MB R3A 1R9, Canada

2 References

1. 1

   Geerlings SE, Stolk RP, Camps MJL, et al. Consequences of asymptomatic bacteriuria in women with diabetes mellitus. Arch Intern Med 2001;161:1421-1427
   CrossRef | Web of Science | Medline

2. 2

   Semetkowska-Jurkiewicz E, Horoszek-Maziarz S, Galinski J, Manitius A, Krupa-Wojciechowska B. The clinical course of untreated asymptomatic bacteriuria in diabetic patients -- 14-year follow-up. Mat Med Pol 1995;27:91-95
   Medline

Citing Articles (4)

Citing Articles

1. 1

   Humberto Saconato, Bernardo Soares, Álvaro N Atallah, Fatima C Giannattasio, Fatima C Giannattasio. 2010. Antibiotics for asymptomatic urinary tract infection in the elderly. .
   CrossRef

2. 2

   Humberto Saconato, G M Souza, Álvaro N Atallah, Eduardo R Parise, Humberto Saconato. 2010. .
   CrossRef

3. 3

   Suzanne E. Geerlings. (2008) Urinary tract infections in patients with diabetes mellitus: epidemiology, pathogenesis and treatment. International Journal of Antimicrobial Agents 31, 54-57
   CrossRef

4. 4

   Ruby Meiland, Suzanne E. Geerlings, Ronald P. Stolk, Arno W. Hoes, Andy I.M. Hoepelman. (2004) History taking and leukocyturia predict the presence of asymptomatic bacteriuria in women with diabetes mellitus. European Journal of Epidemiology 19:11, 1021-1027
   CrossRef