Asymptomatic bacteriuria in children in the era of personalized medicine: from the urinary microbiome to artificial intelligence

Context: Asymptomatic bacteriuria (ASB) in children usually represents colonization, yet positive cultures may trigger antibiotic treatment in high-risk patients. Recognition of a pediatric urinary microbiome and emerging artificial intelligence (AI) technologies challenge the assumption that bacterial detection necessarily indicates infection. Objective: To map the evidence on pediatric ASB epidemiology, natural history, host–microbe biology, high-risk populations, the urinary microbiome, and AI. Data Sources: A structured search of PubMed-indexed literature was completed on 23 August 2026 using predefined queries, supplemented by citation searching and searches of official guideline websites. Study Selection: Fifty-nine PubMed-indexed and nine additional records were identified. After removal of five duplicates, 54 database records were screened; 41 reports underwent eligibility assessment, and 30 sources were included. Pediatric evidence was prioritized, with adult evidence retained only for high-risk states or technologies lacking pediatric equivalents. Data Extraction: Study design, population, definitions, outcomes, treatment effects, microbiological findings, and AI performance were charted narratively. Results: ASB is uncommon in healthy children, and historical treatment studies show no convincing long-term renal benefit from eradication. Pediatric studies confirm the presence of a resident urobiome and biological differences between asymptomatic carriage and symptomatic infection. Pregnancy remains the clearest screen-and-treat state; diabetes and stable kidney transplantation generally favor non-treatment, whereas important evidence gaps remain in oncology and broader immunosuppression. Pediatric AI studies remain insufficiently validated for routine ASB-versus-UTI classification. Conclusions: Management should prioritize selective testing, clinical context, and antimicrobial stewardship. Urobiome profiling and AI are promising but require prospective validation in pediatric populations.