Core Concepts
The current diagnostic paradigm for urinary tract infections (UTIs) is limited and fails to account for the full spectrum of clinical presentations, leading to challenges in appropriate antibiotic use. A new five-category approach can provide a more nuanced and patient-centered approach to UTI diagnosis and management.
Abstract
The article discusses the limitations of the current diagnostic paradigm for urinary tract infections (UTIs), which typically includes three categories: UTI, asymptomatic bacteriuria (ASB), or no UTI. The authors argue that this classification system excludes more ambiguous clinical cases, such as patients with low bacterial counts but symptomatic, or those with nonspecific symptoms that make it difficult to determine if antibiotic treatment is appropriate.
The researchers conducted a retrospective study across one academic medical center and four community hospitals to assess the feasibility of using five categories for UTI diagnosis: the three existing ones plus LUTS/other urologic symptoms (OUS) and bacteriuria of unclear significance (BUS). The analysis covered 3,392 randomly selected encounters where adults received a urinalysis and urine culture order.
The key findings include:
- Nearly two-thirds of patients who underwent testing for a UTI did not have signs or symptoms localized to the urinary tract, and were reclassified as BUS.
- A third of patients initially classified as not having a UTI were reclassified into the new LUTS/OUS category due to their symptoms.
- The sensitivity analysis suggested that lowering the bacterial threshold in some symptomatic patients may capture additional patients with UTI whose symptoms may be dismissed due to concern for contamination or attributed to LUTS rather than infection.
The authors argue that the addition of the BUS and LUTS/OUS categories has the potential to improve and individualize patient care, as clinicians can consider nonantibiotic therapies for LUTS/OUS patients while monitoring BUS cases more closely. They also suggest that more research may help define better colony-forming unit (CFU) thresholds to improve clinical care.
Stats
Up to half of hospitalized patients have asymptomatic bacteriuria (ASB), for which current practice guidelines advise against antibiotics.
Nearly two-thirds of patients who underwent testing for a UTI did not have signs or symptoms localized to the urinary tract.
A third of patients initially classified as not having a UTI were reclassified into the new LUTS/other urologic symptoms (OUS) category.
The sensitivity analysis suggested that lowering the bacterial threshold in some symptomatic patients may capture additional patients with UTI.
Quotes
"Our findings suggest the need to reframe our conceptual model of UTI vs ASB to recognize clinical uncertainty and reflect the full spectrum of clinical presentations."
"For example, I will treat patients for UTI with 10,000-50,000 CFU/mL if they also have UTI symptoms like blood in the urine, burning with urination, bladder pain, increased urgency or frequency, and the urinalysis shows a high white blood cell count."