JU INSIGHT Proposing the “Continuum of UTI” for a Nuanced Approach to Diagnosis and Management of Urinary Tract Infections

By: Sonali D. Advani, MBBS, MPH, Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina; Nicholas A. Turner, MD, MSc, Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina; Rebecca North, PhD, Duke Aging Center, Duke University School of Medicine, Durham, North Carolina; Rebekah W. Moehring, MD, MPH, Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina; Valerie M. Vaughn, MD, MSc, University of Utah School of Medicine, Salt Lake City; Charles D. Scales Jr, MD, MSHS, Duke University School of Medicine, Durham, North Carolina Duke Clinical Research Institute, Durham, North Carolina; Nazema Y. Siddiqui, MD, MHS, Duke University School of Medicine, Durham, North Carolina; Kenneth E. Schmader, MD, Duke Aging Center, Duke University School of Medicine, Durham, North Carolina Durham VA Medical Center, North Carolina; Deverick J. Anderson, MD, MPH, Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina; For the UTI Continuum Workgroup | Posted on: 20 May 2024

Advani SD, Turner NA, North R, et al. Proposing the “continuum of UTI” for a nuanced approach to diagnosis and management of urinary tract infections. J Urol. 2024;211(5):690-698. doi:10.1097/JU.0000000000003874

Study Need and Importance

Current guidelines categorize patients undergoing evaluation for UTI into 3 clinical phenotypes: UTI, asymptomatic bacteriuria (ASB), or no UTI. However, many patients do not fit neatly into these groups (eg, older adults with delirium and positive urine cultures).

What We Found

Based on a focus group discussion with multidisciplinary experts, a new classification scheme was proposed including 3 current phenotypes (UTI, ASB, no UTI) and introducing 2 new categories: lower urinary tract symptoms/other urologic symptoms and bacteriuria of unclear significance (BUS). Bacteriuric patients without genitourinary symptoms who presented with constitutional symptoms (eg, fever) or those who could not express symptoms were reclassified as BUS. We applied these new categories to 3392 randomly selected encounters from a 5-hospital sample of 220,531 unique patients who underwent urine testing. Upon applying the continuum of UTI categories, 68% of ASB patients were reclassified as BUS, and 29% of no-UTI patients were reclassified as lower urinary tract symptoms/other urologic symptoms (Figure). A sensitivity analysis, involving lowering the urine culture bacterial threshold to < 100,000 CFU/mL, identified an additional 152 cases of UTI, 152 cases of BUS, and 50 cases of ASB.

Figure. Classification of patients who received urine tests for suspicion of UTI based on current guidelines and the “continuum of UTI” approach.

Limitations

This retrospective study only included patients who received urinalysis and urine culture, so may not have captured all patients. Definitions were derived from a focus group discussion of experts, which will need to be validated through a Delphi panel in the future.

Interpretation for Patient Care

Our approach led to the reclassification of bacteriuric patients with constitutional symptoms (eg, fever) or those unable to provide symptom data (delirium) from ASB to BUS. Patients with BUS do not necessarily need antimicrobial treatment for bacteriuria but may benefit from additional evaluation or monitoring. Our approach promotes a patient-centered approach to the diagnosis and management of UTIs.