Ann Arbor Guide to Triaging Adults With Suspected Urinary Tract Infection for In-Person and Telehealth Settings

Guidance regarding how to triage adults with symptoms of urinary tract infection. I'm not sure it applies well to older women who may have UTI-like symptoms related to atrophic changes in the urethra. James W. Mold, MD, MPH

View

Importance: Urinary tract infection (UTI) is common in ambulatory care settings and the primary reason for antibiotic prescribing. Despite several guidelines focused on the type and duration of antibiotics prescribed for treating UTI, there is limited outpatient guidance on how to best triage patients with presumed UTI.

Objective: To assess the appropriateness of different triage and management recommendations involving empiric antibiotics, urine testing strategies, and visit types and how these recommendations vary by patient sex, age, presenting symptoms, and clinical history.

Evidence review: Using the RAND/UCLA Appropriateness Method, a 13-member multidisciplinary panel (physicians, advanced practice providers, and nurses) performed a scoping review of the literature publications from 2009 to June 2024 and rated the appropriateness of 136 clinical scenarios (48 for women, 49 for men, and 39 scenarios not specific to sex) with up to 9 management strategies per scenario for a total of 1094 scenarios. For each scenario, experts rated the appropriateness of empiric treatment, types of urine testing, and triage to visit type (in-person, virtual, or none) as appropriate (ie, benefits outweigh risks), inappropriate, or of uncertain appropriateness. Appropriateness ratings were summarized into 2 groups: nonpregnant adult women and adult men.

Findings: Major recommendations based on symptoms included (1) same-day in-person evaluation if symptoms were concerning for pyelonephritis, complicated cystitis, or urinary obstruction; (2) a visit if additional nonurinary symptoms were present (ie, diarrhea, genital discharge, or cough); (3) neither urine testing nor empiric treatment solely due to a change in urine color or appearance without other bladder (cystitis) symptoms; (4) empiric treatment without testing or a visit, for women, if there were new classic cystitis symptoms of dysuria, urinary frequency, urgency, or suprapubic pain without risks for antibiotic resistance; (5) urinalysis with culture (ideally reflexed to culture) before taking first antibiotic dose for women at risk of antibiotic resistance (eg, recent antibiotic treatment for UTI or recurrent UTIs) and all men; and (6) empiric treatment considered for patients with barriers to obtaining timely urine testing or visits.

Conclusions and relevance: The appropriateness of empiric antibiotics, urine testing, and different clinical evaluation options were defined for adults presenting with concerns for UTI in common ambulatory triage settings, including telehealth. These criteria for ambulatory triage of suspected UTI symptoms in adults are anticipated to help standardize and improve the appropriateness of empiric antibiotic prescribing, urine testing, and visit type triage.

Author/s:

Jennifer Meddings, Kristin Chrouser, Karen E. Fowler

Optimal Urine Culture Diagnostic Stewardship Practice-Results from an Expert Modified-Delphi Procedure

Aubrey Delammermore — Thu, 08 Sep 2022 05:00:00 +0000

Date Added:

September 8, 2022

Journal/Publication:

Clinical Infectious Diseases

Publisher:

Infectious Diseases Society of America

Publication Date:

August 1, 2022

Issue:

Volume:

Pages:

382-389

URL:

Optimal Urine Culture Diagnostic Stewardship Practice-Results from an Expert Modified-Delphi Procedure

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1093/cid/ciab987

Keywords

Diagnostic Stewardship

Expert consensus

modified Delphi

urinary tract infections

urine cultures

PMID (1):

34849637

MeSH

Anti-bacterial Agents / therapeutic use

Delphi Technique

anti-bacterial agents

urinalysis

Urinary Tract Infections* / diagnosis

A useful summary of practical recommendations for the appropriate ordering and interpretation of urine cultures. James W. Mold, MD, MPH

Free full text

View

Background: Urine cultures are nonspecific and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. In this study, we aimed to develop expert guidance on best practices for urine culture diagnostic stewardship.

Methods: A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped into three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed during a virtual meeting, then a second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed.

Results: One hundred and sixty-five questions were reviewed. The panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, sending alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional urine cultures and urine white blood cell count as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions.

Conclusions: These 18 guidance statements can optimize use of urine cultures for better patient outcomes.

Keywords: diagnostic stewardship; expert consensus; modified Delphi; urinary tract infection; urine cultures.

Author/s:

Claeys, K. C., Trautner, B. W., Leekha, S., Coffey, K. C., Crnich, C. J., Diekema, D. J., Fakih, M. G., Goetz, M. B., Gupta, K., Jones, M. M., Leykum, L., Liang, S. Y., Pineles, L., Pleiss, A., Spivak, E. S., Suda, K. J., Taylor, J. M., Rhee, C., Morgan, D. J.