#324 Is booking an urgent UTI appointment the best sign of a UTI?
CLINICAL QUESTION
What helps in diagnosing symptomatic uncomplicated urinary tract infections (UTI) in adult women?
BOTTOM LINE
Individual symptoms and leukocytes on urinalysis generally add little to diagnosis. Presence of nitrites increases the probability of UTI, but their absence means little. About 60% of women presenting to primary care with possible UTI have a UTI (before any history, physical or testing). A single urine culture likely misses cases, meaning prevalence is even higher.
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EVIDENCE
- Prevalence of UTI: In primary care, 49%-79% women presenting with possible UTI have a UTI depending on criteria for positive culture.1 Others found average prevalence of 55%, 59%, 40-60%.2-4
- UTI symptoms: 4 systematic reviews1,3-5 (4-16 studies, 948-3711 women) in family practice or emergency departments. The largest1 in primary care pooled data with 16 studies and 3711 patients:
- Frequency: Positive likelihood ratio (LR+)=1.09 and Negative Likelihood Ratio (LR-)=0.58
- Dysuria and urgency similar: LR+= 1.17-1.22, LR-= 0.61-0.7
- Others found similar3-5 with highest LR+=2.3 for any symptom.4
- Therefore, clinician elicited symptoms are not very helpful.
- Urine dip (urinalysis): 6 systematic reviews2-4,6-8 (4-43 studies, 948-12,554 women). The largest pooling primary care data3 (11 studies, 2813 patients):
- Leukocytes (≥1+):3 LR+=1.4 and LR-=0.44
- Others2,4,6,7 found LR- similar but LR+=1.0-4.9.
- Overall, leukocytes not very helpful.
- Nitrite (≥1+):3 LR+=6.5 and LR-=0.58
- Others2,4,6,7 found LR- similar and LR+=1.5-29 (highly inconsistent).
- Overall, nitrites are helpful ‘ruling-in’ when positive; not helpful “ruling-out” if negative.
- Blood (≥1+):4 LR+=2.1 and LR-=0.3
- Leukocytes (≥1+):3 LR+=1.4 and LR-=0.44
- Many limitations, examples include no pooling,4,6 differing (102-108) colony forming units as culture gold standard,2,6,7 older than 30 years,8 and differing populations/asymptomatic patients.7
- Urine culture is an imperfect ‘gold’ standard (likely misses cases). Examples:
- Of 220 symptomatic women, 80% had a positive culture but 96% were coli positive on Polymerase Chain Reaction (PCR).9
- Of 42 untreated symptomatic women with initially negative cultures, 31% had a positive culture within 6 weeks.10
- Likelihood ratios provide more information than sensitivity/specificity.
- LR+ for making diagnosis: ≥10 very helpful, 5-9.9 good, 2-4.9 moderate help and <2 provides little help.
- LR- for ruling-out diagnosis: ≤0.1 very helpful, 0.11-0.2 good, 0.21-0.5 moderate help and >0.5 provides little help.
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My question should pt with UTI symptoms treated with abx in the absence of positive urine dip in office
I foundvtjis very helpful. Surprised no information re possible STI and ways to R/O or R/I
useful information
can do UTI from virtual?
Treat the patient, not the tests.
For so long I’ve wondered this!
This is news to me so I found this helpful since we treat so many women for UTIs.
what is the take home message what to do in our office practice
good information
urine culture in women not always accurate
The LR+ information at the end of the article could be put into an algorithm for anyone of us who is lucky enough to have an RN in the office to triage these patients & if there total LR+ score is >5, then the RN could then communicate with the physician to consider providing antibiotic prescription expeditiously.