Tools for Practice Outils pour la pratique

#324 Is booking an urgent UTI appointment the best sign of a UTI?

What helps in diagnosing symptomatic uncomplicated urinary tract infections (UTI) in adult women?

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.

CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session

  • 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
  • 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.

Suman Sharma October 3, 2022

My question should pt with UTI symptoms treated with abx in the absence of positive urine dip in office

Shelagh Leahey October 3, 2022

I foundvtjis very helpful. Surprised no information re possible STI and ways to R/O or R/I

Tram Anh Thi Nguyen October 3, 2022

useful information

Hoi Sze Fong October 4, 2022

can do UTI from virtual?

Shiraz Shariff October 7, 2022

Treat the patient, not the tests.

Ravi Seyed-Mahmoud October 8, 2022

For so long I’ve wondered this!

Christiane Kuntz October 10, 2022

This is news to me so I found this helpful since we treat so many women for UTIs.

Uthaya somasundaram October 17, 2022

what is the take home message what to do in our office practice

Ingrid Harle October 18, 2022

good information

Gilbert Bretecher November 5, 2022

urine culture in women not always accurate

Patrick Leung February 19, 2023

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.

Latest Tools for Practice
Derniers outils pour la pratique

#365 Shrooms for Glooms: Evidence for psilocybin for depression

What are the benefits and harms of psilocybin for treatment-resistant/recurrent depression?
Read Lire 0.25 credits available Crédits disponibles

#364 Facing the Evidence in Acne, Part II: Oral Antibiotics

How effective are oral antibiotics in treating acne of at least mild-moderate severity?
Read Lire 0.25 credits available Crédits disponibles

#363 Making a difference in indifference? Medications for apathy in dementia

In patients with dementia, how safe and effective are stimulants, antidepressants, and antipsychotics for treating apathy?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session

  • Jennifer Young MD CCFP-EM
  • Betsy Thomas BSc. Pharm
  • G. Michael Allan MD CCFP

1. Giesen L, Cousins G, Dimitrov B et al. BMC Family Practice 2010, 11:78

2. Deville W, Yzermans J, van Duijn N et al. BMC Urology 2004, 4:4.

3. Medina-Bombardó and Jover-Palmer. BMC Family Practice 2011, 12:111.

4. Meister L, Morley E, Scheer D et al. Acad Emerg Med. 2013; 20:632–45.

5. Bent S, Nalmothu B, Simel D et al. JAMA 2002 May 22/29; 287:20,2701-10.

6. Schiemann G, Kniehl E, Gebhardt K et al. Deutsches Ärzteblatt International 2010; 107(21): 361–7.

7. St. John A, Boyd J, Lowes A, et al. Am J Clin Pathol. 2005; 125;428-36

8. Hurlbut T, Littenberg B. Am J Clin Pathol. 1991; 96:5,582-88.

9. Heytens S, De Sutter A, Coorevits L et al. Clin Microbiol Infect 2017; 23:647-52.

10. Ferry S, Holm S, Stenlund H et al. Scand J Infect Dis. 2004; 36:296-301

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.