Diagnosis and Management of Urinary Tract Infections in the Outpatient Setting

Grigoryan, Larissa; Trautner, Barbara W.; Gupta, Kalpana

doi:10.1001/jama.2014.12842

Cited by 155 publications

(153 citation statements)

References 53 publications

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“…Twenty-four percent of the subjects diagnosed with UTIs had no possible UTI-related symptoms documented. Although in several reviews of uncomplicated UTI (3,18,19), empirical therapy without a urine culture is recommended for women with suspected uncomplicated cystitis presenting with at least one traditional lower UTI symptom and without vaginitis symptoms or other complicating factors, we noted that empirical therapy without urine culture was often prescribed for subjects without this combination of symptoms. In addition, although we did not prospectively collect data on symptoms, in our study population, the probability of a positive urine culture with one or more traditional UTI symptoms without documentation of vaginal symptoms was only 58%.…”

Section: Discussionmentioning

confidence: 87%

Overdiagnosis of Urinary Tract Infection and Underdiagnosis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department

et al. 2015

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dUrinary tract infections (UTIs) and sexually transmitted infections (STIs) are commonly diagnosed in emergency departments (EDs). Distinguishing between these syndromes can be challenging because of overlapping symptomatology and because both are associated with abnormalities on urinalysis (UA). We conducted a 2-month observational cohort study to determine the accuracy of clinical diagnoses of UTI and STI in adult women presenting with genitourinary (GU) symptoms or diagnosed with GU infections at an urban academic ED. For all urine specimens, UA, culture, and nucleic acid amplification testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis were performed. Of 264 women studied, providers diagnosed 175 (66%) with UTIs, 100 (57%) of whom were treated without performing a urine culture during routine care. Combining routine care and study-performed urine cultures, only 84 (48%) of these women had a positive urine culture. Sixty (23%) of the 264 women studied had one or more positive STI tests, 22 (37%) of whom did not receive treatment for an STI within 7 days of the ED visit. Fourteen (64%) of these 22 women were diagnosed with a UTI instead of an STI. Ninety-two percent of the women studied had an abnormal UA finding (greater-than-trace leukocyte esterase level, positive nitrite test result, or pyuria). The positive and negative predictive values of an abnormal UA finding were 41 and 76%, respectively. In this population, empirical therapy for UTI without urine culture testing and overdiagnosis of UTI were common and associated with unnecessary antibiotic exposure and missed STI diagnoses. Abnormal UA findings were common and not predictive of positive urine cultures. U rinary tract infections (UTIs) are diagnosed in over 1 million emergency department (ED) visits each year in the United States (1). Sexually transmitted infections (STIs) are also commonly diagnosed in the ED. The Centers for Disease Control and Prevention estimates that nearly 20 million new STIs occur annually, many of which go undiagnosed and unreported (2). Lower UTIs and many STIs have overlapping symptomatology, including the traditional UTI symptoms of dysuria, frequency, and urgency. In addition, abnormal urinalysis (UA) findings of positive leukocyte esterase and pyuria are common in both UTIs and STIs (3-6). Thus, distinguishing between these infections can be challenging.Previous studies in ED settings evaluating women diagnosed with UTIs have demonstrated that only about 50% will have a positive urine culture and 10 to 50% will have an STI (5, 7-10). These studies suggest that UTIs are overdiagnosed and STIs are underdiagnosed in the ED. However, previous studies in the ED setting have several limitations. First, some studies (5, 8) used a cutoff of Ն10 4 CFU/ml of a single uropathogen to define a positive urine culture, which may be inappropriately high for some organisms and populations (11, 12). Thus, the incidence of UTI may have been underestimated. Second, some studies may have underdiagnosed STIs b...

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Section: Discussionmentioning

confidence: 87%

Overdiagnosis of Urinary Tract Infection and Underdiagnosis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department

et al. 2015

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“…Narrowerspectrum antimicrobial agents are more appropriate for less serious infections. Fluoroquinolone therapy is not appropriate in patients with uncomplicated cystitis when other treatment options (e.g., nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole) are available (2,14). In the era of increasing antimicrobial resistance, creative solutions to maintain the adequacy of antimicrobial therapy in patients with serious infections by optimizing the utilization of currently available resources are of paramount importance.…”

Section: Discussionmentioning

confidence: 99%

Application of Fluoroquinolone Resistance Score in Management of Complicated Urinary Tract Infections

Shah

Justo

Bookstaver

et al. 2017

Antimicrob Agents Chemother

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The fluoroquinolone resistance score (FQRS) predicts the probability of fluoroquinolone resistance with good discrimination. The score has been derived from patients with bloodstream infections caused by Gram-negative bacteria and is based on fluoroquinolone use within the past 6 months, among other clinical and health care exposure criteria. This study aims to examine the utility of the FQRS in patients with complicated urinary tract infections (cUTI) and determine whether extension of prior fluoroquinolone use to 12 months improves model discrimination. Adults with cUTI at Palmetto Health in central South Carolina, USA, from 1 April 2015 through 31 July 2015 were prospectively identified. Multivariate logistic regression was used to examine the association between prior fluoroquinolone use and resistance. Among 238 patients, 54 (23%) had cUTI due to fluoroquinolone-resistant bacteria. Overall, the median age was 66 years, 162 (68%) patients were women, and 137 (58%) patients had cUTI due to Escherichia coli. Prior exposure to fluoroquinolones within 3 months (adjusted odds ratio [aOR], 23.4; 95% confidence interval [CI], 8.2 to 76.8; P Ͻ 0.001) and within 3 to 12 months (aOR, 13.2; 95% CI, 3.1 to 68.4; P Ͻ 0.001) was independently associated with fluoroquinolone resistance compared to no prior use. The area under the receiver operating characteristic curve for the FQRS increased from 0.73 to 0.80 when prior fluoroquinolone use was extended from 6 to 12 months. FQRSs of Ն2 and Ն3 had negative predictive values of 91% and 90%, respectively. The modified FQRS stratifies patients with cUTI on the basis of the predicted probability of fluoroquinolone resistance with very good discrimination. Application of the modified FQRS may improve antimicrobial utilization in patients with acute pyelonephritis.

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“…The focus of our intervention was on increasing the proportion of antimicrobial prescriptions for nitrofurantoin. In line with recent updates to guidelines on the treatment of urinary tract infections, 10 the use of quinolones is discouraged, to retain quinolones as a viable alternative if firstline treatment fails. With trimethoprim resistance higher than 20%, prescribing of nitrofurantoin was an alternative outcome.…”

Section: Discussionmentioning

confidence: 99%

Intervention to improve the quality of antimicrobial prescribing for urinary tract infection: a cluster randomized trial

Vellinga¹,

Galvin²,

Duane³

et al. 2015

CMAJ

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Diagnosis and Management of Urinary Tract Infections in the Outpatient Setting

Cited by 155 publications

References 53 publications

Overdiagnosis of Urinary Tract Infection and Underdiagnosis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department

Overdiagnosis of Urinary Tract Infection and Underdiagnosis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department

Application of Fluoroquinolone Resistance Score in Management of Complicated Urinary Tract Infections

Intervention to improve the quality of antimicrobial prescribing for urinary tract infection: a cluster randomized trial

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