A new expert-backed framework helps clinicians decide who needs antibiotics, urine testing, or urgent in-person care for suspected UTIs, often without an exam.
Study: Ann Arbor Guide to Triaging Adults With Suspected Urinary Tract Infection for In-Person and Telehealth Settings. Image credit: HenadziPechan/Shutterstock.com
In a recent consensus-based clinical guidance effort published in JAMA Network Open, researchers developed appropriateness criteria and triage algorithms for managing adult patients with suspected urinary tract infection (UTI) in telehealth and in-person settings.
Unnecessary antibiotics remain common in outpatient UTI care
The diagnosis and treatment of UTIs commonly occur in the outpatient setting. Around one-third of antibiotic courses prescribed for a suspected UTI in the outpatient setting are unnecessary, according to the CDC. Recent guidelines clarify definitions of UTI categories and provide recommendations for optimal selection of antibiotics, urine testing, and antibiotic stewardship.
Nevertheless, clinicians frequently have to make decisions regarding UTI testing, triage, and treatment in telehealth settings, which are not directly addressed in traditional guidelines. With the expansion of telehealth, many clinicians receive frequent virtual requests for treatment of suspected UTIs, often without an in-person visit.
This presents a challenge for clinicians, as they must decide, without a physical examination, whether symptoms are sufficiently consistent with UTIs for antibiotic prescribing or may reflect alternative diagnoses or noninfectious causes, and whether urine testing is required.
Multidisciplinary panel assessed testing, treatment, and visit type
In the present study, researchers developed appropriateness criteria for empirical antibiotic use, urine testing, and triage for clinical evaluation of adults with suspected UTIs. They used the Research and Development Corporation/University of California, Los Angeles (RAND/UCLA) Appropriateness Method, which combines a review of current evidence with the clinical judgment of a multidisciplinary panel including physicians, advanced practice providers, and nurses, to develop guidance statements.
The researchers first performed a scoping review of the literature to identify guidelines, expert consensus documents, and narrative and systematic reviews on diagnostic testing and stewardship for suspected UTIs in nonpregnant adults in outpatient and telehealth settings. Studies of urine microscopy, urinalysis, diagnostic stewardship, and protocols for urinalysis reflex testing were also included.
Next, a panel of 13 experts was recruited from urgent care, primary care, geriatrics, emergency medicine, urology, infectious disease, urogynecology, and obstetrics-gynecology. Panelists were provided with materials needed for the first round and were asked to rate the appropriateness of UTI management strategies for each clinical scenario. A therapeutic strategy was deemed appropriate if the expected health benefits exceeded adverse effects by a sufficiently wide margin, exclusive of cost.
Clinical scenarios included adults with characteristics that could elevate the risk of serious infection or antibiotic resistance, urinary tract symptoms and urologic history for males, urinary tract symptoms and genitourinary history for nonpregnant women, bladder infection symptoms, or kidney infection symptoms. In the second round, a virtual meeting was conducted to discuss preliminary scores and rating differences for each scenario.
Each scenario was re-rated after panel discussion and assessed for disagreement using the interpercentile range adjusted for symmetry method. Other scenarios without disagreement were classified as appropriate or inappropriate based on the panel’s median score. Subsequently, the ratings were used to develop two triage algorithms for patients with suspected UTI symptoms, one for males and one for nonpregnant females, which translate appropriateness ratings into practical triage pathways.
Algorithms flag who needs same-day in-person evaluation
Overall, the final ratings for 136 scenarios, each with up to nine management strategies, resulted in 1,094 indications. The algorithms were designed to triage UTI symptoms for patients presenting in person, by phone, via portal messaging, or in virtual settings. First, symptoms should be reviewed to triage patients with suspected urinary obstruction, pyelonephritis, or complicated cystitis.
Individuals with these symptoms should be triaged to an in-person visit the same day to perform a physical examination, obtain vital signs, assess illness severity, determine the need for additional tests, or provide parenteral therapies. Second, symptoms should be screened for non-UTI causes to triage to virtual or in-person visits, reflecting concern that nonspecific or extra-urinary symptoms may signal alternative diagnoses.
Third, patients should be confirmed as not having typical bladder infection symptoms, educated about noninfectious causes of urine odor or color changes, and ascertained not to need urine testing or antibiotics. The algorithms differ for males and females at this point. Females should be examined for risk factors for antimicrobial resistance; those without these risk factors should be considered for empirical antibiotics without urine testing.
Further, all other females and all males should have a urinalysis with culture, ideally reflexed to culture, before their first antibiotic dose, whether prescribed in a virtual or in-person visit, or without a visit. Urinalysis alone without culture capability before prescribing antibiotics was rated inappropriate by the panel, given high false-positive rates that can drive unnecessary antibiotic use. In addition, females and males with barriers to urine testing or in-person evaluation could be considered for empirical antibiotics without testing.
Guidance supports better antibiotic and testing stewardship
Taken together, the study determined the appropriateness of empirical antibiotics, urine testing, and clinical evaluation options for adult males and nonpregnant females presenting with concerns for UTIs in common ambulatory triage settings, including telehealth.
Overall, these criteria for triaging suspected UTI symptoms could help standardize and improve the appropriateness of urine testing, empirical antibiotic prescribing, and visit-type triage. The authors note that the algorithms have not yet been evaluated for impact on patient outcomes or real-world implementation, and emphasize that future studies are needed to assess clinical effectiveness and uptake.
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