UTI ‘continuum’ may improve diagnostics, treatment
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Key takeaways:
- Expanding beyond UTI vs. not UTI diagnostic guidelines may improve treatment and antimicrobial stewardship.
- Patients with a fever should not be termed “asymptomatic” because they have symptoms.
SEATTLE — Using a more robust diagnostic “continuum” for UTIs could improve the diagnosis and treatment of the most common hospital-acquired infection, according to a study.
Presenting findings at the Society for Healthcare Epidemiology of America Spring Conference, Sonali Advani, MD, MPH, FIDSA, an infectious disease specialist at Duke Health and assistant professor of medicine at the Duke University School of Medicine, said new “continuum of UTI” definitions may help prevent symptoms from being ignored and potentially prevent an infection that turns into a UTI.
Hospital patients do not always fit into clear definitions of “UTI or ... not UTI,” Advani said, “and most commonly, asymptomatic bacteriuria may not really be asymptomatic. They have fever — how is that asymptomatic?”
Current diagnostic standards for UTI have three categories based on symptoms and diagnostic results: not UTI, asymptomatic bacteriuria (ASB) or UTI, Advani and colleagues noted.
Based on symptoms exhibited in patients with ASB with positive urine cultures, they expanded the diagnostic trichotomy to a more descriptive “continuum” by adding categories for patients with chronic lower UTIs (LUTS) and with bacteriuria of unclear significance (BUS).
“Patients who are usually categorized as not [having a] UTI have some kind of symptom,” Advani said. “And the reason why it’s important to categorize them in this category is because these patients have symptoms that get ignored. They don’t get treated, and I’m not saying treat them with antibiotics, I’m just saying treat their underlying symptoms.”
Advani and colleagues conducted a retrospective descriptive cohort study among adult noncatheterized inpatient and ED encounters with paired urinalysis and urine cultures from five community and academic hospitals in Georgia, North Carolina and Virginia.
They analyzed data from 220,531 patient encounters and included 3,392 in their final analysis. Based on current Infectious Diseases Society of America guidelines, 31.2% of patients were categorized as having ASB and 53% were categorized as not having UTI, according to the study.
When researchers applied the expanded continuum, the number of patients categorized as not having UTI decreased to 37.7% because 15.3% were reassigned to the LUTS category. Additionally, the ASB category decreased by 24% when researchers reassigned patients to the BUS category.
“[There are] patients often who are older that have trouble telling clinicians what is going on, and in that moment, they may be BUS, but will later become a UTI or later they become ASB,” Advani said, adding that acknowledging moments when clinicians do not know the significance of bacteriuria could help keep treatment teams on the same page as infectious disease physicians.
The next step, she said, is to use the UTI continuum diagnostic approach and eventually develop targeted interventions, which may include watchful waiting, shorter course therapies or symptomatic relief for patients who need it.
“The goal of this was to understand that diagnostic uncertainty exists,” Advani said. “It’s important to move away from the dichotomous approach of ASB vs. UTI and, when you’re approaching a [medical] team, to acknowledge that something is going on with these patients.”
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Advani S, et al. Proposing the “continuum of UTI” for a nuanced approach to antimicrobial stewardship. Presented at: Society for Healthcare Epidemiology of America Spring Conference; April 11-15; Seattle, Washington.
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