Cleveland Clinic Journal of MedicineDiagnostic Stewardship for Urinary Tract Infection: A Snapshot of the Expert Guidance

Streamlining UTI Diagnosis: Expert Consensus Redefines Urine Culture Use and Antimicrobial Stewardship

Recent expert consensus on urine culture diagnostic practices marks a significant stride in refining the management of urinary tract infections (UTIs). The guidance, spearheaded by Claeys et al., addresses the longstanding issues of unnecessary antibiotic usage and diagnostic inaccuracies associated with urine cultures. By redefining when and how urine cultures should be ordered, processed, and reported, the new guidelines aim to reduce misdiagnoses and enhance antibiotic stewardship across various clinical settings.

Key Points:

• The expert panel recommends that urine cultures should only be ordered for patients displaying symptoms of UTIs to avoid unnecessary antibiotic treatments and reduce misdiagnosis.
• Urine cultures should not be part of standard order sets in emergency departments, hospital admissions, preoperative screenings, or assessments for altered mental status and falls, as these practices often lead to inappropriate testing.
• Central to the new guidance is the avoidance of fluoroquinolones as first-line treatments for acute cystitis, aligning with practices aimed at minimizing side effects and resistance.
• The guidance underscores that high colony-forming unit counts (>100,000 CFU/mL) in urine cultures do not necessarily indicate an infection if the patient is asymptomatic, challenging traditional diagnostic thresholds.
• Reflex-culture protocols are advised, whereby urine cultures are only processed if preliminary urinalysis results meet specific criteria, aiming to streamline testing and reduce workload.
• The consensus panel utilized a modified Delphi method to achieve agreement on best practices, emphasizing the importance of interdisciplinary expertise in developing effective diagnostic stewardship.
• Asymptomatic bacteriuria should generally not be treated with antibiotics, a stance supported by major healthcare guidelines and aimed at curbing antibiotic overuse.
• Special considerations are advised for patient groups like children, pregnant women, and immunocompromised individuals, where the guidance may not apply or needs adaptation.

In a 2015 study, no differences were observed between antibiotics versus no treatment of asymptomatic bacteriuria for the development of symptomatic UTI, complications or death.

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