Proposing the “Continuum of UTI” for a Nuanced Approach to Diagnosis and Management of Urinary Tract Infections

Open AccessJournal of UrologyAdult Urology8 Feb 2024Proposing the "Continuum of Urinary Tract Infection (UTI)" for a Nuanced Approach to Diagnosis and Management of UTIs Sonali D. Advani, Nicholas A. Turner, Rebecca North, Rebekah W. Moehring, Valerie M. Vaughn, Charles D. Scales, Nazema Y. Siddiqui, Kenneth E. Schmader, and Deverick J. Anderson Sonali D. AdvaniSonali D. Advani aCorresponding Author: Sonali Advani, Associate Professor of Medicine-Infectious Diseases, Duke University School of Medicine, 315 Trent Drive, Hanes House, Room 154, Durham, NC 27710 ( E-mail Address: email protected) https://orcid.org/0000-0001-5162-6482 Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina , Nicholas A. TurnerNicholas A. Turner Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina , Rebecca NorthRebecca North Duke Aging Center, Duke University School of Medicine, Durham, North Carolina , Rebekah W. MoehringRebekah W. Moehring Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina , Valerie M. VaughnValerie M. Vaughn Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah , Charles D. ScalesCharles D. Scales Departments of Urology and Population Health Sciences, Duke University School of Medicine, Durham, North Carolina Duke Clinical Research Institute, Durham, North Carolina , Nazema Y. SiddiquiNazema Y. Siddiqui Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina , Kenneth E. SchmaderKenneth E. Schmader Duke Aging Center, Duke University School of Medicine, Durham, North Carolina Durham VA Medical Center, Durham, North Carolina , and Deverick J. AndersonDeverick J. Anderson Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina for the UTI continuum workgroup View All Author Informationhttps://doi.org/10.1097/JU.0000000000003874AboutPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail Abstract Purpose: Patients with suspected urinary tract infections (UTIs) are categorized into three clinical phenotypes based on current guidelines: no UTI, asymptomatic bacteriuria (ASB), or UTI. However, all patients may not fit neatly into these groups. Our objective was to characterize clinical presentations of patients who receive urine tests using the "continuum of UTI" approach. Materials and Methods: This was a retrospective cohort study of a random sample of adult non-catheterized inpatient and ED encounters with paired urinalysis and urine cultures from 5 hospitals in three states between January 01, 2017 and December 31, 2019. Trained abstractors collected clinical (eg, symptom) and demographic data. A focus group discussion with multidisciplinary experts was conducted to define the "continuum of UTI," a 5-level classification scheme that includes two new categories: lower urinary tract symptoms/other urologic symptoms (LUTS/OUS) and bacteriuria of unclear significance (BUS). The newly defined "continuum of UTI" categories were compared to current UTI classification scheme. Results: Of 220,531 encounters, 3392 randomly selected encounters were reviewed. Based on the current classification scheme, 32.1% (n = 704) had ASB and 53% (n = 1614) did not have a UTI. When applying the "continuum of UTI" categories, 68% of patients (n = 478) with ASB were reclassified as BUS and 29% of patients (n = 467) with "no UTI" were reclassified to LUTS/OUS. Conclusions: Our data suggest the need to reframe our conceptual model of UTI vs ASB to reflect the full spectrum of clinical presentations, acknowledge the diagnostic uncertainty faced by front line clinicians, and promote a nuanced approach to diagnosis and management of UTIs. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CC-BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.© 2024 The Author(s). Published on behalf of the American Urological Association, Education and Research, Inc.FiguresReferencesRelatedDetails Supplementary Materials Advertisement Copyright & Permissions© 2024 The Author(s). Published on behalf of the American Urological Association, Education and Research, Inc.Keywordsbacteriuria of unclear significanceBUSbacteriuriaLUTSasymptomatic bacteriuriaurinary tract infectionantibiotic stewardshipMetrics Author Information Sonali D. Advani Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina aCorresponding Author: Sonali Advani, Associate Professor of Medicine-Infectious Diseases, Duke University School of Medicine, 315 Trent Drive, Hanes House, Room 154, Durham, NC 27710 ( E-mail Address: email protected) More articles by this author Nicholas A. Turner Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina More articles by this author Rebecca North Duke Aging Center, Duke University School of Medicine, Durham, North Carolina More articles by this author Rebekah W. Moehring Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina More articles by this author Valerie M. Vaughn Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah More articles by this author Charles D. Scales Departments of Urology and Population Health Sciences, Duke University School of Medicine, Durham, North Carolina Duke Clinical Research Institute, Durham, North Carolina More articles by this author Nazema Y. Siddiqui Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina More articles by this author Kenneth E. Schmader Duke Aging Center, Duke University School of Medicine, Durham, North Carolina Durham VA Medical Center, Durham, North Carolina More articles by this author Deverick J. Anderson Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina More articles by this author Expand All Advertisement PDF downloadLoading ...