A multidisciplinary expert panel developed clinical algorithms to guide triage and treatment among adults with suspected urinary tract infections (UTIs) in common ambulatory care settings, including telehealth. The findings were published by Jennifer Meddings, MD, of University of Michigan Medical School, Ann Arbor, and colleagues in JAMA Network Open.

“To our knowledge, these are the first clinical algorithms that include guidance for all the ways patients can present with UTI symptoms: phone, portal messaging, and in-person and virtual visit settings,” the researchers commented. “As UTI is one of the most common symptoms prompting care in the outpatient setting, these clinical algorithms are anticipated to lead to more appropriate use of urine testing, empiric antibiotics, and referral to in-person evaluation when necessary.”

Study Details

Researchers assessed the appropriateness of triage and management recommendations for suspected urinary tract infection, including empiric antibiotic use, urine testing strategies, and visit type. They also examined how these recommendations varied by patient sex, age, presenting symptoms, and clinical history.

The study used the RAND/UCLA Appropriateness Method, informed by a 13-member multidisciplinary panel of physicians, advanced practice providers, and nurses to develop guidance for phone, portal messaging, in-person, and virtual visit settings. Panelists conducted a scoping review of the published literature from 2009 through June 2024 and evaluated 136 clinical scenarios—48 involving women, 49 involving men, and 39 not specific to sex—each with up to 9 potential management strategies, totaling 1,094 appropriateness ratings.

For each scenario, the panel rated the appropriateness of empiric treatment, urine testing strategies, and triage to visit type (in-person, virtual, or none) as appropriate, inappropriate, or of uncertain appropriateness, based on whether anticipated benefits outweighed potential risks. Appropriateness ratings were summarized separately for nonpregnant adult women and adult men.

Key Findings

Major recommendations based on symptoms identified by the researchers included the following:

• Same-day in-person evaluation when symptoms raised concern for pyelonephritis, complicated cystitis, or urinary obstruction

• A visit when additional nonurinary symptoms were reported, such as diarrhea, genital discharge, or cough

• No urine testing or empiric treatment based solely on changes in urine color or appearance in the absence of other bladder (cystitis) symptoms

• Empiric treatment without testing or a visit in women with new classic cystitis symptoms—such as dysuria, urinary frequency, urgency, or suprapubic pain—when no risk factors for antibiotic resistance were present

• Urinalysis with culture, preferably reflexed to culture, obtained before the first antibiotic dose in women at risk for antibiotic resistance (eg, recent UTI antibiotic use or recurrent UTIs) and in all men

• Empiric treatment considered for patients with barriers to obtaining timely urine testing or visits.

“These criteria for ambulatory triage of suspected UTI symptoms in adults are anticipated to help standardize and improve the appropriateness of empiric antibiotic prescribing, urine testing, and visit type triage,” the researchers concluded. “For health systems and clinics interested in implementing these criteria, it will be important to review which visit options within the health system have the capability of ordering urinalysis with cultures or urinalysis with reflex to culture to tailor our algorithms for the most appropriate visit options for patients presenting by phone, portal message, virtual visit, or in-person visit.”

Disclosure: The study was funded by the Veterans Affairs National Center for Patient Safety. The funder had no role in the study design, conduct, analysis, or reporting. Several researchers reported financial relationships outside the submitted work; no other disclosures were reported. For full disclosures of the researchers, visit jamanetwork.com.

Source: JAMA Network Open