Healthy, nonpregnant women presenting with the triad of frequency, dysuria, and no vaginal symptoms have about a 96% chance of having an urinary tract infection (UTI) (positive likelihood ratio [LR+]=24.6). Since no urinalysis result would substantially change the high likelihood of disease for these patients, empiric therapy is appropriate (strength of recommendation [SOR]: B)

DeAlleaume, Lauren

Tweed, Elizabeth M.

University of Missouri: MOspace

338 VOL 55, NO 4 / APRIL 2006  THE JOURNAL OF FAMILY PRACTICEE V I D E N C E - B A S E D A N S W E RWhen are empiric antibiotics appropriate for urinary tract infection symptoms? ■ Evidence summaryAn evidence-based review1 found 5 high-quality studies on the diagnosis of acuteuncomplicated UTI among women.(“Uncomplicated” was defined as normalurinary tract and no contributing medicalproblems, such as diabetes, neurogenicbladder, renal stones.) UTIs were definedas the presence of significant bacteriuria (≥104 to 105 colony-forming units) on culture. A patient presenting to a clinicianwith 1 or more UTI symptoms hadapproximately a 50% chance of havingsignificant bacteriuria on culture.1 Theauthors estimated the pretest probabilityof UTI as 5% from the incidence of asymp-tomatic bacteriuria among healthywomen.1,2 This produced a LR+ of 19 sim-ply for presenting to a clinician with 1 ormore UTI symptoms.1 The summary LRsfor clinical signs and symptoms in the pre-diction of UTI after presentation to theoffice are found in TABLE 2. A history of avaginal discharge or irritation has a LR– of0.3, decreasing the probability of UTI for apatient presenting to the office fromapproximately 50% to 20%, so furthertesting would be indicated.1Healthy, nonpregnant women presenting with the triad of frequency, dysuria, and novaginal symptoms have about a 96% chance ofhaving an urinary tract infection (UTI) (positivelikelihood ratio [LR+]=24.6). Since no urinalysisresult would substantially change the high likelihood of disease for these patients, empiric therapy is appropriate (strength of recommendation [SOR]: B).A triage system based only on having 1 ormore urinary symptoms is more sensitive but lessspecific: the chance of having a UTI drops to 50%(LR+ =19). While empiric therapy is still likely to be appropriate, rates of false positives andinappropriate antibiotic use may rise (SOR: B).Empiric treatment by telephone may also beconsidered (SOR: C). While no studies havespecifically addressed the diagnostic value of UTIsymptoms reported by phone, no increase inpyelonephritis or other adverse events has beenseen with telephone treatment protocols. Andwhile telephone treatment protocols can increasethe use of guideline-recommended antibioticsand decrease costs, they may increase unneces-sary antibiotic use overall. Contraindications toempiric therapy are listed in TABLE 1.Lauren DeAlleaume, MD, Elizabeth M. Tweed, BSN, MLISUniversity of Colorado Health Sciences Center, DenverC L I N I C A L C O M M E N T A R YTelephone protocol for UTI reduces unnecessary office visits and lab testingWe have 10 years of experience with a telephonetreatment protocol we developed for uncomplicated UTI; it has since been adopted bythe Institute for Clinical Systems Improvement(ICSI). The protocol reduces unnecessary office visits and lab testing. We believe the protocol actually increases our prescribing of preferred first-line antibiotics for UTI. While it is convenientfor our patients, its use has resulted in patientswanting to be treated over the phone even if they have “failed” the protocol. Overall, ourpatients are thankful we have a telephone protocol for uncomplicated UTI. We enjoy the use of a handful of other telephone protocols and hope to move toward web-based protocols in the future.Robert Bonacci, MDMayo Clinic, Rochester, Minn C O N T I N U E DCLINICAL INQUIRIESJFP_0406_CI.FinalREV  3/17/06  2:37 PM  Page 338Copyright® Dowden Health Media  For personal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.VOL 55, NO 4 / APRIL 2006 341www. j f p o n l i n e . c omEmpiric therapy is appropriate in nonpregnantwomen with thetriad of frequency,dysuria, and novaginal symptomsFAST TRACKNo single sign or symptom accuratelypredicted UTI. However, the triad ofdysuria with frequency but without vaginalsymptoms increased the probability of sig-nificant bacteriuria on culture from 50%to 96% (LR+ =24.6).1 In contrast, a 1999review of 51 studies calculated that if boththe nitrites and leukocyte esterase are posi-tive on urine dipstick testing, the LR+ is4.2; if both are negative the LR– is 0.3.1,3Since the probability of UTI for patientswith the symptom triad is so high, dipstickurinalysis is unlikely to alter managementregardless of whether nitrites and leukocyteesterase were both positive or negative(posttest probability=98%–99% and 80%,respectively). If urine dipstick or otheroffice-based tests are not needed to makethe diagnosis of uncomplicated UTI for apatient with the classic triad of symptoms,then telephone treatment based on symp-toms may be reasonable. Women who haverecurrent UTIs (2 or more culture positiveUTIs over the previous 12 months) canaccurately self-diagnose subsequent UTIsbased on symptoms (LR+ =4.0).4,5A recent retrospective case series6 evalu-ated a telephone guideline for the empirictreatment of UTI for 4177 women in aCalifornia HMO. UTI criteria were ≤10 daysof dysuria; frequency, urgency, pressure, orincreased nocturia; or gross hematuria.Women were excluded if they had any one ofa variety of contraindications (TABLE 1).Upper tract infection occurred in 21patients (1.1%) within 60 days of telephonetreatment, two thirds of which likely repre-sented treatment failures. This is similar torates in control groups of other studies.Fourteen women (1.5%) received care forsexually transmitted diseases or other gyne-cologic conditions, primarily bacterialvaginitis, within 60 days of telephone treat-ment. Of note, 6% of the cohort were eld-erly, diabetic, taking glucocorticoids or earlyin pregnancy and are typically excludedfrom other studies. This higher-risk groupdid not have an increased incidence of eithersepsis or pyelonephritis.6 No increase inadverse outcomes was seen in another studyof a telephone treatment protocol.7Several studies6–8 have noted that tele-phone treatment protocols increase the useof protocol-recommended antibiotics (eg,generally less expensive agents such astrimethoprim-sulfamethoxazole), whichmay help limit resistance to fluoro-quinolones. However, specific data are notavailable. McIssac et al9 reviewed a cohort of231 women presenting to family physi-cians’ offices with uncomplicated cystitissymptoms. Empiric therapy resulted inapproximately 40% of women unneces-sarily receiving antibiotics. Treating onlywomen with classic cystitis symptoms andpyuria would have decreased the unneces-sary use of antibiotics to 26.2%, but fewerwomen with confirmed cystitis would havereceived immediate antibiotics (66.4% vs91.8%). They derived a clinical decisionrule designed to balance false positives andfalse negatives. It recommends immediateantibiotic treatment if women have ≥2 of 4signs or symptoms: dysuria, leukocyteesterase (greater than trace), positivenitrites, or blood (greater than trace) ondipstick (LR+ =2.29). Otherwise the rulerecommends a culture to guide antibioticTA B L E 1Vaginal discharge Prolonged symptomsSevere or intolerable flank, side, or abdominal painInability to urinate for more than 4 hoursBody temperature higher than 38.1°C (100.5°F) with flank pain, chills, nausea, or abdominal painPregnancy Recent urologic surgery, procedure, or bladder catheterization; UTI within the last 6 weeks or frequent UTI (≥3 times) in the last 12monthsAny symptoms that warrant urgent office-based evaluation according to the clinicianAdapted from Vinson and Quesenberry, Arch Intern Med 2004.6Contraindications to empiric antibiotics for urinary tract infection (telephone treatment)CLINICAL INQUIRIESJFP_0406_CI.Final  3/16/06  2:56 PM  Page 341342 VOL 55, NO 4 / APRIL 2006  THE JOURNAL OF FAMILY PRACTICECLINICAL INQUIRIEStherapy. This decision rule would havereduced unnecessary antibiotic use by27.5% while ensuring that more womenwith confirmed UTIs received immediateantibiotics (81.3%).In 1999, Saint et al8 estimated savingsof $367,000 for 147,000 women enrolledover 1 year after widespread guidelineimplementation. Two cost-effectivenessstudies10,11 of office treatment concludedthat empiric treatment without additionaltesting is the least costly option in this set-ting. However, a recent, comprehensivecost-effectiveness study11 concluded that ifa patient presents to an office, the margin-al cost of performing a pelvic examinationand urine culture for women with a nega-tive dipstick was relatively low ($4 to $32per symptom day avoided). Recommendations from othersA 2002 Institute for Clinical SystemsImprovement guideline12 advised offeringtelephone treatment of uncomplicated UTIfor low-risk patients if preferred by bothprovider and patient.R E F E R E N C E S1. Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S.Does this woman have an acute uncomplicated  uri-nary tract infection? JAMA 2002; 287: 2701–2710.2. Hooton T, Scholes D, Stapleton AE, et al. A prospectivestudy of asymptomatic bacteriuria in sexually activeyoung women. N Engl J Med 2000; 343:992–997.3. Hurlbut T, Littenberg B. The diagnostic accuracy ofrapid dipstick tests to predict urinary tract infection.Am J Clin Pathol 1991; 96:582–588.4. Gupta K, Hooton TM, Roberts PL, Stamm WE. Patient-initiated treatment of uncomplicated recurrent urinarytract infections in young women. Ann Intern Med2001; 135:9–16.5. Schaeffer AJ, Stuppy BA. Efficacy and safety of self-start therapy in women with recurrent urinary tractinfections. J Urol 1999; 161:207–211.6. Vinson DR, Quesenberry CP Jr. The safety of telephonemanagement of presumed cystitis in women. ArchIntern Med 2004; 164:1026–1029.7. Barry HC, Hickner J, Ebell MH, Ettenhofer T. A random-ized controlled trial of telephone management of sus-pected urinary tract infections in women. J Fam Pract2001; 50:589–594.8. Saint S, Scholes D, Fihn SD, Farrell RG, Stamm WE.The effectiveness of a clinical practice guideline for themanagement of presumed uncomplicated urinarytract infection in women. Am J Med 1999;106:636–641.9. McIsaac WJ, Low DE, Biringer A, Pimlott N, Evans M,Glazier R. The impact of empirical management ofacute cystitis on unnecessary antibiotic use. ArchIntern Med 2002; 162:600–605.10. Barry HC, Ebell MH, Hickner J. Evaluation of suspectedurinary tract infection in ambulatory women: a cost-utility analysis of office-based strategies. J Fam Pract1997; 44:49–60.11. Rothberg MB, Wong JB. All dysuria is local. A cost-effectiveness model for designing site-specific man-agement algorithms. J Gen Intern Med 2004; 19(5 Pt1): 433–443.12. Uncomplicated urinary tract infection in women.Bloomington, Minn: Institute for Clinical SystemsImprovement; July 2004. Available at guidelines.gov/summary/summary.aspx?doc_id=5570. Accessed onMarch 7, 2006.T A B L E 2SUMMARY DIAGNOSTIC CRITERIA LR+ LR– LRPresenting to medical care 19.0with possible UTIDysuria 1.5 0.5Frequency 1.8 0.6Hematuria 2.0 0.9Recurrent UTI symptoms for 4.0 0.0a woman with history of UTIVaginal discharge or irritation 0.2–0.3 2.7–3.1Dysuria, frequency, 24.6and absence of vaginaldischarge or irritationDysuria absent, 0.3+ vaginal dischargeDysuria and  0.7+ vaginal discharge + Leukocytes* or + nitrate  on urine dipstick analysis 4.2 0.3†“UTI Rule”‡ 2.3* Leukocyte greater than trace on dipstick† Leukocytes negative and nitrite negative‡ “UTI Rule”—positive if 2 or more present: dysuria, + leukocytes, + nitrate, + heme (> trace) LR, likelihood ratio; UTI, urinary tract infection.Adapted from Bent et al, JAMA 2002.1Diagnosis of urinary tract infectionJFP_0406_CI.Final  3/16/06  2:56 PM  Page 342

When are empiric antibiotics appropriate for urinary tract infection symptoms?

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