UTI

Sonya Collins

An international cohort of 54 experts, predominantly pharmacists and physicians, from 12 countries has compiled new clinical practice guidelines for the prevention, diagnosis, and management of UTIs. Traditionally, clinical practice guidelines are written by members of the professional societies relevant to that condition, which can result in major discrepancies between the strength of the recommendation and the strength of the evidence behind it.

The new crowdsourced consensus statement, which uses an approach established by the nonprofit organization WikiGuidelines, seeks to close the gap between recommendations and evidence to provide recommendations that are relevant across all practice settings and economic realities.

“A lot of those society guidelines disproportionately reflect clinicians who work at universities,” said Zachary Nelson, PharmD, statement coauthor and clinical pharmacy specialist in infectious diseases at HealthPartners and Park Nicollet Health Services in St. Louis Park, MN.

“The UTI guidelines are much more broadly applicable,” Nelson said, “because UTIs, unlike these other infections, are treated and diagnosed in a variety of settings and, in most cases, infectious disease experts are not involved.”

Published online November 4, 2024, in JAMA Network Open, the statement addresses 37 common clinical questions in the domains of prevention; diagnosis; empirical and definitive treatment; antimicrobial stewardship; and special populations. Contributors reviewed 914 articles before making their recommendations.

Time to retire the term ‘UTI’

“We should just call the UTI what it is,” said Nelson.

The consensus statement suggests that the term “UTI” is too broad to be useful. Auxiliary terms “complicated” and “uncomplicated” are equally vague as there is a variety of interpretations as to the circumstances that warrant these labels.

“ ‘Kidney infection’ or ‘cystitis’ makes much clearer the source of the infection and the intensity of the treatment. The term UTI should be obsolete,” said Nelson.

UTIs are a clinical, not laboratory, diagnosis

The consensus statement emphasizes UTI as a clinical and not a laboratory diagnosis.

“Having bacteria in the urine without any symptoms is common, especially in older women,” Nelson said. “Inevitably, these women are treated with antibiotics, which do nothing for them besides put them at risk.”

Urine cultures and urinalyses are likely unnecessary in many people, Nelson notes.

Description of hallmark symptoms, including burning and increased urinary frequency or urgency, is often enough to make a diagnosis.

“It’s more challenging to determine symptoms in somebody with a catheter, but by and large, it’s a clinical diagnosis,” Nelson said. “If there aren’t urinary symptoms, there’s no indication for treatment or testing. That’s just going to potentially lead to a misadventure with antibiotics.”

Shortest treatment duration is best

When antibiotics are indicated, more is not better.

“We achieve similar outcomes with shorter durations of treatment while avoiding the risks and adverse effects associated with longer courses,” Nelson said.

It’s a misconception that a drug-resistant infection would benefit from a longer course of treatment, he adds. “Resistance is inherently linked to exposure.”

Cranberry has real benefits

One of the most surprising findings of the crowdsourced research, Nelson said, was robust evidence that both cranberry juice and supplements can reduce risk of UTIs in women, children, and people susceptible to infections after medical interventions.

“Sometimes claims about supplements are made to take advantage of people with low health literacy,” Nelson said, “so we were surprised to find sufficient evidence for cranberry.”

There was insufficient evidence for prophylactic use of cranberry products in older adults, pregnant patients, or people with problems emptying their bladder.

Vaginal estrogen prevents UTIs

Statement contributors found sufficient evidence that topical vaginal estrogen prevents UTIs in postmenopausal women. Loss of estrogen causes changes in the vaginal microbiome that raises risk for UTIs. Topical estrogen mitigates this risk. The authors noted that topical estrogen is thought to have minimal systemic absorption and, as a result, does not present significant safety risks.

“There are a lot of misconceptions about the use and safety of vaginal estrogen,” Nelson said. “We were able to provide a very strong recommendation for its use in postmenopausal women.” ■