Clinical Question

How can signs, symptoms, and urine dipstick testing best be used for the diagnosis of urinary tract infection (UTI) in women?

Evidence Summary

The prevalence of positive results from urine cultures among women presenting to a primary care physician with symptoms of UTI ranges from 25% to 88% in published studies, but it is usually more than 50%.^1–6 Treatment based on history alone without testing urine is relatively common, especially in otherwise healthy women with a history of UTI. This practice may result in overuse of antibiotics.⁷

A systematic review and individual patient data meta-analysis investigated the effects of analgesics, herbal formulations, and delayed prescription of antibiotics in women with uncomplicated UTI compared with immediate antibiotic treatment strategies.⁸ Data showed an increased likelihood of incomplete recovery when using analgesics, herbal formulations, and delayed prescription strategies instead of immediate antibiotics (odds ratio = 3.0; 95% CI, 1.7 to 5.5), but a two-thirds reduction in the use of antibiotics. Erythrocytes and bacteria in the urine were the best predictors of which patients would benefit from antibiotics. Although rapid point-of-care tests have been developed to detect gram-negative bacteria in urine, they have not been widely adopted.⁹ Use of a clinical prediction rule or risk score integrating signs, symptoms, and urine findings could help guide the use of empiric antibiotics in women with a high likelihood of UTI, with urine culture and anti-inflammatory medications for those at lower risk.