Urinary tract infections (UTIs) are among the most commonly diagnosed infections across outpatient, nursing home, and inpatient health facilities. UTIs are often over-diagnosed, which can lead to negative consequences for the patient and antibiotic resistance. Below is general guidance regarding UTI diagnosis, which focuses on the importance of urinary symptoms. Additional considerations in patients with suspected sepsis and patients with abnormal bladder function, such as patients with spinal cord injuries, are also discussed.
Avoid Treating Asymptomatic Pyuria and Bacteriuria
To establish the diagnosis of a UTI, patients generally need to have urinary symptoms and compatible diagnostic data, such as the presence of pyuria in the urinalysis (UA) and a positive urine culture. Pyuria and bacteriuria are very common, especially in older adults, and their presence (without urinary symptoms) does not generally warrant treatment. This is because antibiotic treatment of asymptomatic pyuria or bacteriuria is of no benefit to the patient, with a few exceptions for asymptomatic bacteriuria, such as during pregnancy or preceding invasive urological procedures.
How about patients who present with sepsis? And how about patients who do not have a functional bladder, such as patients with spinal cord injury or neurogenic bladder due to another etiology?
Patients with Suspected Sepsis
Cystitis does not present with sepsis unless there is progression to acute pyelonephritis. Patients with acute pyelonephritis typically also have a picture of sepsis (fever, leukocytosis, tachycardia), which in some cases can progress to septic shock. Patients with chronic indwelling catheters can also present with sepsis in the setting of a UTI; it is reasonable to assume that these patients, too, have acute pyelonephritis when they present with sepsis due to a UTI. Most patients with sepsis due to a UTI, who have a normal urinary system, also have urinary symptoms, such as dysuria, urinary urgency/frequency, and flank pain. These urinary symptoms point towards the diagnosis. Occasionally, patients with acute pyelonephritis may present with “undifferentiated sepsis” (i.e., without localizing symptoms), but this is less common. In patients presenting with sepsis without urinary symptoms, a workup for possible UTI is indicated if there is no other obvious source of infection. If another infection source is obvious, there is generally no need to send urine for testing in the absence of urinary symptoms.
It can be easy to assume that sepsis is due to a UTI and miss the true cause.
Patients without Normal Bladder Function
Diagnosis of urinary tract infections in patients who do not have normal bladder function can be very challenging. This includes patients with neurogenic bladder (for example, in the setting of spinal cord injury or diseases such as multiple sclerosis) who often have a chronic indwelling Foley catheter or suprapubic catheter or need in-and-out catheterization. It also includes patients with a chronic indwelling Foley catheter or suprapubic catheter due to another cause of bladder dysfunction, such as bladder outlet obstruction. They often do not have typical lower urinary symptoms, such as dysuria, urgency, and suprapubic pain. In these scenarios, pyuria and bacteriuria are also more likely, so a “dirty” UA or positive urine culture may represent their baseline status and not a new infection requiring antibiotic treatment.
Caring for such patients necessitates several considerations. If they are asymptomatic and in their usual state of health, there is generally no need to investigate for a urinary tract infection (malodorous or cloudy urine are non-specific symptoms that do not warrant further evaluation).
If patients present with sepsis, workup for possible UTI is indicated, especially if there is no other obvious source of infection. Still, it is important to remember that an abnormal UA does not establish the diagnosis (given that the UA is often abnormal in these patients at baseline), so one should keep one’s mind open to other diagnostic possibilities. It can be easy to assume that sepsis is due to a UTI and miss the true cause.
It may be appropriate to proceed with a watchful waiting approach in stable patients.
Patients with Spinal Cord Injuries
Patients with neurological conditions such as spinal cord injury and associated quadriplegia or paraplegia and neurogenic bladder may have some additional symptoms in the setting of a urinary tract infection. These include increased spasticity or autonomic dysreflexia. It is important to remember that these symptoms are not specific to a urinary tract infection and can have multiple etiologies, including other infections or non-infectious causes. Because these patients often have pyuria/bacteriuria at baseline, it is important to also think of other possible explanations for these symptoms. Sometimes it may be appropriate to proceed with a watchful waiting approach in stable patients, addressing another more likely cause of the symptoms and watching for improvement to decide if patients may need evaluation for a possible UTI).
Patient Scenarios
Below are some examples and suggested management.
| Scenario | Suggested Management |
| 60-year-old female with dysuria for three days, now also with fever and right flank pain
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Diagnosis is consistent with acute pyelonephritis, so it is recommended to send UA and urine culture.
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| 58-year-old male with acute onset fever, cough, right pleuritic chest pain, and right lung base crackles in physical exam
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Probably pneumonia. There is no need to send for UA/urine culture given that there is an obvious alternative source for sepsis and no urinary symptoms.
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| 50-year-old female with acute onset fever found to have tachycardia and leukocytosis
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Non-localizing exam: It is reasonable to send UA/urine culture for the possibility of acute pyelonephritis, given the picture of sepsis without a clear source.
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| 45-year-old male with paraplegia and neurogenic bladder with chronic suprapubic catheter presenting with acute onset fever, found to have tachycardia and leukocytosis
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It is reasonable to send for UA/urine culture, especially if there is no other obvious source of infection, and consider other sources of infection, even if pyuria or bacteriuria is present.
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For additional clinical resources for UTI diagnosis and management, consider reviewing the UTI tool kit, including the adult and pediatric clinical pathways.