Millions of Americans each year seek urgent care for urinary tract infections (UTIs), and recent advances in telehealth have changed how they access diagnosis and treatment. Patients can now consult clinicians by video, send messages through their phones, or use direct-to-consumer services to obtain rapid UTI tests and antibiotics without seeing their regular health care provider.
While these developments may provide faster care, experts warn that they also increase the risk of inappropriate antibiotic use and underuse of urine culture tests. Overprescribing antibiotics contributes to the rise of drug-resistant bacteria, known as "superbugs." This is especially concerning for women who experience frequent UTIs.
A new guide for clinicians, published in JAMA Network Open by a team from the VA Ann Arbor Healthcare System (VAAAHS) and the University of Michigan Medical School, aims to address these challenges. The Ann Arbor Guide to Triaging Adults with Suspected UTI was developed with input from national experts and is among the first designed for telehealth and direct-to-consumer health care settings. The project was funded by the VA National Center for Patient Safety.
The guide includes two algorithms—one for non-pregnant women and one for men—that help clinicians decide which tests to order and when to prescribe antibiotics for patients with UTI symptoms. It also covers complex cases involving patients with conditions such as organ transplants, chemotherapy, immunosuppression, kidney disease, or recurrent UTIs requiring ongoing antibiotics.
Jennifer Meddings, M.D., M.Sc., primary care clinician at VAAAHS and Michigan Medicine, noted that a shortage of primary care providers has contributed to more patients seeking virtual care rather than in-person visits where urine samples can be collected and cultured. She said: "Now, far fewer patients are being seen in person in a setting where a urine sample can be collected, cultured and used by the same provider as the basis for a treatment recommendation a few days later. So it's more important than ever for providers to know which patients can safely receive antibiotics empirically – that is, without a urine culture and not just a dipstick test or no test."
The guide uses the RAND/UCLA Appropriateness Method to bring together expert opinions on best practices. It also provides triage instructions based on symptoms that could signal more serious conditions beyond simple UTIs.
Karen Fowler, M.P.H., patient safety specialist at the VA Center for Clinical Management Research who helped develop the guide, stated that it is currently being piloted during telehealth visits at local VA health centers. The team will evaluate how well providers feel it works when triaging emergency or urgent virtual UTI cases.
The authors caution that over-the-counter or online at-home UTI tests are not accurate enough to confirm an infection. They recommend confirming abnormal urinalysis results with a urine culture whenever possible due to high rates of false positives.
U-M Health has updated its testing strategy so that most patients whose rapid urinalysis comes back negative will not have further cultures performed; only those with abnormal results will undergo additional testing.
Meddings explained: "We hope that this guide will help both patients and providers be aware that even though they're now able to take a questionnaire or interact with a provider completely virtually, that alone may not be enough to get the right diagnosis or treatment." She added: "At the same time, we recognize that telehealth has removed barriers to care such as access to transportation, time off from work and caregiving, and more." The new algorithms allow empiric antibiotic treatment if transportation is unavailable within three days or if travel distance or lab hours make timely testing difficult.
Meddings advised women who frequently get UTIs—and most men—to request a urine culture even during virtual consultations or when using online-only services.
Other contributors include Kristin Chrouser, M.D., M.P.H.; Jessica Ameling, M.P.H.; Jason Engle, M.P.H.; Sanjay Saint, M.D., M.P.H.; and Steven Bernstein, M.D., M.P.H.—all affiliated with U-M or VA research teams focused on patient safety initiatives.
Saint and Meddings co-direct the Patient Safety Center of Inquiry project behind this work; several authors are members of the U-M Institute for Healthcare Policy and Innovation.
