Minimising urine dipstick use improves UTI management

Antibiotic prescribing for urinary tract infection (UTI) is common in community, hospitals and aged care settings. But over-reliance on urine dipstick testing to guide UTI management contributes to antibiotic overuse and misuse.

Pharmacists can make a difference by raising awareness of this issue among peers, consumers, and other healthcare professionals. In aged care settings, pharmacists are likely to be increasingly involved in antimicrobial stewardship (AMS) around UTI.

Here are three important questions about UTI diagnosis and antibiotic prescribing, answered.

1. How should you recognise UTI in adults?

The diagnosis should be based on the person’s clinical symptoms and signs. Do they display at least two local urinary tract symptoms (new dysuria, urgency, frequency) that are highly suggestive of UTI? If so, the best testing options are doing nothing (if no risk factors for complicated UTI) or midstream urine, according to the Therapeutic Guidelines: Antibiotics.

Do they display isolated symptoms that could also be related to other causes, such as new urinary frequency? If so, a careful clinical assessment is required taking into consideration all other potential causes. For example, change in hydration pattern, medications or diabetes control. 

2. But doesn’t a positive urine dipstick test result mean the person has a UTI?

No, interpreting a positive dipstick result as confirmatory of a UTI may result in alternative diagnoses being missed.  The urine dipstick test result can be positive because of asymptomatic bacteriuria (ASB), a condition with bacteria in urine that is part of a person’s urinary tract microbiome. ASB occurs with increasing frequency as we age (over the age of 65, up to half of us will have ASB), and does not require antibiotic treatment.

Health professionals tend to overestimate the probability of UTI if given urine dipstick testing results and may incorrectly prescribe antibiotics. In a recent study published in The Journal of the American Medical Association, practitioners were given a scenario of a patient seen for osteoarthritis. A urine dipstick showed trace blood. He described smelly urine with no other symptoms. This scenario describes ASB. Prior to being provided with the dipstick result, nearly half the practitioners correctly estimated the probability of UTI as negligible. After the dipstick result, around 40% now estimated the probability of UTI as 90% or higher.

Apart from smelly urine, other common prompts for urine dipstick testing are dark urine, cloudy urine, person with recurrent falls, collapse, altered behaviour, loss of appetite and lethargy. These are examples where urine dipstick test results without considering the person holistically can be misleading rather than helpful.

3. Does minimising urine dipstick use improve antibiotic prescribing for UTI?

Yes. There have been numerous studies that have shown educating clinicians around ASB and how to assess their patients for UTI has safely reduced inappropriate antibiotic prescribing for UTI, and reduced prescriptions for UTI prophylaxis. 

The Aged Care Quality and Safety Commission has resources to support quality use of medicines pharmacist AMS activities in residential aged care facilities.  

Pharmacists should also refer to the Australian Commission on Safety and Quality in Health Care’s Antimicrobial Stewardship Clinical Care Standard, endorsed by PSA. 

The standard was designed to promote the delivery of evidence-based clinical care and approve the appropriateness of care for particular clinical conditions or procedures.

References:

1. Aged Care Quality and Safety Commission. AMS Clinician resources. To Dip or Not to Dip. At: https://agedcarequality.gov.au/antimicrobial-stewardship/clinician-resources
2. Lim LL, Bennett N. Improving management of urinary tract infections in residential aged care facilities. Aust J Gen Pract. 2022 Aug;51(8):551-557. At: https://.racgp.org.au/ajgp/2022/august/utis-in-residential-aged-care-facilities
3. Morgan DJ, Pineles L, Owczarzak J, Magder L, Scherer L, Brown JP, Pfeiffer C, Terndrup C, Leykum L, Feldstein D, Foy A, Stevens D, Koch C, Masnick M, Weisenberg S, Korenstein D. Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing. JAMA Intern Med. 2021 Jun 1;181(6):747-755. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2778364
4. Lim LL, Goyal N. Hospital clinical practice around urinalysis is an important opportunity for antimicrobial stewardship improvement activities. Infect Dis Health. 2021 Nov;26(4):243-248. https://idhjournal.com.au/article/S2468-0451(21)00026-2/fulltext
5. eTG: Antibiotics. Urinary tract infections. (Accessed 12 August 2022).