This protocol provides guidance on appropriate testing for suspected urinary tract infection (UTI) in adults  16 years. It also includes guidance in certain populations with potential asymptomatic bacteriuria, such as the elderly, pregnant women and those who will undergo urological procedures. Individual antibiotic recommendations and testing for sexually transmitted infections are out of scope. A link to resources for antibiotic management is provided. Please see the BC Centre for Disease Control website for information on testing for sexually transmitted infections (STIs).1. UTI is a clinical diagnosis. 2. Urine microscopy is NOT recommended for investigating UTI. 1,2 3. Urine dipstick is more helpful in some scenarios than others: - In women with a clear presentation of acute cystitis (high pre-test probability), the dipstick is not required as the result will not change management. A negative dipstick is not sensitive enough to rule out infection in this scenario. 3 - However, in women with atypical or unclear symptoms (low pre-test probability), a positive urine dipstick can support the diagnosis, while a negative urine dipstick can rule out UTI. 4 - Male UTIs are atypical and dipstick testing is warranted for suspected UTI. 5 4. Urine culture is not required in most cases of cystitis. It should be requested only when there is a higher risk of resistant uropathogen, or in specific circumstances to confirm the diagnosis (see Table 2). 5. Asymptomatic bacteriuria is common and does NOT require treatment in most patients (see Table 3). - Two exceptions where screening for and antibiotic treatment of asymptomatic bacteriuria are warranted are: a) in pregnant women; and b) in those who will undergo urological procedures with mucosal trauma. 6 - New onset confusion and delirium alone are NOT considered symptoms of UTI. In elderly or debilitated patients with new cognitive or functional changes and no symptoms of UTI, testing for, and treatment of, UTI is not warranted. 6,7 6. If indicated, the sample for urine culture should ideally be collected at the laboratory to prevent organism overgrowth. However, if collected at the point of care, the urine should be stored in the fridge for no more than 24 hours prior to submission to the laboratory under refrigerated conditions. 7. Empiric fluoroquinolone therapy should be avoided in the treatment of UTIs due to moderate resistance rates and increased risk of adverse events 8-10 (hypoglycemia, 11 tendonitis, 12 CNS toxicity, 12 aortic dissection 13 and C. difficile infection 14 ). - Prescribe fluoroquinolone therapy only if the likelihood of resistance is low and the patient has contraindications and/or allergies to other antibiotics. 8. Gross hematuria in the absence of other symptoms requires referral to urology. In the case of isolated microscopic hematuria, refer to BCGuidelines.ca: Microscopic Hematuria.# Rationale
- Suspected UTI is one of the most common presentations in the primary care setting.
- Urine dipstick, urine microscopy and urine cultures are some of the most commonly utilized tests.
- UTI can be misdiagnosed, resulting in inappropriate test utilization and/or unnecessary antibiotics. - Normal bladders are not necessarily sterile. Bacteria in the urine may be normal for an individual and does not need treatment unless/until it causes urinary symptoms or fever, or if they are pregnant or about to have urological procedure with mucosal trauma. - Asymptomatic bacteriuria is common: 6,15 o Premenopausal women -up to 5% o Postmenopausal women -up to 10% o Elderly (> 70 years) in the community -up to 16% in women, and up to 7% in men o Elderly in long-term care (LTC) facilities -up to 50% in women and up to 40% in men o Indwelling catheter -100% after 1 month from insertion 16 - To promote laboratory and antimicrobial stewardship, this protocol provides the following: o information on collection and interpretation of urine dipstick, urine microscopy and urine cultures; o approach to diagnosing and classifying UTI; and o indications for appropriate testing in symptomatic and asymptomatic patients.

# Urine Collection and Storage
- Prolonged and/or improper storage of urine can negatively impact the analysis. 17 o Urine dipstick: may cause false positive nitrites. o Urine microscopy: cells (i.e. red blood cells and white blood cells) may degrade (at room temperature for > 1 hour; in the fridge > 4 hours), 18 resulting in lower counts than actual. o Urine culture: improper storage conditions (i.e. at room temperature for > 30 minutes) can promote growth of bacteria and result in higher organism counts which can falsely be interpreted as positive. - The preferred location for urine dipstick is at the point of care (i.e. in the clinic). However, the preferred location for urine microscopy and culture specimen collection is in a laboratory (e.g. patient service centres and hospitals) as this minimizes degradation and/or organism overgrowth from prolonged storage and transportation. - For urine cultures, in circumstances where either the patient is unable to go to the laboratory, or where the patient will start an antibiotic imminently (and hence suppress organism growth), the patient may have their urine collected at the point of care and transported to the laboratory. o Avoid collecting urine from old urinary catheters, catheter bags and diapers due to contamination. 16,17 o The optimal volume of collected urine is 10-12 cc. o The urine should be stored in the fridge (2-8C) for no more than 24 hours prior to submission under refrigerated conditions. o See Appendix 1 for instructions on point of care urine collection prior to urine culture.

# Tests for UTI Urine dipstick (also known as macroscopic urinalysis, routine urinalysis, chemical reagent strip)
- The test used in the laboratory is the same as the one used in the clinic at the point of care.
- The relevant reagents to diagnose UTI/bacteriuria are (see Appendix 2): 19 a) Leukocyte esterase (LE) -detects pyuria (white blood cells). Pyuria is not specific for UTI and may occur with other inflammatory disorders (e.g. vaginitis). b) Nitrite -detects presence of certain bacteria, such as E. coli. c) Blood -detects hematuria. For assessing UTI, it should be used in conjunction with LE or nitrite. o In the case of isolated microscopic hematuria, refer to BCGuidelines.ca: Microscopic Hematuria. - LE and/or nitrite are frequently positive in asymptomatic bacteriuria, especially in the elderly. 6 Hence, do not order in the elderly if isolated altered mental status, cloudy urine or malodorous urine. 7,20 - Sensitivity of urine dipstick testing ranges between 64.3-100% for presence of bacteria with or without pyuria. 3 The accuracy of urine dipstick depends on the pretest probability and the population tested. o In premenopausal women who have a clear presentation of acute cystitis (probability of UTI is high), the urine dipstick is not necessary as a negative dipstick does not rule out infection. 3 o Conversely, in women with atypical or unclear symptoms (probability of UTI is < 50%), a positive urine dipstick can support the diagnosis, while a negative urine dipstick can rule out UTI. 4 Urine microscopy (also known as microscopic urinalysis)
- Urine microscopy (white blood cells, red blood cells and bacteria) is NOT needed to diagnose a UTI. 1,2 If the dipstick is negative, urine microscopy does not provide an advantage over dipstick testing and it is important to reassess the diagnosis. - Urine microscopy is used to confirm microscopic hematuria in the absence of infection (See BCGuidelines.ca: Microscopic Hematuria) and to investigate parenchymal renal diseases (see Appendix 2 below).

# Urine culture (may include susceptibility results if uropathogen(s) is/are identified)
- A urine culture should be requested in specific circumstances to confirm the diagnosis (if needed) and to guide antibiotic therapy (see Table 2 and Appendix 2). - This test may be positive due to UTI, asymptomatic bacteriuria or contamination from skin, perineal or gastrointestinal flora. - If the patient has antibiotic allergies or is being treated with an antibiotic, it is important to document this on the requisition.
This may impact the antibiotic susceptibilities reported. - The organism concentration (i.e. colony count) reported varies by collection type and laboratory. While the threshold of  10 5 CFU/mL, but treatment may not be warranted (see Table 3). 6 - The laboratory workup considers both the number of different bacterial species identified and their respective concentrations. The following can affect the cultures and results: 16,17 a) Collection from old urinary catheters may produce false positive results from contaminating organisms. b) Improper collection due to contamination with skin, perineal or gastrointestinal flora can produce a false positive result (if the urine was indeed sterile) or a "mixed organisms" result. c) Prolonged storage without refrigeration or preservatives (e.g. boric acid) can produce false positive culture results due to organism overgrowth. d) Antibiotics prior to urine collection can suppress bacterial growth and produce false negative results. This suppression may also permit the growth of flora (e.g. Candida), which are non-contributory to the infection and are misinterpreted as pathogens. - Profiles of antimicrobial susceptibility testing are available at your local laboratory.

# UTI Classification
- For this protocol, UTI is classified as cystitis, where the infection is confined to the bladder, or complicated UTI, with extension outside the bladder (i.e. pyelonephritis and systemic infection) based on Table 1. This definition of complicated UTI may be different than that described in some literature. 

# Diagnosis
- Symptoms, clinical history, and demographics determine the approach to diagnosis and testing (see Summary in Figure 1 and details in Table 2 and Table 3). If there are symptoms of vaginitis or urethritis, evaluate for other genitourinary infections, including STIs.  Within BC, the most common uropathogens (E.coli) are > 95% susceptible to first line antibiotics. 5,27 In non-pregnant women, antibiotic-sparing strategies (i.e. symptomatic management with NSAID, 28,29 or delayed prescription 30,31 ) can be considered based on patient preference, symptom severity and risk of complications. However, this may result in delayed symptom resolution by a few days and up to 5% increased risk of pyelonephritis. 28 If symptoms resolve despite laboratory confirmed resistance and the patient is NOT pregnant, continue antibiotics. However, if the patient is pregnant, change to suitable antibiotics. 32 Cystitis, unresolving or recurring within < 4 weeks after treatment Dipstick and urine culture 5 Consider complicated UTI 5

# Figure 1. Summary of investigations of UTI
Cystitis, frequent culture-positive recurrence (> 3 per year, expert opinion) Urine culture 5,33 If coitus related:
- consider post-coital prophylaxis 34 If non-coitus related:
- Kidney/bladder ultrasound with post-void residual (PVR) - Consider referral to urology and/or infectious diseases
Evaluate for risk factors related to recurrence, and rule out structural or functional abnormalities. 33 In patients who remain symptomatic despite prophylactic therapy, consider repeating urine cultures to assess for possible resistance to antimicrobials. 35 Do not order routine urine cultures (e.g., monthly) in the absence of symptoms, even in patients with recurrent UTI and/or on prophylactic antibiotics.
Complicated UTI Dipstick and urine culture 5,18 - 

# Complicated and recurrent UTI (> 1 UTI), including prostatitis
Dipstick and urine culture 5 - Kidney/bladder ultrasound with PVR and prostate size - Consider referral to urology 5 Consider STI 26 For immunocompromised states (e.g. transplant patients, neutropenia, HIV): If febrile, do blood culture, pre-treatment urine cultures are recommended. Consultation with microbiologist or Infectious Diseases physician recommended for all culture negative recurrent UTI. 5 No antibiotics 6,7 For renal transplant patients (< 8 weeks posttransplant)  refer to renal transplant service

# Spinal cord injury (including intermittent catheter use)
No testing required if symptoms of UTI or systemic infection are absent. 6 UTI symptoms may be atypical, and include increased spasticity, autonomic dysreflexia, new or worsening urinary incontinence or leakage, a sense of unease with vague back and abdominal pains. 37 

# No antibiotics
This is a diagnostically challenging group as patients with neurogenic bladders have a high prevalence of bacteriuria and high incidence of UTI. Treatment may be warranted in patients who present with recent onset or change in signs or symptoms in the setting of bacteriuria and pyuria with no alternate diagnosis. 6 Elderly, functionally or cognitively impaired patient with:
- Delirium/new confusion; or - New falls
No testing required if symptoms of UTI or systemic infection are absent. 6,7 No antibiotics 6,7 Before assuming UTI is the cause, assess for other issues with careful observation. Hydrate patient and evaluate for: 6,7 - New medication/drug interactions - Hypoxia - Hypoglycemia - Trauma There is high certainty of harm (risk of antibioticassociated diarrhea, including C. difficile infection and increased risk of antimicrobial resistance) and low certainty of benefit from treatment of asymptomatic bacteriuria in older adults. 6 With indwelling urinary catheter
- Catheterized patients usually do not manifest symptoms of cystitis. Instead, monitor for symptoms of complicated UTI. 16 No testing required if symptoms of UTI or systemic infection are absent. 6,16 If patient is symptomatic, collect urine for culture after removal of old catheter or from a newly inserted catheter. 16 Catheters can be colonized with bacteria after 24 hours of insertion, and 100% are colonized within 1 month. 5,16 

# Management
In non-pregnant women with clinically suspected UTI (cystitis, first or infrequent episode), antibiotic-sparing strategies (i.e. symptomatic management with NSAID 28,29 , or delayed prescription 30,31 ) can be considered based on patient preference, symptom severity and risk of complications. However, this may result in delayed symptom resolution by a few days and up to 5% increased risk of pyelonephritis. 28 Treatment resources for the management of urinary tract infections can be found through your local hospital, health authority or laboratory, as well as through the following resources: 
Bugs &

# Methodology
These protocol recommendations are tailored to support practice in British Columbia and are based on guidance from the Association of Medical Microbiology, Infectious Disease Canada, the Infectious Diseases Society of America 6 and Bugs & Drugs. 5 Where available, key references are provided. In situations where there is a lack of rigorous evidence, we provide best clinical opinion to support decision making and high-quality patient care. The protocol development process included significant engagement and consultation with primary care providers, specialists and key stakeholders, including the Provincial Laboratory Medicine Services. For more information about GPAC protocol development processes, refer to the GPAC handbook available at BCGuidelines.ca.

# Resources
Practitioner Resources