Adult Guidelines
Urine Testing Algorithm

Urine Testing Algorithm

Clinical Signs of a UTI

  • Localizing urinary symptoms
    • No Catheter: dysuria, frequency, suprapubic pain, gross hematuria, CVA tenderness/flank pain, or new/worsening urgency or urinary incontinence
    • Catheterized: fever, chills, pelvic discomfort/suprapubic pain, gross hematuria, and altered mental status with no other identifiable cause

OR

  • Non-localizing infectious symptoms/sepsis (fevers, rigors, leukocytosis) AND 
  • No symptoms suggesting infection at another site or patient unable to provide history

Urine Testing Algorithm

Does the patient have clinical signs/symptoms of a UTI?

Urinalysis Pearls

Sending UA is NOT recommended if/based on:

  • Change in urine color, odor, or turbidity typically due to dehydration, diet, medications, liver disease or other etiologies
  • Patient lacks symptoms of a UTI
  • Automatically in workup of fever or sepsis patients who can provide a history should not have a UA/urine culture obtained as part of fever evaluation unless symptoms suggest a UTI is present
  • Pre-operatively except in urologic surgery where mucosal bleeding is anticipated
  • When a urinary catheter is placed or changed
  • After treatment of UTI to document cure
  • Negative leukocyte esterase and absence of pyuria (≤5-10 WBCs/hpf) have good negative predictive value for UTI
  • Positive leukocyte esterase and/or presence of pyuria (≥5-10 WBCs/hpf) have poor positive predictive value for UTI
    • Indicates inflammation but is not indicative of UTI in the absence of symptoms
  • Positive nitrite can indicate presence of Gram-negative bacteriuria, but it does not diagnose UTI in the absence of symptoms
    • Can also be false positive from air exposure or contamination
    • Poor sensitivity and specificity for UTI

Additional Information

May 12, 2022

  • Cortes-Penfield et al. Infect Dis Clin North Am. 2018.
  • Advani et al. Antimicrobial Stewardship & Healthcare Epi. 2021.