What are the recommendations for discontinuing antibiotics in a patient started on antibiotics for a possible urinary tract infection (UTI) with a negative urine culture?

Discontinuing Antibiotics for Possible UTI with Negative Urine Culture

Antibiotics should be discontinued when urine culture results are negative in patients started on empiric therapy for possible UTI, provided the patient is clinically improving and there is no other infection requiring treatment. 1

Evidence-Based Recommendations for Antibiotic Discontinuation

When to Discontinue Antibiotics

• Discontinue antimicrobial agents when all of the following criteria are met:

  1. All bacterial cultures are negative at 24-36 hours
  2. Patient is clinically well or improving (e.g., fever resolving, improved symptoms)
  3. There is no other infection requiring treatment (e.g., otitis media) 1

• Continuing antibiotics despite negative cultures contributes to antimicrobial resistance, disrupts the patient's microbiome, and increases the risk of adverse drug reactions without providing clinical benefit 1

Implementation of Discontinuation Process

• A pharmacist-driven follow-up process can be effective in ensuring antibiotics are discontinued after negative urine culture results 2
• This approach has been shown to increase the percentage of patients contacted to discontinue antibiotics from 0% to 40% in emergency department settings 2

Special Considerations

Asymptomatic Bacteriuria

• Clinicians should not treat asymptomatic bacteriuria in patients 1
• Treating asymptomatic bacteriuria has been shown to foster antimicrobial resistance and increase the number of recurrent UTI episodes 1, 3

Diagnostic Accuracy

• UTI misdiagnosis is common, with studies showing rates as high as 54.6% in some settings 4
• Implementing diagnostic algorithms coupled with callback systems can safely reduce UTI misdiagnoses and unnecessary antibiotic usage 4

Pediatric Patients

• For well-appearing febrile infants, strong evidence supports discontinuing antibiotics when cultures are negative at 24-36 hours and the infant is clinically well or improving 1
• This approach has been shown to limit costs, disruption to the microbiome, and adverse reactions 1

Antimicrobial Stewardship Considerations

• Inappropriate antibiotic use for UTIs contributes significantly to antimicrobial resistance, with UTIs accounting for 25-40% of antibiotics consumed in primary care 5
• The worldwide increase in antibiotic resistance, especially in Escherichia coli, has complicated treatment choices for UTIs 6, 5
• Continuing antibiotics despite negative cultures contributes to this problem without providing clinical benefit 3

Alternative Approaches for Symptomatic Patients with Negative Cultures

• For patients with persistent urinary symptoms despite negative cultures, consider:
  • Re-evaluation for other causes of symptoms
  • Non-antibiotic symptomatic treatment such as NSAIDs for pain relief 5
  • Avoiding classification of patients with recurrent UTI as "complicated" as this often leads to use of broad-spectrum antibiotics with long durations of treatment 1

Common Pitfalls to Avoid

• Continuing antibiotics "just to be safe" despite negative cultures 3
• Failing to communicate negative culture results to patients who were started on empiric therapy 2, 4
• Treating asymptomatic bacteriuria, which fosters antimicrobial resistance 1, 3
• Using broad-spectrum antibiotics when narrower options would be sufficient based on local resistance patterns 6

By following these evidence-based recommendations, clinicians can improve antimicrobial stewardship while maintaining patient safety and optimizing outcomes in patients with suspected UTIs.