Should antibiotics be stopped if a Urinary Tract Infection (UTI) test is negative?

Discontinuing Antibiotics for UTI with Negative Urine Culture Results

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

Rationale for Discontinuing Antibiotics

• 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
• Treating asymptomatic bacteriuria has been shown to foster antimicrobial resistance and increase the number of recurrent UTI episodes 1
• For rapid de-escalation and rational antibiotic use, bacteriological samples should be collected before any antibiotic therapy 2

Clinical Decision Algorithm

• Discontinue antimicrobial agents when all bacterial cultures are negative at 24-36 hours if:

  • The patient is clinically well or improving 1
  • There is no other infection requiring treatment 1
  • No signs of severe infection are present 2

• Continue antibiotics despite negative cultures only if:

  • Patient shows clinical deterioration 1
  • There is high suspicion of false-negative culture (e.g., antibiotics given prior to culture collection) 3
  • Patient has signs of severe infection requiring continued treatment 2

Special Populations Considerations

Neurogenic Lower Urinary Tract Dysfunction Patients

• Clinicians should not perform surveillance/screening urine testing, including urine culture, in asymptomatic patients 2
• Clinicians should not treat asymptomatic bacteriuria in patients with neurogenic lower urinary tract dysfunction 2
• Only obtain urinalysis and urine culture in patients with signs and symptoms suggestive of UTI 2

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
• If CSF is positive for enterovirus, clinicians may discontinue antimicrobial agents as long as there are no other factors suggesting bacterial infection 2

Antibiotic Stewardship Principles

• Antibiotics should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria 4
• When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy 4
• Avoiding unnecessary antibiotic use is critical to prevent the development of resistant bacteria 2, 1

Common Pitfalls to Avoid

• Do not continue antibiotics "just to be safe" when cultures are negative and patients are improving, as this contributes to antimicrobial resistance 1
• Avoid treating asymptomatic bacteriuria, which is common especially in elderly patients and those with catheters 1, 5
• Do not rely solely on nitrite testing to rule out UTI, as it has limited sensitivity (53%) despite high specificity (98%) 6
• Recognize that false-positive urine cultures can lead to unnecessary antibiotic use and potential harm 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 1
• Consider symptomatic treatment with nonsteroidal anti-inflammatory drugs and delayed antibiotics for uncomplicated cases 7
• Evaluate for other conditions that may mimic UTI symptoms, such as vaginitis in women or prostatitis in men 7