What is the recommended approach for an adult patient with no significant medical history presenting with symptoms of a urinary tract infection regarding urine culture and subsequent antibiotic treatment?

When to Obtain Urine Culture in Adults with UTI Symptoms

For otherwise healthy, nonpregnant women with typical uncomplicated cystitis symptoms (dysuria, frequency, urgency), urine culture is NOT routinely needed—clinical diagnosis alone is sufficient to initiate treatment. 1

Clinical Diagnosis Without Culture

In women presenting with acute-onset dysuria plus typical lower urinary tract symptoms (frequency, urgency, suprapubic pain) and without vaginal discharge, the diagnosis can be made clinically with >90% accuracy. 1, 2

• No urinalysis or culture is required for straightforward cases of uncomplicated cystitis in women. 1
• Dipstick testing adds minimal diagnostic value when symptoms are typical. 1
• Self-diagnosis by women with classic symptoms is accurate enough to proceed directly to treatment. 2

Mandatory Situations Requiring Urine Culture

The European Association of Urology (2024) specifies that urine culture MUST be obtained in the following scenarios: 1

• Suspected acute pyelonephritis (fever, flank pain, systemic symptoms)
• Symptoms that do not resolve or recur within 4 weeks after completing treatment
• Women with atypical symptoms (unclear presentation)
• Pregnant women (all suspected UTIs)
• Recurrent UTIs (≥2 infections in 6 months or ≥3 in 12 months)—culture should be obtained with each symptomatic episode prior to treatment 1

Special Populations Requiring Culture

Men

All men with lower UTI symptoms should receive urine culture with susceptibility testing to guide antibiotic choice, as urethritis and prostatitis must be considered. 2

Older Adults (≥65 years)

Urine culture with susceptibility testing is necessary in nonfrail older adults with no relevant comorbidities to adjust antibiotics after initial empiric treatment. 2

Catheterized Patients

• Obtain culture from a freshly placed catheter after changing the existing catheter and allowing urine accumulation while plugging it. 1
• Never obtain specimens from extension tubing or collection bags. 1

Treatment Failure or Recurrence

For women whose symptoms do not resolve by end of treatment or recur within 2 weeks, perform urine culture and susceptibility testing. 1

• Assume the organism is not susceptible to the original agent
• Retreat with a 7-day regimen using a different antibiotic 1

Cost-Effectiveness Considerations

Obtaining urine culture simultaneously with starting empiric antibiotics is the most cost-effective strategy when antibiotic resistance rates are moderate (6-80%), maximizing symptom-free days. 3

• If resistance is expected to be <6%, empiric antibiotics alone are most cost-effective 3
• If resistance is expected to be >80%, symptomatic treatment first is preferred 3

Critical Pitfalls to Avoid

Do NOT obtain urine cultures for asymptomatic bacteriuria in non-catheterized patients—this leads to unnecessary antibiotic use and resistance development. 1

Do NOT perform routine post-treatment cultures in asymptomatic patients who have clinically improved. 1

Do NOT obtain surveillance/screening urine cultures in asymptomatic patients, including those with neurogenic bladder dysfunction. 1