Urinary tract infections (UTIs) are the most common conditions managed in outpatient care. Inappropriate antibiotic prescribing remains widespread, with an estimated one in three outpatient antibiotic courses for suspected UTIs considered unnecessary. Existing clinical guidelines, which define UTI categories and recommend testing and empiric treatment strategies, were largely developed for traditional in-person care and do not adequately address the realities of modern telehealth. Clinicians increasingly manage UTI symptoms via phone calls, portal messages, synchronous video visit and asynchronous e-visits, often without any physical examination or immediate access to urine testing, a trend accelerated by the COVID-19 pandemic. This shift has created uncertainty about when antibiotics are beneficial, when urine testing is required, and when patients should be triaged for in-person evaluation.
A study published in the JAMA Network aimed to determine the appropriateness of empiric antibiotic prescribing, urine testing strategies, and triage decisions for adults presenting with suspected UTI symptoms in both ambulatory and telehealth environments. The goal was to provide practical, evidence-informed guidance that supports antibiotic stewardship while accounting for real-world constraints like limited testing access, variable visit types, and patient barriers to care.
 This study used the RAND/UCLA Appropriateness Method, using a structured and two-round modified Delphi process that combines systematic review of evidence with expert clinical judgement. A comprehensive scoping literature review was conducted in major databases like PubMed/MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane Database without any initial date restrictions. From 10,982 detected records, stepwise screening and exclusions narrowed the evidence base to 72 key publications (40 guidelines or systematic reviews, 24 intervention studies, and 8 additional key references) that were included. Evidence summaries were supplemented with relevant clinical guidance from UpToDate to reflect common real-world practice.
A multidisciplinary panel of 13 experts representing primary care, urgent care, infectious disease, geriatrics, obstetrics-gynaecology, urology, urogynaecology, and emergency medicine was convened. Panelists independently rated appropriateness of UTI management strategies in predefined clinical scenarios using a 1-to-9 scale in round 1, followed by moderated virtual discussions and rerating in round 2. Disagreement was assessed using the Interpercentile Range Adjusted for Symmetry (IPRAS) method. Scenarios were classified as appropriate, uncertain, or inappropriate based on median scores.
The panel evaluated 136 clinical scenarios, each with up to nine management options, which generate 1,094 individual appropriateness indications. Key results showed strong agreement on symptom-based triage. Same-day in-person evaluation was rated appropriate for patients with symptoms concerning for pyelonephritis, complicated cystitis, or urinary obstruction, and for symptoms suggesting non-UTI diagnoses like diarrhea, genital discharge, or cough. For isolated changes in urine color or odor without bladder symptoms, neither urine testing nor antibiotics was rated appropriate.
For women with new onset and classic cystitis symptoms like dysuria, urinary frequency, urgency, or suprapubic pain, without risk factors for antimicrobial resistance, empiric antibiotics without urine testing or an in-person visit were rated appropriate. Women with resistance risk factors and all men were rated appropriate for urinalysis with urine culture or reflex to culture before initiating antibiotics. Urinalysis alone without culture capability was rated inappropriate due to high false positive rates. Empiric treatment without testing was considered appropriate when patients faced barriers to timely urine testing or in-person evaluation.
These ratings were synthesized into two clinical triage algorithms, one for nonpregnant adult women and one for adult men, designed for use in phone, portal, virtual, and in-person care settings. The algorithms prioritize the least resource-intensive appropriate care and clearly define when escalation to in-person evaluation is necessary.
This study provides the first comprehensive, evidence-informed clinical triage algorithms specifically designed for modern outpatient and telehealth management of suspected UTIs in adults. By applying the RAND/UCLA Appropriateness Method, the authors translated expert judgment and available evidence into practical guidance that clarifies when empiric antibiotics, urine testing, or in-person evaluation are appropriate. These criteria are expected to improve antibiotic stewardship, reduce unnecessary testing and treatment, and support consistent, high-quality UTI care across diverse ambulatory settings. Future work is needed to evaluate the impact of these algorithms on patient outcomes and clinician practice, but they offer a strong foundation for standardizing UTI triage in an increasingly virtual healthcare landscape.
Reference: Meddings J, Chrouser K, Fowler KE, et al. Ann Arbor Guide to Triaging Adults with Suspected Urinary Tract Infection for In-Person and Telehealth Settings. JAMA NetwOpen. 2026;9(1):e255613. doi:10.1001/jamanetworkopen.2025.56135
