The latest updated American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (AUA/CUA/SUFU) guideline simplifies urinary tract infection (UTI) terminology by distinguishing localized bladder infections from systemic ones and emphasizing symptom-based diagnosis and treatment. It also reinforces avoiding the treatment of asymptomatic bacteriuria (except in specific circumstances) and clarifies which nonantibiotic strategies can help prevent uncomplicated UTIs based on the latest evidence.

The shift in terminology in the recently updated AUA/CUA/SUFU guideline on recurrent uncomplicated UTIs in women is welcome. In the past, many clinicians focused heavily on the distinction between complicated and uncomplicated UTIs, and, quite frankly, the definitions were quite confusing. The guideline aimed to simplify these terms. Basically, the new guideline states that uncomplicated UTIs are confined to the bladder, and complicated infections are those UTIs that have systemic symptoms outside the bladder, such as fever, chills, and rigors. If all the symptoms are local in the bladder (eg, dysuria, frequency, and urgency), then that UTI would be considered uncomplicated (or localized).

So, the question that providers should address, according to the updated AUA/CUA/SUFU guideline, is: Is the infection localized to the bladder, or are there signs of it being more systemic? This distinction is then used to guide treatment. Uncomplicated (local) infections are treated for relatively shorter periods. Systemic infections (again, also called complicated infections) are typically treated with antibiotics for longer periods. Treatment duration, especially for uncomplicated (local) infections, is often determined by the antibiotic that is being used and is often 3 days. Complicated infections are typically treated for 7 days.

Discussions about whether to treat patients were in previous guidelines, but the guideline updates reemphasize the point that patients are only to be treated for uncomplicated UTIs if they have symptoms. A UTI should be a clinical diagnosis, not a laboratory diagnosis. Clinicians overdiagnose and overtreat what they consider to be a UTI based on other parameters, for example, purely based on laboratory results. Overtreatment is a problem everywhere: in the outpatient setting, the inpatient setting, every part of the country, and every part of the world.

If you get a laboratory test result showing bacteria in the urine or pyuria, the first step is to ask whether the patient has symptoms. If they have symptoms such as dysuria, frequency, urgency, and/or flank pain, then yes, they have a UTI and treatment is indicated. However, there is still a large proportion of patients with positive test results but no symptoms who are being treated.

If patients do not have UTI symptoms, treatment is not indicated, although there are several common exceptions. For example, you do want to treat pregnant women with uncomplicated UTIs even if they have no symptoms. Another common exception is for prophylaxis in a patient who is about to undergo a urologic procedure that is potentially going to break their mucosal barriers. Any bacteria need to be eradicated because there is a risk of a surgical site infection if you do not. Treating asymptomatic bacteriuria is one of the largest drivers of inappropriate antibiotic use.

As additional data have become available, we have gotten a little more precision in the AUA/CUA/SUFU guideline on which nonantibiotic agents may be useful for the prevention of recurrent UTIs. Cranberries are not as effective as antibiotics, but antibiotics have limitations (eg, drug side effects and driving further risk of the emergence of antibiotic-resistant uropathogens). Thus, cranberries are now recommended as an option for prophylaxis in women with uncomplicated UTIs. Additionally, D-mannose seemed promising in early studies, but more robust data now show that D-mannose is relatively ineffective for preventing uncomplicated UTIs, and the AUA/CUA/SUFU guideline deemphasizes its role as prophylaxis. In the past, the data on drinking a lot of fluids for the prevention of recurrent uncomplicated UTIs were mixed, but a clinical trial has shown that increased fluid intake can be helpful for UTI prevention in women with low baseline hydration. Moreover, methenamine is relatively effective, so this is something that should be in our armamentarium for recurrent UTI prevention as well. Finally, for patients who have either an acute UTI or recurrent uncomplicated UTIs for which there are few or no oral options due to drug allergies and antibiotic resistance, newer treatment options such as gepotidacin, which has a novel mechanism of action compared with the other available antibiotic options, give us additional new treatments to consider.