Antibiotic resistance in uncomplicated urinary tract infections (UTIs) is driven largely by the unnecessary treatment of patients with positive laboratory findings but no symptoms. Emphasizing symptom-based diagnosis, avoiding the treatment of asymptomatic bacteriuria, educating patients and providers, and using system-level safeguards can help reduce antibiotic resistance in patients with uncomplicated UTIs.

There is a sizable minority of patients with uncomplicated UTIs whose uropathogen is going to be resistant to 1 or more commonly used antibiotic(s). This can worry some clinicians and make them want to reach for newer antibiotics with less documented resistance. However, I do not think that we have to do this initially, unless the patient has other clinical factors that warrant broader treatment coverage.

It is interesting to note that there may actually be a sizable rate of symptom resolution for uncomplicated UTIs with placebo. Most patients have functioning immune systems, and the good news is that some uncomplicated UTIs will resolve by just the immune system. Obviously, we want to achieve optimal outcomes for our patients, and this is why we use antibiotics for UTIs. Antibiotics plus the immune system is our best bet to get rid of infection.

One struggle that we have with antibiotic-resistant pathogens is antibiotic overuse. There are many studies worldwide in every care setting showing that clinicians overtreat positive urine cultures. Clinicians either do not document UTI symptoms or, even when symptoms that are not consistent with a UTI are documented, patients are still treated with antibiotics for a UTI. Treating positive cultures in the absence of a true UTI is driving the emergence of antibiotic-resistant uropathogens.

It is important to educate patients about only using antibiotics for the treatment of symptomatic UTIs. I have found that the following message has resonated with patients: When a person receives antibiotics unnecessarily and then later gets a UTI, the germ causing that UTI is now more likely to be resistant to whatever their provider gives them, and the antibiotic may not work. In my experience, this message strikes a deeper chord than a message telling patients that studies show no benefit to treating bacteria in the urine without symptoms.

Provider education about asymptomatic bacteriuria is also a continuous effort. In medical school, students are taught that when you see a pathogen, you treat it with antibiotic X, Y, or Z. However, when I teach trainees, I emphasize the saying “no symptoms, no infection.” When you see a positive culture, you should not immediately think of using an antibiotic. You should take a step back and ask, “Are there associated symptoms?”

In health systems, there are now antibiotic stewardship programs in place to help stem antibiotic overuse. One example is when a provider orders a urine culture, the laboratory automatically requires that urinalysis to be done first. If there are no or only a few white blood cells, the laboratory will reject the culture without an additional overriding reason because we know that, in this situation, a UTI is very unlikely. This approach has been shown to reduce inappropriate antibiotic use, with minimal impact on appropriate antibiotic use.