UTI Diagnosis & Treatment: Practical Strategies and Emerging Therapies
In this interview, Neal Skolnik, MD, professor of family and community medicine at Sidney Kimmel Medical College at Thomas Jefferson University, provides a practical overview of the diagnosis and treatment of urinary tract infections (UTIs). He discusses best practices for diagnosing simple cystitis, recent antibiotic approvals, and strategies for preventing recurrent infections, with a focus on primary care implications. Dr Skolnik shared these clinical insights during his presentation, Evolving Approaches to UTI Management: What's Next?, at the 2025 Practical Updates in Primary Care Conference.
Reference:
- Skolnik N, Snodgrass B. Evolving approaches to UTI management: What's next? Presented at: Practical Updates in Primary Care Conference; May 8, 2025; Virtual. Accessed May 5, 2025. https://www.hmpglobalevents.com/pupc
TRANSCRIPTION
Neil Skolnik, MD: I'm Dr Neal Skolnik, professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University and we're going to be talking about diagnosis and treatment of UTIs.
Consultant360: What are the key themes of your presentation?
Dr Skolnik: The key themes, and we're splitting it between myself and Brett Snodgrass, and we're going to basically be talking about a practical approach to UTI, including some emerging treatments.
C360: Why is this topic particularly relevant right now?
Dr Skolnik: UTIs have always been relevant, because they're one of the most common things that we take care of in primary care.
C360: What are the most important takeaways for clinicians in practice?
Dr Skolnik: I think that we can divide those takeaways into diagnosis and treatment, and the most important takeaway is from the diagnosis part of the talk, and we are splitting the talk. I'm doing the first part, Brett is doing the second.
The most important takeaways are, one: Don't be testing for UTIs unless someone has treatment. We do not want to be finding asymptomatic bacteria, particularly in older adults, and chasing it down and potentially treating that doesn't help them and increases bacterial resistance second thing. Symptoms are a very accurate indicator of UTIs. If you have the classic symptoms of urgency, frequency, and burning, you don't even need to get a urinalysis because the urinalysis is not more sensitive or specific than those classic symptoms. And in fact, you can do, and we often do, treat based on symptoms over the phone. You don't need a culture for simple cystitis. You do for pyelonephritis or complicated UTI, but during this talk we're restricting our discussion to simple cystitis or UTI urinary infections of the bladder.
The other thing to be aware of with regard to diagnosis is that you need to think about and ask about sexually transmitted infection because for all the world they can mimic a UTI. They can also cause urgency. They can cause burning because both chlamydia and gonorrhea can cause urethritis. So if that is a concern, obviously one needs to test for that as well.
With regard to treatment, again, we're restricting the bulk of our discussion to cystitis, not pyelonephritis. The first step is of course making sure we're only dealing with the cystitis because the treatment will be very different for pyelonephritis. So for cystitis, first line, often nitrofurantoin works great, doesn't cause a lot of resistance, and since it's a very narrow spectrum drug, it is a good choice for first line because you don't have to worry about developing resistance to nitrofurantoin for treatment of other infections because you don't use it for a lot of other infections.
We'll talk about some new antibiotics, which is very exciting in a moment. Other first-line choices include Bactrim and Fosfomycin. It's a pretty exciting time in the era of UTIs because there have been literally three new antibiotics approved within the last year, and that's very unusual. I can't think of the last time that that has happened. So three antibiotics are now newly approved for treatment of simple cystitis in women. Pivmecillinam, which was approved by the FDA in April of 2024. Sulopenem, which was approved in, I think it was October of '24. And Gepotidacin, which was literally just approved a month ago, and all of these were approved on really excellent data that they are effective for treatment of simple UTI or cystitis in women. And again, this is exciting because it offers us a new opportunity with new antibiotics where the resistance level, of course, is very low because they are new.
In the last part of the talk, we're gonna touch on recurrent UTIs, which are a lot more common than we often think they are. And there's actually good data to do some things we've been doing for years, which is to recommend an increase in water intake, to recommend cranberry juice, And then if someone is a postmenopausal woman, particularly if they're postmenopausal and clinically have atrophic vaginitis, estrogen cream, prescribing estrogen cream, can decrease recurrent rates by about 80%.
So in summary, there's really a lot going on with UTI. It's important to be able to both make the diagnosis with confidence but not over-diagnose some people who are not symptomatic to know when you need further testing and when you can go without testing and by so doing not increase the cost of treatment without increasing the benefit and then be familiar with what really are your go to first line agents as well as new emerging agents.
C360: What gaps in knowledge or areas for future research still remain?
Dr Skolnik: The "always" area of future research has to do with new medications for avoiding antibiotic resistance.