New UTI Guidelines: Addressing the Shift to Localized, Systemic Infection Classification

Four international urinary tract infection (UTI) guidelines published a novel classification separating localized from systemic infection.¹ Zachary Nelson, PharmD, MPH, BCIDP, infectious diseases pharmacist and West Region lead for infectious diseases and antimicrobial stewardship at HealthPartners in Minneapolis, Minnesota, was involved in drafting guidelines as he served as co-chair and lead author for the WikiGuidelines Group.

He explains the classification shift makes clinical sense.

Nelson says earlier classifications hinged on specific risk factors, which clinicians often struggled to confirm in an individual patient. Systemic vs localized illness, by contrast, is more readily apparent at the bedside. He noted the agreement among US and European infectious diseases and urologic societies reinforces the rationale for the new dichotomy.

Updated guidance came from the aforementioned WikiGuidelines Group, the Infectious Diseases Society of America (IDSA), and the European Association of Urology (EAU).¹ The American Urological Association, Canadian Urological Association, and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) also issued joint recommendations.¹ Nelson discussed classification, antibiogram use, cost, and equitable access. He also wrote on the topic for Contagion’s last issue and that piece can be found here: Recent Guideline Updates in the Management of Urinary Tract Infections.

The WikiGuidelines Group broadly agrees with the IDSA approach to systemic presentations. Pyelonephritis, febrile UTI, and bacteremic UTI, all considered complicated UTI under the IDSA framework, are generally managed alike.² Nelson’s lingering concern centers on whether clinicians will default to older terminology and whether labeling affects antibiotic selection and duration.

Nelson said the guidelines have achieved reasonable harmonization, though he favors defining specific infectious syndromes over sorting patients into broad categories. He cited prostatitis, which the IDSA guideline treats as a distinct clinical entity rather than a complicated UTI.² Catheter-associated UTI likely warrants similar separate handling, he added.

Applying Antibiograms and Severity-Based Thresholds

The IDSA guideline ties empiric agent selection to illness severity, with susceptibility thresholds of 90% for patients in septic shock and 80% for sepsis without shock.² Nelson praised the guideline for acknowledging the limited reliability of antibiograms for individual patients. He pointed to patients with cancer as one example where population-level data can mislead.

Such patients may be hospitalized frequently for chemotherapy complications yet have urine cultures collected in outpatient settings. Their extensive health care exposure may make the hospital antibiogram a better predictor of resistance than the outpatient antibiogram. Stewardship programs can bridge this gap by embedding recommendations into institutional guidelines and the electronic medical record (EMR).

“I do worry about the applicability of those antibiograms on a routine basis, but I think it is able to be operationalized within the health systems, especially if you have a stewardship program,” said Nelson. He added the severity framework is intuitive, since clinicians facing a critically ill patient accept less risk of choosing an ineffective antibiotic.

On cost, Nelson said health systems increasingly credit reduced length of stay and avoided admissions, outcomes once viewed as soft dollars, when weighing newer high-cost agents. Many of these drugs prove favorable from a cost-benefit perspective despite a high per-course price. For catheter-associated UTI, where testing is unreliable and treatment delays are common, he urged clinicians to anchor decisions on symptoms, severity, and individual resistance risk.

Nelson’s HealthPartners spans large urban hospitals and small critical access hospitals, and his team relies on EMR order sets, embedded education, and institutional guidelines to standardize care. “We want those clinicians in those rural areas or the smaller sites to feel as empowered as our clinicians in the urban sites with regard to doing the right thing,” Nelson said.

Whether the new terminology changes antibiotic selection and duration in practice remains an open question, says Nelson and he calls for continued movement toward syndrome-specific definitions across future guideline updates.

REFERENCES

1. Nelson Z. Recent guideline updates in the management of urinary tract infections. Contagion. October 4, 2026. Accessed October 8, 2026. https://www.contagionlive.com/view/recent-guideline-updates-in-the-management-of-urinary-tract-infections

2. Trautner BW, Cortés-Penfield NW, Gupta K, et al. Clinical practice guideline by Infectious Diseases Society of America (IDSA): 2025 guideline on management and treatment of complicated urinary tract infections. Infectious Diseases Society of America. July 17, 2025. Accessed October 8, 2026. https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections/