Table 3. Examples of cases diagnosed as urinary tract infection by providers, but classified as unlikely or rejected based on medical record review.

Description	Classification	Reason for classification
20 year old woman diagnosed with genital herpes infection one day ago presented with continued dysuria and difficulty urinating despite acyclovir treatment. Tender genital ulcers on exam. Urinalysis (UA) with 30–100 white blood cells (WBC) per high power field and nitrite negative. Diagnosed with urinary retention due to primary herpes infection and UTI and prescribed 7 days of ciprofloxacin. Urine culture negative.	Rejected	Definite alternative diagnosis and negative urine culture
19 year old woman presented with suicidal ideation. No urinary symptoms, but UA ordered due to mild leukocytosis (13,500 WBC/mL) and because Psychiatry recommended ruling out infection.* UA with negative nitrite, positive leukocyte esterase, 30–100 WBC and 10–30 squamous epithelial cells per high power field. Diagnosed with depression with suicidal ideation and UTI and prescribed 3 days of trimethoprim-sulfamethoxazole. No urine culture sent. The patient was diagnosed with chlamydia 5 months later.	Unlikely	No urinary symptoms
21 year old with motor vehicle accident 2 months ago presented with lower back pain exacerbated by movement and right foot numbness. No urinary symptoms or fever. UA with negative blood and nitrite, 10–30 WBC and 10–30 squamous epithelial cells per high power field. Diagnosed with acute lumbar strain and UTI and prescribed 7 days of nitrofurantoin. No urine culture sent.	Unlikely	Probable alternative diagnosis and no significanturinary symptoms
65 year old post-menopausal woman presented with heavy vaginal bleeding, but no urinary symptoms or fever. On exam a mass was noted protruding from the cervical os. Clean catch UA with large blood, large leukocyte esterase, positive nitrite, 10–30 WBC and 2–5 squamous epithelial cells per high power field. Diagnosed with vaginal bleeding (suspected cervical cancer) and UTI based on abnormal UA and prescribed 5 days of nitrofurantoin. Straight catheterization urine culture negative.	Rejected	Vaginal symptoms and definitive alternative diagnosis. Urine culture negative.
33 year old woman presented with epigastric burning pain, nausea and vomiting. No urinary symptoms, fever, or flank pain. Mild epigastric tenderness on exam. UA with negative blood, positive nitrite, small leukocyte esterase, 2–5 WBC and 30–100 squamous epithelial cells per high-power field. Diagnosed with dehydration and UTI and prescribed 7 days ciprofloxacin. No urine culture sent.	Unlikely	Probable alternative diagnosis (GI) and no urinary symptoms
33 year old woman presented with fever, cough, headache, myalgias, back pain, and sick contacts with similar illness. No urinary symptoms. On exam, temperature was 38.5 °C. There was neither abdominal tenderness nor costovertebral angle tenderness. UA not done, but the provider listed abnormal findings from a UA from 6 months earlier with pyuria (10–30 WBC per high power field). Diagnosed with viral syndrome and UTI and prescribed trimethoprim-sulfamethoxazole for 3 days.	Unlikely	Probable alternative diagnosis (influenza-like illness during influenza season)

^*Interviews with Emergency Department providers suggested that Psychiatry personnel recommended sending a UA to rule out “infection” in anyone presenting with psychiatric illness.