AUA/CUA Recurrent UTI 2019 Flashcards
Clinicians should obtain a complete patient ……. and …….. in women presenting with rUTIs.
history
perform a pelvic examination
To make a diagnosis of rUTI, clinicians must document ……. associated with prior symptomatic episodes.
positive urine cultures
Clinicians should ……….when an initial urine specimen is suspect for contamination, with consideration for ………
obtain repeat urine studies
obtaining a catheterized specimen
….. and ……. should not be routinely obtained in the index patient presenting with rUTI.
Cystoscopy
upper tract imaging
Clinicians should obtain ….. and ……. and ….. with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs.
urinalysis
urine culture
sensitivity
Clinicians may offer patient-initiated treatment (self-start treatment) to select rUTI patients with acute episodes while awaiting urine cultures.
True
Clinicians should omit …….., in asymptomatic patients with rUTIs
surveillance urine testing, including urine culture
Clinicians should treat ASB in patients.
False
Clinicians should not treat ASB (asymptomatic bacteriuria) in patients.
Clinicians should use first-line therapy …….. dependent on the local antibiogram for the treatment of symptomatic UTIs in women.
(i.e., nitrofurantoin, TMP-SMX, fosfomycin)
Clinicians should treat rUTI patients experiencing acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than ……….
seven days.
In patients with rUTIs experiencing acute cystitis episodes associated with urine cultures resistant to oral antibiotics, clinicians may treat with culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than ………
seven days
Following discussion of the risks, benefits, and alternatives, clinicians may prescribe antibiotic prophylaxis to decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs.
True
Clinicians may offer …..(hint: non antibiotics prohylaxis) for women with rUTIs.
cranberry prophylaxis
Clinicians should perform a post-treatment test of cure urinalysis or urine culture in asymptomatic patients.
False
Clinicians should not perform a post-treatment test of cure urinalysis or urine culture in asymptomatic patients.(the guidelines says so)
Clinicians should repeat urine cultures to guide further management when UTI symptoms persist following antimicrobial therapy.
True
In peri- and post-menopausal women with rUTIs, clinicians should recommend ……. to reduce the risk of future UTIs if there is no contraindication to …..
vaginal estrogen therapy
estrogen therapy.
What percentage of women experience symptomatic acute bacterial cystitis in their lifetime?
60%
what is uncomplicated cystitis?
An infection of the urinary tract in a healthy patient with an anatomically and func-tionally normal urinary tract and no known factors that would make her susceptible to develop a UTI
Complicating factors: anatomic or functional abnormality of the urinary tract.( stone disease, diverticulum, neurogenic bladder), immunocompromised host, infection with MDR bacteria.
What is recurrent UTI?
two episodes of acute bacterial cystitis within six months or three episodes within one year.
symptoms of UTI
Dysuria- most important
Others: frequency, urgency, SP pain, hematuira, incontinence
in the elderly evaluation and treatment for suspected UTI should be reserved for acute-onset (<1 week) dysuria or fever in association with other specific UTI-associated symptoms and signs, which primarily include gross hematuria, new or significantly worsening urinary urgency, frequency and/or incontinence, and suprapubic pain
Correct
What is the definition of positive urine culture?
> 10^2 CFU/Ecoli
with symptoms/strong suspicion of infection
Use clinical judgment
10^5 threshold is better for diagnosing bacteriuria and making sure it is not from contamination
asymptomatic women with a history of rUTIs randomized to treatment for ASB in a placebo-controlled trial were more likely to have additional symptomatic cystitis episodes in a year of follow-up than those randomized to placebo
Correct!
higher prevalence of antibiotic resistance, a higher incidence of pyelonephritis, and a poorer quality of life
Multiple randomized placebo-controlled trials have demonstrated that antibiotic treatment for acute cystitis offers little but mildly faster symptomatic improvement compared to placebo in patients with acute dysuria and significant bacteriuria
correct
incidence of pyelo is low in these people and not substantially different from those receiving placebo/ supportive care( hydration, analgesics)
Shared decision making
Correct
Share decision make the shit out of everything in urology
Why are spermicides and barrier contraceptives bad for UTI?
bc they fuck up the lactobacillus/vaginal microbiome and “shitty” bacteria can grow
What are some behavioral things women can do to stop rUTIs?
stop using spermicide and barrier contraception
Drink more water
Case-control studies clearly demonstrate that changes in hygiene practices (e.g., front to back wiping), pre- and post-coital voiding, avoidance of hot tubs, tampon use, and douching do not play a role in rUTI prevention
CORRECT
Interesting!
How long can a collected urine specimen sit at room tempeature?
no longer than 30 min
When can a cystoscopy be helpful?
In patients who do not respond to antibiotics or keep having rapid recurrence of UTI with the same organism( complicated UTI).
History of previous pelvic surgery, to look for anatomic abnormalities.
How can UA suggest contamination?
presence of epithelial cells
In patients who present for rUTI management without any microbiological information regarding prior presumed episodes of acute cystitis, it is reasonable to proceed with the assumption of rUTI if their clinical history is consistent with that diagnosis
Correct
BUT every effort should be made to get culture and do proper fu etc
What are the only indications for screening and treating ASB?
Pregnancy and patients undergoing elective urologic procedures
ASB and Struvite stones:
Dont treat proteus in the abscence of symptoms and stone. But if other measures have failed to prevent stone formation then screening and treating the urease producing bacteria cab be indicated.
What are second line agents for treatment of UTIs?
fluoroquinolones and beta lactams
Remember first line are nitrofurnatoin, fosfomycin( single dose) and TMP-SMX.
what are side effects of fluoroquinolones?
QTc prolongation, tendon rupture, increased risk of aortic rupture.
Does antibiotic prophylaxis reduce the risk of UTI once you stop taking it?
Nope,
once patient stop taking it their risk equaled to placebo.
Should you rotate antibiotics being used for prophylaxis?
nope
little evidence for this
What are possible side effects of nitrofurantoin
lung(dry cough and dyspnea, IPF) and hepatic toxicity.
Some advocate for avoidance of nitrofurantoin in elderly esp if CrCl is less than 30
What are side effects of TMP-SMX
Skin rash
Neurologic effects( aseptic meningitis, tremor, delirium, gait disturbances)
decreased O2 capacity (methemglobenemia, blood dyscrasia)
toxic epidermal necrolysis
reproductive toxicity
Drug interaction(P450 inhibitor)
a bunch of other stuff BUT long term administration appears safe
How long can one be on antibiotic ppx?
as long as you want
BUT passed 6-12 months is no longer evidence based. Some people continue with post-coital ppx or just stay on it
What are options for ppx antibiotics?
TMP 100mg once daily TMP-SMX 40mg/200mg once daily TMP-SMX 40mg/200mg thrice weekly Nitrofurantoin monohydrate/macrocrystals 50mg daily Nitrofurantoin monohydrate/macrocrystals 100mg daily Cephalexin 125mg once daily Cephalexin 250mg once daily Fosfomycin 3g every 10 days
What are Abx options for women with Post-coital UTIs and when should they take it?
Before or after, one dose
TMP-SMX 40mg/200mg
TMP-SMX 80mg/400mg
Nitrofurantoin 50-100mg
Cephalexin 250mg
How can cranberry prevent UTIs?
proanthrocyanidines(PAC)
prevent adhesion of bacteria to the urothelium
Is lactobacillus recommended for recurrent UTIs?
NO
Does increased H2O intake help reduce recurrent UTIs?
yes
esp in women with daily H2O intake of less than 1.5L.
This is based on one study and not a formal recommendation by the guideline
What are some nonabx agents not listed in the recommendations for rUTIs in AUA/CUA guideline?
D-Mannose, Methenamine, intravesical hyaluronic acid, immuno-active therapy, biofeedback
Vaginal estrogen therapy has not been shown to increase risk of cancer recurrence in women undergoing treatment for or with a personal history of breast cancer.
Correct
vaginal estrogen therapy should be considered in prevention of UTI women with a personal history of breast cancer in coordination with the patient’s oncologist.
