AUA/CUA Recurrent UTI 2019

Question 1

Clinicians should obtain a complete patient ……. and …….. in women presenting with rUTIs.

Answer 1

history

perform a pelvic examination

Question 2

To make a diagnosis of rUTI, clinicians must document ……. associated with prior symptomatic episodes.

Answer 2

positive urine cultures

Question 3

Clinicians should ……….when an initial urine specimen is suspect for contamination, with consideration for ………

Answer 3

obtain repeat urine studies

obtaining a catheterized specimen

Question 4

….. and ……. should not be routinely obtained in the index patient presenting with rUTI.

Answer 4

Cystoscopy

upper tract imaging

Question 5

Clinicians should obtain ….. and ……. and ….. with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs.

Answer 5

urinalysis

urine culture

sensitivity

Question 6

Clinicians may offer patient-initiated treatment (self-start treatment) to select rUTI patients with acute episodes while awaiting urine cultures.

Answer 6

True

Question 7

Clinicians should omit …….., in asymptomatic patients with rUTIs

Answer 7

surveillance urine testing, including urine culture

Question 8

Clinicians should treat ASB in patients.

Answer 8

False

Clinicians should not treat ASB (asymptomatic bacteriuria) in patients.

Question 9

Clinicians should use first-line therapy …….. dependent on the local antibiogram for the treatment of symptomatic UTIs in women.

Answer 9

(i.e., nitrofurantoin, TMP-SMX, fosfomycin)

Question 10

Clinicians should treat rUTI patients experiencing acute cystitis episodes with as short a duration of antibiotics as reasonable, generally no longer than ……….

Answer 10

seven days.

Question 11

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 ………

Answer 11

seven days

Question 12

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.

Answer 12

True

Question 13

Clinicians may offer …..(hint: non antibiotics prohylaxis) for women with rUTIs.

Answer 13

cranberry prophylaxis

Question 14

Clinicians should perform a post-treatment test of cure urinalysis or urine culture in asymptomatic patients.

Answer 14

False

Clinicians should not perform a post-treatment test of cure urinalysis or urine culture in asymptomatic patients.(the guidelines says so)

Question 15

Clinicians should repeat urine cultures to guide further management when UTI symptoms persist following antimicrobial therapy.

Answer 15

True

Question 16

In peri- and post-menopausal women with rUTIs, clinicians should recommend ……. to reduce the risk of future UTIs if there is no contraindication to …..

Answer 16

vaginal estrogen therapy

estrogen therapy.

Question 17

What percentage of women experience symptomatic acute bacterial cystitis in their lifetime?

Answer 17

60%

Question 18

what is uncomplicated cystitis?

Answer 18

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.

Question 19

What is recurrent UTI?

Answer 19

two episodes of acute bacterial cystitis within six months or three episodes within one year.

Question 20

symptoms of UTI

Answer 20

Dysuria- most important

Others: frequency, urgency, SP pain, hematuira, incontinence

Question 21

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

Answer 21

Correct

Question 22

What is the definition of positive urine culture?

Answer 22

> 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

Question 23

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

Answer 23

Correct!

higher prevalence of antibiotic resistance, a higher incidence of pyelonephritis, and a poorer quality of life

Question 24

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

Answer 24

correct

incidence of pyelo is low in these people and not substantially different from those receiving placebo/ supportive care( hydration, analgesics)

Question 25

Shared decision making

Answer 25

Correct

Share decision make the shit out of everything in urology

Question 26

Why are spermicides and barrier contraceptives bad for UTI?

Answer 26

bc they fuck up the lactobacillus/vaginal microbiome and “shitty” bacteria can grow

Question 27

What are some behavioral things women can do to stop rUTIs?

Answer 27

stop using spermicide and barrier contraception

Drink more water

Question 28

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

Answer 28

CORRECT

Interesting!

Question 29

How long can a collected urine specimen sit at room tempeature?

Answer 29

no longer than 30 min

Question 30

When can a cystoscopy be helpful?

Answer 30

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.

Question 31

How can UA suggest contamination?

Answer 31

presence of epithelial cells

Question 32

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

Answer 32

Correct

BUT every effort should be made to get culture and do proper fu etc

Question 33

What are the only indications for screening and treating ASB?

Answer 33

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.

Question 34

What are second line agents for treatment of UTIs?

Answer 34

fluoroquinolones and beta lactams

Remember first line are nitrofurnatoin, fosfomycin( single dose) and TMP-SMX.

Question 35

what are side effects of fluoroquinolones?

Answer 35

QTc prolongation, tendon rupture, increased risk of aortic rupture.

Question 36

Does antibiotic prophylaxis reduce the risk of UTI once you stop taking it?

Answer 36

Nope,

once patient stop taking it their risk equaled to placebo.

Question 37

Should you rotate antibiotics being used for prophylaxis?

Answer 37

nope

little evidence for this

Question 38

What are possible side effects of nitrofurantoin

Answer 38

lung(dry cough and dyspnea, IPF) and hepatic toxicity.

Some advocate for avoidance of nitrofurantoin in elderly esp if CrCl is less than 30

Question 39

What are side effects of TMP-SMX

Answer 39

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

Question 40

How long can one be on antibiotic ppx?

Answer 40

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

Question 41

What are options for ppx antibiotics?

Answer 41

 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

Question 42

What are Abx options for women with Post-coital UTIs and when should they take it?

Answer 42

Before or after, one dose

 TMP-SMX 40mg/200mg
 TMP-SMX 80mg/400mg
 Nitrofurantoin 50-100mg
 Cephalexin 250mg

Question 43

How can cranberry prevent UTIs?

Answer 43

proanthrocyanidines(PAC)

prevent adhesion of bacteria to the urothelium

Question 44

Is lactobacillus recommended for recurrent UTIs?

Answer 44

NO

Question 45

Does increased H2O intake help reduce recurrent UTIs?

Answer 45

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

Question 46

What are some nonabx agents not listed in the recommendations for rUTIs in AUA/CUA guideline?

Answer 46

D-Mannose, Methenamine, intravesical hyaluronic acid, immuno-active therapy, biofeedback

Question 47

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.

Answer 47

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.