Recurrent Urinary Tract Infections in Women and UTIs/Infectious Dz Flashcards
What should a clinician do when evaluating a patient with recurrent urinary tract infections?
–Clinicians should obtain a complete patient history and perform a pelvic examination in women presenting with rUTIs.
–To make a diagnosis of rUTI, clinicians must document positive urine cultures associated with prior symptomatic episodes.
–Clinicians should obtain repeat urine studies when an initial urine specimen is suspect for contamination, with consideration for obtaining a catheterized specimen.
What should a clinician NOT do when evaluating a woman for recurrent UTIs?
Cystoscopy and upper tract imaging should not be routinely obtained in the index patient presenting with rUTI.
If a patient with rUTIs has a symptomatic acute cystitis episode, what should be done?
Clinicians should obtain urinalysis, urine culture and sensitivity with *each* symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs.
Clinicians may offer patient-initiated treatment (self-start treatment) to select rUTI patients with acute episodes while awaiting urine cultures.
If a healthy, (female) index patient has asymptomatic bacteriuria, what should be done?
Clinicians should omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs.
Clinicians should not treat ASB in patients.
What should be first line antibiotic treatment for a UTI in a woman? How long should it be given for?
Clinicians should use first-line therapy (i.e., nitrofurantoin, TMP-SMX, fosfomycin) dependent on the local antibiogram for the treatment of symptomatic UTIs in women.
Clinicians should treatr UTI 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, what should be given and for how long?
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.
Antibiotic Prophylaxis in rUTIs
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.
Non-Antibiotic Prophylaxis
Clinicians may offer cranberry prophylaxis for women with rUTIs.
Follow up for recurrent UTIs
Clinicians should not perform a post-treatment test of cure urinalysis or urineculture in asymptomatic patients.
Clinicians should repeat urine cultures to guide further management when UTI symptoms persist following antimicrobial therapy.
Estrogen in rUTIs
In peri- and post-menopausal women with rUTIs, clinicians should recommend vaginal estrogen therapy to reduce the risk of future UTIs if there is no contraindication to estrogen therapy.
What is the definition of a complicated UTI?
An infection in a patient in which one or more complicating factors may put her at higher risk for development of a UTI and potentially decrease efficacy of therapy. Such factors include the following:
Anatomic or functional abnormality of the urinary tract (e.g., stone disease, diverticulum, neurogenic bladder)
Immunocompromised host
Multi-drug resistant bacteria
What is the definition of a recurrent urinary tract infection?
Two separate culture-proven episodes of acute bacterial cystitis and associated symptoms within six months or three episodes within one year
History to obtain in patients with recurrent UTIs
Patients with rUTIs should have a complete history obtained, including LUTS such as dysuria, frequency, urgency, nocturia, incontinence, hematuria, pneumaturia, and fecaluria.
Further information to obtain includes
- Any history of bowel symptoms such as diarrhea, accidental bowel leakage, or constipation
- Recent use of antibiotics for any medical condition
- Prior antibiotic-related problems (e.g., C. difficile infection)
- Antibiotic allergies and sensitivities; back or flank pain
- Catheter usage
- Vaginal discharge or irritation
- Menopausal status
- Post-coital UTIs
- Contraceptive method
- Use of spermicides
- Use of estrogen- or progesterone-containing products.
Details of prior urinary tract or pelvic surgery should be obtained
Patients should be queried as to travel history.
Baseline genitourinary symptoms between infections may also be illuminative, including the number of voids per day, sensation of urge to void, straining to void, a sensation of incomplete emptying, pelvic pressure or heaviness, vaginal bulge, dysuria, dyspareunia, as well as the location, character, and severity of any baseline genitourinary or pelvic pain or discomfort.
UTI history includes frequency of UTI, antimicrobial usage, and documentation of positive cultures and the type of cultured microorganisms. Risk factors for complicated UTI should also be elucidated.
History of specific details of UTI to obtain in a patient with rUTIs
Patient history should document the symptoms the patient considers indicative of a UTI:
- The relationship of acute episode to infectious triggers (e.g. sexual intercourse)
- Antimicrobials used for each episode, responses to treatment for each episode
- The results of any prior diagnostic investigations.
It is also important to note the relationship of infections to hormonal influences (e.g., menstruation, menopause, exogenous hormone use) as well as concomitant medication usage or behaviors that may alter infection susceptibility, including prior antimicrobial treatment, immunosuppressive medications, and topicals such as spermicides.
Physical Exam for rUTI
A physical examination including an abdominal and detailed pelvic examination should be performed to look for any structural or functional abnormalities.
Pelvic support for the bladder, urethra, vagina, and rectum should be documented, noting the compartment and stage of any clinically significant prolapse.
The bladder and urethra should be palpated directly for evidence of urethral tenderness, urethral diverticulum, Skene’s gland cyst, or other enlarged or infected vulvar or vaginal cysts.
A focused examination to document any other infectious and inflammatory conditions, such as vaginitis, vulvar dermatitis, and vaginal atrophy (genitourinary syndrome of menopause) should also be performed.
The pelvic floor musculature should be examined for tone, tenderness, and trigger points.
A focused neurological exam to rule out occult neurologic defects may also be considered.
Evaluation for incomplete bladder emptying to rule out occult retention can be considered for all patients, but should be performed in any patient with suspicion of incomplete emptying, such as those with significant anterior vaginal wall prolapse, underlying neurologic disease, diabetes, or a subjective sensation of incomplete emptying.
Dosing of First Line Antibiotic Treatment for Uncomplicated UTI
Nitrofurantoin - 100 mg BID for 5 days (narrow spectum: E coli, S saprophyticus)
Bactrim - 1 DS BID for 3 days
Fosfomycin - 3 g single dose (covers VRE, ESBL, GNRs)
Why should you watch out for nitrofurantoin?!
- -Bad for old people
- -Pulmonary toxicity
- -Hepatotoxicity
- -Peripheral neuropathy
- -Watch out if GFR <30
Nitrofurantoin use in older adults has been controversial.
Nitrofurantoin is listed as a potentially inappropriate medication for older adults by the AGS Beers Criteria, with the strength of recommendation as strong and a listed quality of evidence of low.
The 2015 Beers update has been modified to recommend avoidance of nitrofurantoin when creatinine clearance is below 30mL/min.
The rationale for avoiding nitrofurantoin included pulmonary toxicity, hepatotoxicity, and peripheral neuropathy, with concern about long-term use if other alternatives are available for use.
Nitrofurantoin-induced lung injury can occur in the acute, subacute or chronic setting, most commonly presenting with a dry cough and dyspnea.
- -The mechanism underlying pulmonary toxicity is related to the direct effects of nitrofurantoin metabolites on lung tissue.
- -Acute pulmonary reactions appear after a mean of nine days from starting nitrofurantoin therapy, while symptoms of subacute and chronic pulmonary reactions develop between one and six months of treatment, respectively.
What should you watch out for with Bactrim?
Gastrointestinal disturbances and skin eruptions are the most common adverse reactions associated with TMP and TMP-SMX.
TMP-SMX has been uncommonly associated with other adverse effects.
These adverse effects include neurologic effects (e.g., aseptic meningitis, tremor, delirium, gait disturbances), decreased oxygen carrying capacity (e.g., methemoglobinemia, blood dyscrasia), toxic epidermal necrolysis (e.g., drug hypersensitivity, fixed drug eruption), reproductive toxicity (e.g., structural malformations including neural tube, small for gestational age, hyperbilirubinemia), interactions with other drugs (e.g., inhibition of the P450 system), hypoglycemia, hyperkalemia and nephrotoxicity.
Long- term administration of TMP-SMX appears to be safe, though hematologic and laboratory monitoring may be indicated.
Dosing for continuous prophylaxis
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
If you have UTIs after intercourse, what should you do?
In women who experience UTIs temporally related to sexual activity, antibiotic prophylaxis taken before or after sexual intercourse has been shown to be effective and safe.
This use of antibiotics is associated with a significant reduction in recurrence rates.
Additionally, intermittent dosing is associated with decreased risk of adverse events including gastrointestinal symptoms and vaginitis.
What is the dosing for post-coital antibiotics?
TMP-SMX 40mg/200mg
TMP-SMX 80mg/400mg
Nitrofurantoin 50-100mg
Cephalexin 250mg
Should we recommend lactobacillus for rUTIs?
No
While lactobacillus probiotics have been studied with greater interest in recent years given growing concerns for antibiotic resistance, the Panel is unable to recommend the use of lactobacillus as a prophylactic agent for rUTI given the current lack of data indicating benefit in comparison to other available agents.
Is increased water good?
Maybe.
One medium risk of bias trial of women with recurrent UTIs who reported <1.5 L/day of fluid intake at baseline (n=140, mean age 36 years) found increased water intake associated with fewer UTI recurrences compared with no additional fluids (mean 1.7 versus 3.2 UTI episodes over 12 months, p<0.001).
Increased water take was also associated with lower likelihood of having at least 3 UTI episodes over 12 months (<10% versus 88%) and greater interval between UTI episodes (143 versus 84.4 days, p<0.001). The increased fluid intake intervention was based on provision of three 500 mL bottles of water to be consumed daily.
Daily fluid intake increased from 0.9 L/day to 2.2 L/day in the increased water intake group compared with no change in the no additional fluids group.
While these data are promising, no conclusions can be drawn as to whether or not increased water intake is beneficial to women who regularly drink higher quantities of fluids than those reported in this study or those who may be at a lower risk for UTI recurrence.
What is the dosing for vaginal estogen tablet, ring, cream?
Tablet: Estradiol hemihydrate: 10 mcg per day for 2 weeks, then 10 mcg 2-3 times weekly
Ring: 17b-estradiol - 2 mg ring released 7.5 mcg per day for 3 months (changed by patient or provider)
Cream:
- 17b-estradiol : 2 g daily for 2 weeks, then 1 g 2-3 times per week
- Conjugate equine estrogen : 0.5 g daily for 2-weeks, then 0.5 g twice weekly
In HIV + male or immunosuppressed patient with obstructive pyelonephritis/sepsis, what should be sent in addition to labs and UCX? What is ddx of ureteral obstructing in this patient that doesn’t demonstrate on CT?
Blood culture
FUNGAL culture
DDX: fungus ball, blood clot, radiolucent calculus, sloughed papilla
How do you treat renal candidiasis?
Fluconazole Amphotericin B (50 mg in 1L sterile water over 24 h, can repeat up to a week)
Can perform renal/bladder anti-fungal irrigant via PCN or Foley
Side effects of Amphotericin B
Chills
Rigors
Phlebitis
Bone Marrow Tox
K/Mg depletion (make sure you follow BMP)
What are appropriate abx for PCNL?
1st/2nd Gen Cephalosporin or Aminoglycoside + Metronidazole or Clinda
Alternatives:
Unasyn or FQ
FOR 24 H
Pt HIV, HTN, BPH, elevated PSA, s/p TRUS bx with f/c/n/v, dribbling, labs? Initial steps?
CBC
BMP
UA
UCx
Fungal Cx
Blood Cx
Gentle prostate exam (may worsen sepsis), vitals, IVF
Evaluate bladder (PVR), Foley/SPT
IV abx: Carbapenems are the first line treatment given the high FQR rates and increasing presence of extended spectrum beta-lactamase producing bacteria
CT A/P + contrast
common side effects of sulfamethoxazole-trimethoprim?
GI upset (n/v) Skin reactions (rash, urticaria)
Stevens-Johnson
Toxic Epidermal Necrolysis
Fulminant Hepatic Necrolysis
Blood dycrasias such as aplastic anemia, agranulocytosis
Angioedema
55 yo AA male DMII with scrotal pain and black necrotic eschar 3 cm on scrotum with erythema, tenderness, and crepitus, assessment? Labs? Next steps?
Vitals
CBC, BMP, UA, UCX, BCX, Wound CX
Stabilize, IV abx, IVF
Vanco or PCN, Gent, Metronidazole or Clinda
CT w/contrast to assess gas (if stable), don’t delay debridement
CXR, EKG, PT/PTT, T&C
Possible SPT, debridement, possible diverting colostomy
Spread can be along anterior abdominal wall along Scarpa’s
DDX of sterile pyuria?
TB
bladder tumor (CIS)
overactive bladder
IC
If concerned for urinary TB, labs? Dx?
Place PPD, or fresh voided am urine for AFB stain (pos “red snappers”) and TB Cx
ESR
CXR
LFTs (anti-Tb meds)
CTU
Cysto (bx → granulomatous cystitis)
Ureteral strictures common
Tx for urinary Tb? Ureteritis?
INH
Rifampin
Ethambutol
Pyrazinamide
All 4 daily for 2 mo, then INH and Rifampin 3 x week for 2 more mo
Follow Tb culture
Repeat imaging CTU 3-6 mo
Tb ureteritis → Prednisone 20 mg PO daily x 4-6 weeks, can consider balloon dilation if it doesn’t work
What can happen to bladder or ureter from urinary tb?
bladder → contracted/fibrotic, small capacity
ureter → stricture
For TOV, removal of foley or drain (stent, PCN), should abx ppx be used?
Only if risk factors:
advanced age
anatomic anomaly
poor nutritional status
smoking
chronic steroids
immunodeficiency
occurring infection
prolonged hospitalization
If you have a staghorn and an XGP kidney, treatment plan
PCNL, remove infected stone first
Asynchronous Simple Nx
Recommended abx for PCNL
MUST have neg UCX before Sx
1st/2nd Gen Cephalosporin
Or
Aminoglycoside and Metronidazole or Clinda
or
Aztreonam and Metronidazole or Clinda
Alternative: Unasyn for < 24 h
NIH Classification of Prostatitis
I. Acute prostatitis
II. Chronic bacterial prostatitis
IIIa. Chronic pelvic pain syndrome - inflammatory
IIIB. Chronic pelvic pain syndrome - non-inflammatory
IV. Asymptomatic inflammatory prostatitis
Abx for Prostatitis?
4-6 weeks of Bactrim DS BID or FQ
What are initial evaluation questions to ask a male with recurrent UTI?
Gross hematuria
Immunologic state
Other LUTS (AUA SS)
Urinary Tract Anomalies
Pediatric Hx (anomalties, sx, UTIs)
Urologic hx (prostatitis, BPH, meds, Sx, sxs, instrumentation)
Recent UTIs (hx orchitis, prostatitis, pyelo)
Abx exposure
NGB (SCI, spine surgery, DMII)
What do you look for on office based dipstick/micro analysis?
Absence of epithelial cells
Bacteruria
Pyuria
Protein
Blood (RBC on micro)
LE
Nitrites
Indications for admission for UTIs?
significant complicating comorbidities
immunocompromised state
elderly/disabled unable to care for themselves
inability to tolerate PO
Obstruction
VS instability, fever
UTI preventative measures for BPH males?
alpha blocker
timed voiding
double voiding
probiotics
cranberry
diabetic control
increased fluid intake
