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.
