© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 156 (5): ITC3-1. * For Best Viewing:...

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in the clinic

Urinary Tract Infection


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What patient populations are at greatest risk for UTI?

Women more than men

Patients with voiding abnormalities related to:

Diabetes

Neurogenic bladder

Spinal cord injury

Pregnancy

Prostatic hypertrophy

Urinary tract instrumentation (catheter)


What lifestyle factors or comorbid conditions are risk factors for UTI?

All patients: diabetes, foreign bodies in urinary system, diseases associated with neurogenic bladder

Premenopausal women: sexual intercourse, spermicides; pregnancy; previous UTI; history maternal UTI & age at 1st UTI (genetic component)

Perimenopausal women: changes in vaginal microbial flora

Postmenopausal women: mechanical & physiologic factors affecting bladder emptying

Men: prostatic hypertrophy with advancing age

Hospitalized patients: instrumentation of urinary tract


Is there a role for screening for UTI or asymptomatic bacteriuria?

Early in pregnancy

High rate progression to symptomatic UTI

Associated with low birthweight and preterm labor

Use urine culture not dipstick urinalysis

Men undergoing transurethral resection of prostate

Risk for bacteremia, with associated sepsis syndrome

Urinary tract instrumentation causing mucosal bleeding

Simple catheter placement does not warrant screening

Renal transplant and neutropenic patients


How can UTI be prevented? Postcoital antibiotic prophylaxis

For women with 3 to 4 UTIs/yr, particularly if associated with coitus

Continuous prophylaxis

For more frequent recurrences

Patient-initiated prophylaxis

For recurrent, uncomplicated UTI unrelated to coitus

Taken at symptom onset

Intravaginal estriol cream

Daily topical application for postmenopausal women

Supports vaginal flora, acid vaginal pH, and reduced vaginal colonization with E. coli


CLINICAL BOTTOM LINE: Screening and Prevention… Don’t screen for asymptomatic bacteriuria…

Nonpregnant women, diabetic women, elderly persons, patients with spinal cord injury, or catheterized patients

Do screen and treat for asymptomatic bacteriuria… Pregnant women and patients about to have an invasive

urologic procedure

Consider prophylaxis to prevent UTIs If ≥2 UTIs/yr: postcoital antibiotic if associated with coitus;

or patient-initiated or continuous antibiotics Recurring symptomatic UTIs in postmenopausal women:

topical intravaginal estrogen


What signs and symptoms should raise suspicion of UTI?

In noncatheterized individuals

Dysuria, urinary frequency, urgency

History provided by patient has high predictive value

In catheterized patients

Fever, rigors, altered mental status, malaise or lethargy with no other identified cause

Flank pain, CVA tenderness, acute hematuria, or pelvic discomfort

If ≤48h since catheter removed: dysuria, urgency, frequent urination, suprapubic pain or tenderness


What other disorders should be considered?

Vaginitis Candida, Trichomonas vaginalis, Bacteroides species,

Gardnerella vaginalis

Vaginal discharge, odor, or itching; “external” dysuria

Urethritis Chlamydia trachomatis, Neisseria gonorrhoeae, or HSV

Gradual onset of symptoms ± vaginal discharge; ± urinary frequency or urgency

Irritation Vaginal itching or discharge; usually diagnosis of exclusion

Pyelonephritis (or in men, prostatitis)

Constitutional symptoms, GI symptoms, local renal symptoms ± voiding symptoms


What tests should be done to diagnose UTI?

Culture pretreatment urine sample

If diagnosis unclear from history and physical exam

If unusual or antimicrobial-resistant organism suspected

If suspected relapse or treatment failure

If therapeutic options limited by medication intolerance

Blood tests (including cultures)

To screen for alternative diagnoses suggested by history or physical exam

To assess status of known underlying medical condition


What organisms are generally found in UTI?

Uncomplicated cystitis and pyelonephritis

E. coli: >90%; S. saprophyticus: 5%-10%

Other coliforms (Klebsiella, Proteus)

Short-term catheters

E. coli and typical hospital-acquired pathogens

Klebsiella, Citrobacter, Enterobacter, Pseudomonas, coagulase-negative staphylococci, enterococci, Candida

Long-term catheters

Typically polymicrobial

Proteus, Morganella, and Providencia common, as well as pathogens above


Is there a role for diagnostic imaging in diagnosing UTI?

If suspicion high for an alternative diagnosis

If suspicion high for anatomical problem

If male acute cystitis patient is >45y and has voiding difficulties or hematuria


CLINICAL BOTTOM LINE: Diagnosis and Evaluation… Detailed history has high predictive value Consider pyelonephritis diagnosis (or in men, prostatitis) Consider complicating factors

Underlying medical or urologic conditions that may predispose to treatment failure

Infection with antibiotic-resistant organisms Infectious complications affecting workup and Rx course

To confirm diagnosis, use Urinalysis via dipstick, microscopy, or automated

microscopy when history alone isn’t diagnostic Culture urine in pyelonephritis, complicated UTI, men,

pregnant women, or those with Hx of Rx failure Initiate empirical therapy and adjust based on urine culture


What are the preferred treatments for UTI?

Acute uncomplicated cystitis: Recommended agents Nitrofurantoin monohydrate / macrocrystals

Trimethoprim-sulfamethoxazole

Avoid in pregnancy

Fosfomycin trometamol

For multidrug-resistant pathogens; may be less effective

Acute uncomplicated cystitis: Alternative agents Fluoroquinolones

Reserve for more serious conditions; avoid in pregnancy

Beta-lactams

Resistance varies by agent; increased AEs vs other options


Acute uncomplicated pyelonephritis: Recommended agents

Fluoroquinolones If local resistance prevalence <10% Add initial 1-time IV dose long-acting parenteral antimicrobial

if patient borderline for oral therapy but doesn’t meet admission criteria or if start of oral therapy delayed

Trimethoprim-sulfamethoxazole If pathogen susceptible; otherwise give initial IV agent Add initial 1-time IV dose long-acting parenteral antimicrobial

if patient borderline for oral therapy but doesn’t meet admission criteria or if start of oral therapy delayed

Beta-lactams Oral less effective: use when other agents can’t be used Give initial IV dose of long-acting parenteral antimicrobial

when using oral beta-lactams


Is there a role for nonpharmacologic therapies in treating UTI?

No known benefit

Including from increased fluid intake, acupuncture

Cranberries may prevent E. coli infection, but in vitro findings not yet proven to have clinical relevance


When should patients be hospitalized for UTI?

Serious comorbid condition, including pregnancy

Sepsis

Unable to take oral therapy

Vomiting

Intolerance for available oral agents

Upper urinary tract condition requires drainage or surgery

Abscesses, emphysematous pyelonephritis, papillary necrosis, xanthogranulomatous pyelonephritis

Multidrug-resistant organism susceptible only to parenterally administered antimicrobials


What are the usual reasons for failure of UTI therapy?

Underlying medical condition

Pregnancy, poorly controlled diabetes, immunosuppression

Antibiotic resistance

Urologic complications

Urinary tract stones Voiding disorder Indwelling catheter Stent Urinary obstruction, Anatomical abnormalities Vesicoureteral reflux


When should clinicians consider consultation with a specialist?

Organisms in urine resist standard antibiotics

Possible upper urinary tract involvement that doesn’t respond to therapy within 72h

Possible surgically correctable lesion in men who:

Report voiding difficulties or acute urine retention

Have early recurrent UTI or persistent microscopic hematuria


How should patients treated for UTI be followed?

Uncomplicated cystitis

No specific follow-up as long as symptoms resolve

Pregnant women

Urine culture to confirm bacteriuria eradicated

Repeat urinalyses or urine cultures at intervals to confirm sterility of urine through delivery

Complicated UTI

Monitor for symptomatic resolution

Reevaluate if symptoms don’t improve ≤48h, worsen, or recur quickly

In CAUTI: monitor response by symptoms not by repeated urine cultures


What is the correct approach to secondary prevention in patients with a history of UTI?

Advise on appropriate antimicrobial prophylaxis (slide 7)

No association between behavioral risks and recurrence Pre- and postcoital voiding Frequency of urination, daily fluid consumption Wiping patterns, douching Use of hot tubs, use of pantyhose or tights

Counsel women with recurrent UTI on true risk factors

Recurrence occurs in up to 50% of women within 1y


CLINICAL BOTTOM LINE: Treatment and Management…

Use IDSA standard-of-care guidelines for… Treatment of acute, uncomplicated cystitis Treatment of acute uncomplicated pyelonephritis Treatment of catheter-associated UTI

Nonpharmacologic therapies for acute cystitis… Have no proven benefits May lead to adverse outcomes

Posttreatment follow-up should include… Monitoring therapy response, not repeat urine cultures

(except in pregnant women)

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