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Transcript of © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 156 (5): ITC3-1. * For Best Viewing:...
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
in the clinic
Urinary Tract Infection
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
Terms of Use
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets constitutes copyright infringement.
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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)
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (5): ITC3-1.
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)