Treating Students with Urinary Tract Infections
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Transcript of Treating Students with Urinary Tract Infections
Treating Students with Urinary Tract Infections
Sara Mackenzie, MD, MPH
Regional Health Specialist
October 18, 2012
After this presentation, you will be able to:
• Describe the prevalence of UTI in men and women
• Describe how to assess for uncomplicated UTI
• List common antibiotics and indications for treatment of uncomplicated UTI
• Identify red flags for complicated UTI or other infections (such as STI)
Can I get a sense of who is on call?
• Center physician?• Center health and wellness
manager?• Center nurse or LPN?• TEAP/CMHC? • Other?
Terminology:
UTI = urinary tract infection
Lower urinary tract: UTI=cystitis= bladder infection
Upper urinary tract: pyelonephritis=
kidney infection
Why discuss?
• Global:> 250 million UTIs/yr
> $7 billion direct costs• United States, annual figures:
> 7 million uncomplicated UTIs
> 250,000 acute pyelonephritis
> 4 million UTIs in pregnancy
> 1 million catheter-associated UTIs
In women:
• Acute, uncomplicated UTI:– 3% of all women visit ≥ once a year– ≥ 50% report at least one per lifetime
• Recurrent UTI:– 20-40% develop frequent (≥ 3/yr.)
In men:
• Incidence significantly lower– 5 to 8 UTI per year per 10,000 men
• Longer urethral length, drier periurethral environment, less frequent colonization with bacteria around urethra, and antibacterial substances in prostatic fluid
Mechanism of infection:
Complicated• A UTI is said to be “complicated” UTI if:
– Diabetes– Pregnancy– History of pyelo in last year– Antibiotic resistance– Symptoms more than 7 days before seeking care– Hospital acquired infection– Functional or structural abnormality (such as stones,
anatomical)– Immunosuppression– Male
• Important to identify as higher risk of failing therapy
Uncomplicated
• To say another way—a UTI is said to be “uncomplicated” if:– Female– Non-pregnant– Otherwise healthy– Normal urinary tract
Case 1:
22-year-old female who is otherwise healthy comes in to Health and Wellness complaining that “it hurts when I pee, I feel like I have to go right away, and I have to pee all the time”.
A. Uncomplicated UTI
B. Complicated UTI
C. Need more information
Presentation lower UTI• Dysuria, urgency and frequency [Suprapubic
pain +/- hematuria (blood in urine)]• The probability of cystitis in a woman with one
of the first three symptoms is 50% • The probability of cystitis in a woman with
dysuria, frequency and NO vaginal discharge or irritation is 90%
Evaluation:• Review clinical history – up to date
problem list • Review recent antibiotic use• Ask about recent new sexual partners
(STI risk) and pregnancy risk• Physical exam: assess for fever,
costovetebral angle tenderness and abdominal exam
• Pelvic not usually indicated
Evaluation (continued):• Do you need to do urinalysis:
– Leukocyte esterase detects white blood cells– Nitrite detects enterobacteriaceae– Hematuria common in UTI
• Dipstick most accurate for predicting UTI if positive for either leukocyte esterase or nitrite
***Results of dipstick provide little additional useful information if history strongly suggestive of UTI!
Back to the Case• 22 Y/O with dysuria, frequency, urgency, • No prior medical history, antibiotic use,
previous UTI or risk for STI or pregnancy• No fever, no CVA tenderness
• Do you need to do a urine culture?– Yes – No– Need more information
Urine Culture
• Empiric treatment usually indicated as pathogens are predictable
Microbiology
*Uncomplicated UTI and pyelo 75-95% e.coli
Urine culture
Culture indicated if:– Symptoms not characteristic– Persist or recur within 3 months of prior
infection or antibiotic use– If not responding to empiric treatment
within 24 to 48 hours– If suspect complicated infection– In all women with suspected pyelonephritis – All men suspected to have UTI
What antibiotic for uncomplicated cystitis?
• Target for e. coli• Weigh cost, availability, allergy
profile• Nitrofurantoin 100mg twice daily for
7 days
OR• Trimethaprim sulfamethoxazole
(Bactrim DS) 1 pill twice daily for 3 days
What antibiotic should be used?
• Consider local resistance patterns • Local public health department or
hospital should have information on resistance patterns in community
E. coli resistance (UW Hall Health N=1,284)
Empiric bactrim treatment should be avoided if local resistance patterns exceed 20%
Fluoroquinolones:
• Not recommended as first line by IDSA 2011 guidelines– Selection of more drug resistant
organisms– Colonization with multidrug resistant
organisms– Reserve for more serious infections
UTI Prevention• 20 to 40% of women will develop
recurrent (>3/year)• Frequency of sexual intercourse strong
risk factor• Review contraceptive options – avoid
spermicides• Discuss urination after sex and increase
fluids• Cranberry juice ??
UTI Prevention
• Consider antibiotic prophylaxis – Prophylaxis advocated if 2 or more in
6 months or 3 or more over 12 months• After sex – single post coital dose• Daily – proven reduction in recurrence;
take for 6 to 12 months; • Nitrofurantoin or bactrim or cipro can be
used