Urinary Tract Infections How to diagnose and when to treat: Evidence based answers for the primary care physician KRIST IN N IEREN BERG, M D S W E D I S H FA M I LY M E D I C I N E R E S I D E N C Y – F I R S T H I L L R 3 TA L K S : M AY 9 , 2 0 1 4 Declarations  None. Objectives  Review the epidemiology of UTIs  Define how to properly diagnose cystitis ,     pyelonephritis, and asymptomatic bacteriuria Review the evidence behind antibiotic treatment Overview of care of the pregnant woman What to do about recurrent UTI Further areas of investigation Definitions  Uncomplicated UTI: acute cystitis or pyelonephritis occurring in healthy premenopausal, nonpregnant women with no history of abnormal urinary tract  Complicated UTI: infections in patients with functional, metabolic, or anatomical conditions that may increase risk of infection or treatment failure / serious outcomes  Acute Cystitis: Infection of the urinary bladder (lower urinary tract)  Acute pyelonephritis: infection of the kidney (upper urinary tract) Epidemiology  UTI: Most commonly occurring bacterial infection in the outpatient setting. ~50% of women by age 30  Estimated incidence 10-15%  average of 6 days of discomfort, leading to ~ 7 million outpatient visits / year, estimated costs > $1.5 billion!  Risk factors: Sexual intercourse, spermicide, new sexual partner in past year, previous UTI, family hx of UTI Pathogenesis  Colonization of vaginal introitus by uropathogens from fecal flora > ascension via urethra to bladder  Pyelonephritis: occurs when pathogen ascends to kidneys via ureters  E. Coli causes 75-95% of all uncomplicated UTI Acute Cystitis: Diagnosis  History: New onset of frequency and dysuria, with absence of vaginal discharge or irritation: PPV 90%  Physical exam: usually normal. 10-20% suprapubic tenderness.  Labs: urine dip vs. urinalysis with urine microscopy.    Nitrites and LE most accurate indicators of acute uncomplicated cystitis in symptomatic women Culture recommended only if suspected pyelo, recurrence, atypical symptoms, or complicated infection Colony count of > 103 CFU / mL is diagnostic > other studies showing use of 102 in women with classic symptoms. Urine Dip: what’s that again?  Leukocyte Esterase: indicates presence of bacteria. Sensitivity up to 96%, specificity up to 87%  Nitrite: Found in nitrate reducing bacteria: fairly good at detecting enterobacteriaceae. Not as sensitive, but very specific (up to 98%) Microbiology  Main cause is E.Coli (75-95%)  Other enterobacteriaceae (proteus, klebsiella) or Staph     saprophyticus. Contaminants include lactobacilli, enterococci, GBS, or coag neg staph Resistance rates > 20% common for ampicillin Fluoroquinolone resistance generally < 10% but increasing over past decade Use of TMP-SMX in past 3-6 months or international travel: independent risk factors for bacteria resistance, concern if > 20% Diagnosis of Pyelonephritis  History: variable with similar symptoms of cystitis but may additionally have fever, chills, flank pain, N/V  Physical exam: Fever, tachycardia, CVAT (any signs of sepsis)  Labs: Urinalysis and Urine culture   Urine culture > 104 cfu/mL indicates clinically relevant bacteriuria Imaging not needed generally if clinical response within 72 hours. Treatment of Pyelonephritis  OUTPATIENT tx: Ok for those with mild to moderate illness who can be stabilized with rehydration, and follow up with close supervision. Ciprofloxacin: 500mg BID x 7 days Ciprofloxacin 1000mg ER x 7 days or Levofloxacin 750mg x 5 days Trimethoprim-sulfamethoxazole DS BID x 14D  INPATIENT tx: severe illness, high fever, pain, inability to hydrate or take oral meds, pregnancy, or concern about compliance.  - initial IV abx (fluoroquinolone, aminoglycoside, extended spectrum cephalosporin or penicillin, or carbapenem. Regimen tailored to susceptibility results.  Treatment response within 48 hours Self-diagnosis and telephone management  Studies indicate that if a woman has 2 symptoms of UTI, without vaginal discharge or irritation she has > 90% chance of having UTI  Numerous studies have looked at treatment of UTI over the phone.  Randomized trial in 2001: similar symptoms and patient satisfaction  Retrospective cohort study of > 4,000 women showed that it was safe to treat as outpatient but up to 20% women require office evaluation within 6 weeks. Outcomes of telephone based treatment UTI in men UTI in men  Usually considered complicated because majority occur in infants or elderly associated with urologic abnormalities  Small number occur in men age 15-50. (5-8 / 100,000 men per year)  Labs: Recommended UA and culture.  104 CFU/ml is diagnostic.  Men with recurrent UTI > undergo evaluation for prostatitis  Treatment:   TMP-SMX BID, Cipro BID / daily, Levo daily. (7-14 days) Do not use nitrofurantoin or beta-lactams due to poor tissue concentrations > less effective for occult prostatitis. Asymptomatic Bacteriuria  Diagnosis  >105 CFU/mL in asymptomatic women collected in 2 consecutive voided specimens  1 clean catch needed for men  Single catheterized specimen > 102 for men or women.  Screening: in pregnant women (more to follow), before urologic procedures  Treatment: 3-7 days.  Prevalence: 2-7% in healthy young pregnant or nonpregnant women. What to do in Pregnancy? Asymptomatic bacteriuria in pregnancy  Increases risk of complications:  20-30x increased risk of pyelonephritis  More likely for premature delivery and low birth weight  Screen: at least once in early pregnancy > treated if positive.  Periodic screening after therapy (per ACOG 3rd trimester)  No recommendation for screening for culture-negative women in later pregnancy (consider in high risk women)  Treatment:  Decreases risk of pyelo from 20-35% > 1-4%  No determined duration of treatment (3-7 days)  Fluoroquinolones contraindicated  TMP-SMX: avoid during 1st trimester > category C  Nitrofurantoin: 100mg BID x 5 days > category B (50-100mg qhs > suppression)  Amoxicillin: 500mg BID 3-7 days > category B  Augmentin: 500mg BID 3-7 days > category B  Cephalexin: 500mg BID 3-7 days. > category B  Test of cure Cystitis in pregnancy  Diagnosis: Should perform urine culture  103 CFU/mL  Treatment:  Nitrofurantoin 100mg BID x 5 days  Cefpodoxime 100mg BID x 3-7 days  Augmentin 500mg BID x 3-7 days  Fosfomycin 3g x 1  TMP-SMX DS BID x 3 days (avoid in 1st trimester or term)  Amoxicillin 500mg BID x 7 days  Suppressive therapy: bacteria persists after 2 or more courses, or for recurrent infection   Nitrofurantoin 50-100mg qhs Cephalexin 250-500mg qhs  GBS: treated as GBS carriers and receive prophylactic abx during labor. Pyelonephritis in pregnancy  Pathogenesis:  Pressure on bladder, smooth muscle relaxation, immunosuppression of pregnancy, increased plasma volume  Treatment:      Hospitalization and IV abx until afebrile x 48 hours 3rd generation cephalosporins favored over 1st /2nd gen Avoid aminoglycosides due to ototoxicity Carbapenems > effective vs ESBL Complete 10-14 days tx  Recurrence:    Occurs in 6-8% or women > treat with prophylaxis Nitrofurantoin 50-100mg qhs Cephalexin 250-500mg qhs Recurrent UTI Recurrent UTI: Symptomatic UTI that follows resolution of an earlier episode, usually after appropriate treatment Relapse: Symptomatic recurrent UTI with the same organism < 2 weeks after treatment. Reinfection: Either recurrent UTI with previously isolated bacteria with a negative intervening culture, OR a recurrent UTI caused by a 2nd bacterial isolate. > 2 weeks after treatment. *Most are due to REINFECTION with same organism.  Epidemiology: In college women > 25% will have recurrence within 6 months, ~ 3% will have > 1 recurrence. In all women: ~35-50% recurrence within 1 year.  Diagnosis: Obtain urine culture Recurrent UTI  Treatment: same as for regular UTI > consider test of cure  Prophylaxis: consider if 2UTIs in 6 months or 3 in 1 year. 6-12 mo tx will reduce rate of relapse.  Postcoital prophylaxis results in less abx use.  Cranberry juice / probiotics: Lacking randomized trials. Recurrent UTI What are the bugs at Swedish? Effect of stewardship intervention on adherence to UTI / pyelo guidelines in ED setting  ED chose to use UTI orderset as a quality indicator  Feedback given to ED doc by ID and stewardship  Primary outcome > adherence to IDSA guideline  Secondary outcome > total days of abx, fluoroquinolones for cycsitis, diagnositic accuracy. Outcomes of stewardship interventions  Improved adherence to guidelines with minimal resources  Decreased unnecessary days of abx use  Reduced overuse of fluoroquinolones  No change in UTI diagnostic accuracy Swedish ED smartset… not so smart?  Labs: not possible to obtain UA without culture if indicated, blood culture available, but no PCT  No wet mount, GC/CT  Treatment: amoxicillin, cefpodoxime, azithro, doxy, erythro, levo, nitrofurantoin, phenazopyridine, bactrim (no specification re: duration)  No delineation of complicated vs. uncomplicated, cystitis vs. pyelonephritis  Appropriate inpatient supplemental orders Take Home Points  Cephalosporins are NOT first line for UTI treatment  Beware of Bactrim resistance > 20%  Reserve use of fluoroquinolones in cystitis  If resistance pattern unknown in pyelo > good to treat with 1 dose CTX  Antibiotic stewardships and ordersets > could be helpful in helping to follow treatment guidelines.  Treating over the phone may not cause harm to patient, but could worsen collateral damage! 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