1. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 156 (5): ITC3-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide

2. © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 156 (5): ITC3-1. in the clinic Urinary Tract Infection

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4. © Copyright Annals of Internal Medicine, 2012 Ann 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)

5. © Copyright Annals of Internal Medicine, 2012 Ann 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 1 st 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

6. © Copyright Annals of Internal Medicine, 2012 Ann 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

7. © Copyright Annals of Internal Medicine, 2012 Ann 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

8. © Copyright Annals of Internal Medicine, 2012 Ann 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

9. © Copyright Annals of Internal Medicine, 2012 Ann 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

10. © Copyright Annals of Internal Medicine, 2012 Ann 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

11. © Copyright Annals of Internal Medicine, 2012 Ann 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

12. © Copyright Annals of Internal Medicine, 2012 Ann 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

13. © Copyright Annals of Internal Medicine, 2012 Ann 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

14. © Copyright Annals of Internal Medicine, 2012 Ann 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

15. © Copyright Annals of Internal Medicine, 2012 Ann 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

16. © Copyright Annals of Internal Medicine, 2012 Ann 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

17. © Copyright Annals of Internal Medicine, 2012 Ann 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

18. © Copyright Annals of Internal Medicine, 2012 Ann 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

19. © Copyright Annals of Internal Medicine, 2012 Ann 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

20. © Copyright Annals of Internal Medicine, 2012 Ann 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

21. © Copyright Annals of Internal Medicine, 2012 Ann 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

22. © Copyright Annals of Internal Medicine, 2012 Ann 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

23. © Copyright Annals of Internal Medicine, 2012 Ann 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)