UTIs in Women CATHERINE M BETTCHER M D

UTIs in Women CATHERINE M. BETTCHER, M. D. CME DIRECTOR, ASSISTANT PROFESSOR DEPARTMENT OF FAMILY MEDICINE UNIVERSITY OF MICHIGAN

Learning Objectives �Apply evidence-based recommendations to the diagnosis of UTI in adult women �Determine when telephone triage for diagnosis is appropriate �Apply evidence-based recommendations for the treatment of UTI in adult women �Implement strategies to prevent recurrence of UTI

Incidence �Most common bacterial infection in women � 27% of college-aged women had another UTI within 6 months Colgan R, Williams M. Am Fam Phys. 2011; Kodner CM, Thomas Gupton, EK. Am Fam Phys. 2010.

Etiology E. Coli 86% Staph saprophyticus 4% Klebsiella species 3% Proteus species 3% Enterobacter species 1. 4% Colgan R, Williams M. Am Fam Phys. 2011

Complicating Factors for Cystitis Ø Diabetes Ø Immunosuppression Ø Pregnant Ø Urologic abnormalities, including nephrolithiasis and catheter use Ø Recent hospitalization / nursing home Ø Symptoms for > 7 days Ø ? Postmenopausal Gradwohl SE et al. University of Michigan guideline. 2011.

Lower Urinary Tract Symptoms �Dysuria, frequent voiding of small volumes, urinary urgency �Less commonly hematuria and suprapubic discomfort �Not vaginal discharge or irritation

Use of Urine Dipstick �Leukocyte esterase indirectly indicates pyuria �Nitrite only turns positive in presence of bacteria that make nitrate reductase �Negative nitrites and leukocyte esterase decreases the odds of UTI by 40 -60% Simati et al. Am Fam Phys. 2013.

Use of Urine Culture �Suspicion of acute pyelonephritis �Atypical symptoms �Symptoms that do not resolve or that recur within 2 - 4 weeks after treatment Colgan R, Williams M. Am Fam Phys. 2011; Gradwohl SE et al. University of Michigan guideline. 2011.

Asymptomatic Bacteriuria �Defined as >50, 000 CFU/ml of bacteria in urine culture of asymptomatic patients �Higher incidence in patients with chronic indwelling catheters �No screening or treatment recommended except for: Pregnancy Before urologic procedures Gradwohl SE et al. University of Michigan guideline. 2011.

What counts as positive urine culture? �Sensitivity of 50% if threshold for positive > 100, 000 CFU/ml �Sensitivity > 90% if threshold for positive > 100 CFU/ml Gradwohl SE et al. University of Michigan guideline. 2011.

Complicated Cystitis �Send culture with sensitivities �Treat with trimethoprim/sulfa or a fluoroquinolone for 7 -14 days �Obtain follow up urinalysis �Consider evaluation for structural abnormalities

Kodner CM, Thomas Gupton EK. Recurrent urinary tract infections in women: diagnosis and management. Am Fam Phys. 2010; 82(6): 638 -643.

Phone Triage by RN �Avoid office visits reduce cost, increase appropriate antibiotic use �Use in women with previous UTI responsive to antibiotic

Phone Triage Gradwohl SE, Bettcher CM, Chenoweth CE, Harrison RV, Zoschnick LB. Urinary tract infection. Ann Arbor, MI: Office of Clinical Affairs, University of Michigan Health System, 2011.

Treatment of UTI � 3 -5 day course of antibiotic �Longer courses for complicated UTI �Increasing resistance to trimethoprim / sulfa, but antibiotic concentrates in the urine Gradwohl SE et al. University of Michigan guideline. 2011

Treatment Regimens 1 st Line: 2 nd Line: 3 rd Line: Trimethoprim / Sulfamethoxazole 160/800 mg (1 DS tab) bid x 3 days Nitrofurantoin 100 mg bid x 5 days Fosfomycin 3 -g single dose Ciprofloxacin 250 mg bid x 3 days Ciprofloxacin extended release 500 mg daily x 3 days Levofloxacin 250 mg daily x 3 days Amoxicillin / clavulanate 500/125 mg bid x 7 days Cefdinir 300 mg bid x 10 days Cefpodoxime 100 mg bid x 7 days ü Avoid trimethoprim / sulfa if resistance exceeds >20% or if used for UTI in previous 3 months ü Avoid fluoroquinolones in pregnancy Colgan R, Williams M. Am Fam Phys. 2011.

Recurrent UTIs �Defined as > 3 / year, or 2 within past 6 months �Probably caused by reinfection �Obtain urine culture �No specific guidelines to recommend imaging Consider US or CT with recurrent non-coital UTIs, persistent hematuria associated with UTIs, acute pyelonephritis, or renal insufficiency �Treat the same as uncomplicated UTI �Consider follow up urine culture to distinguish relapse from recurrence Kodner CM, Thomas Gupton, EK. Am Fam Phys. 2010; Gradwohl SE et al. University of Michigan guideline. 2011.

Risk Factors for Recurrent UTI Risk factor Odds ratio Sex > 9 times in past month 10. 3 Sex 4 -8 times in past month 5. 8 Age at 1 st UTI ≤ 15 yrs 3. 9 Maternal history of UTIs 2. 3 New sex partner in past year 1. 9 Spermicide use in past year 1. 8 * Post-menopausal with post-void residual > 50 ml Kodner CM, Thomas Gupton, EK. Am Fam Phys. 2010

Prevention of UTI �Antibiotic prophylaxis �Intravaginal estrogen in post-menopausal women �Self-initiated therapy Antibiotic Continuous prophy Postcoital prophy cephalexin 125 to 250 mg ciprofloxacin 125 mg nitrofurantoin 50 to 100 mg norfloxacin 200 mg trimethoprim 100 mg trimethoprim/sulfamethoxazole 40/200 mg 40/200 to 80/400 mg Kodner CM, Thomas Gupton, EK. Am Fam Phys. 2010

Do cranberry products prevent UTIs? � 2008 guideline: cranberry products decrease UTIs in sexually active women � 2012 Cochrane review included 14 more studies, total of 4473 participants cranberries do not reduce UTIs overall or for subgroups (women with recurrent UTIs, older people, pregnant women, children with recurrent UTI) Jepson RG, et al. Cochrane Database of Systematic Reviews 2012.

UTIs in Pregnancy �Screen for asymptomatic bacteriuria between 12 and 16 wks �Treat with 7 day course of Category B drug �Send follow up urine culture �Hospitalize for acute pyelonephritis

Conclusions �Diagnose UTI based on history, possibly supplemented by UA �Prescribe trimethoprim/sulfa or nitrofurantoin as 1 st line treatment �Counsel patients about risk factors for recurrent UTI �Prescribe antibiotic prophylaxis, or allow patients to self treat

References � Arnold JJ, Hehn LA, Klein DA. Common questions about recurrent urinary tract infections in women. Am Fam Phys. 2016; 93(7): 560 -569. � Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Phys. 2011; 84(7): 771 -776. � Flower A, Wang LQ, Lewith G, Liu JP, Li Q. Chinese herbal medicine for treating recurrent urinary tract infections in women. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No. : CD 010446. � Gradwohl SE, Bettcher CM, Chenoweth CE, Harrison RV, Zoschnick LB. Urinary tract infection. Ann Arbor, MI: Office of Clinical Affairs, University of Michigan Health System, 2011. � Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No. : CD 001321. � Kodner CM, Thomas Gupton EK. Recurrent urinary tract infections in women: diagnosis and management. Am Fam Phys. 2010; 82(6): 638 -643. � Simati B, Kriegsman W, Safranek S. Dipstick urinalysis for the diagnosis of acute UTI. Am Fam Phys. 2013; 87(10).