Disclosures BEST PRACTICES FOR • None WOMEN WITH UTI S Michelle Y. Morrill MD Director of Urogynecology, Kaiser San Francisco Assistant Professor, Volunteer Faculty, Department of ObGyn, UCSF Objectives Sources 1) review guidelines for diagnosis and management of Gupta et al. International Clinical Practice Guidelines for uncomplicated UTIs the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for 2) discussion of evidence based recommendations for Microbiology and Infectious Diseases . Clinical Infectious prevention of UTIs Diseases 2011;52(5):e103–e120 3) diagnosis, work up and management of complicated Endorsed by: UTIs (pyelonephritis, recurrent UTI, chronic UTI) American College of Obstetrics and Gynecology American Urology Association 4) initial diagnosis, work up and management of non- Society for Academic Emergency Medicine infectious bladder pain
Sources Definitions Urinary Tract Infection (UTI or cystitis) • Positive urine culture and symptoms Hooton TM. Uncomplicated Urinary Tract Infection . N Engl J Med 2012;366:1028-37. • Urgency/frequency • Dysuria • Hematuria Foxman B. Urinary Tract Infection Syndromes Occurrence, • Urinary incontinence Recurrence, Bacteriology, Risk Factors, and Disease Burden . Infect Dis Clin N Am 2014;28:1–13 • Suprapubic pain Not a UTI • Asymptomatic bacteriuria Definitions Epidemiology • ~50% of 32yo women report having had at least 1 UTI • Uncomplicated UTI • A short course of antibiotics will usually (90% efficacy) • 25% of young healthy women will have a recurrence resolve clinical symptoms within 6 month of their initial UTI episode • Recurrent UTI • ≥ 3 UTI’s in 12 month period or ≥2 UTIs in 6 months • 20% of women >65yo have asymptomatic bacteriuria • Often reinfection with colonized bacteria • *Same bacteria repeatedly (by sensitivities) may indicate nidus in urinary tract / chronic UTI Hooton TM. Uncomplicated Urinary Tract Infection. N Engl J Med 2012;366:1028-37. Hooton TM. Uncomplicated Urinary Tract Infection. N Engl J Med 2012;366:1028-37. Treatment of urinary tract infections in nonpregnant women. ACOG Practice Bulletin No. 91. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:785–94.
Microbiology Risk Factors for UTI Catheters • 75-95% of Uncomplicated UTIs are cause by E. coli • Cause 30-40% of nosocomial infections • Uropathogenic E. coli are a specific subset of • One catheterization 2% risk of bacteriuria extraintestinal pathogenic E. coli that have the potential • Every day of an indwelling catheter 3-10% risk of for enhanced virulence. bacteriuria • Only treat for symptoms • But there are plenty of others: Enterobacter, • Place indwelling cath only for clear indications (not for incontinence) Klebsiella, Pseudomonas, Proteus, Streptococcus faecalis, Morganella, Staphylococcus, Chlamydia • Antibiotic prophylaxis should not be done routinely Hooton TM, et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases 2010; 50:625–663 Foxman B. Urinary Tract Infection Syndromes Occurrence, Recurrence, Bacteriology, Risk Factors, and Disease Hooton TM. Uncomplicated Urinary Tract Infection. N Engl J Med 2012;366:1028-37. Burden. Infect Dis Clin N Am 28 (2014) 1–13 Risk Factors for UTI Not Risk Factors for UTI • Gender (female) • Post coital (or pre-coital) voiding • Menopausal status • Fluid intake • Delaying voids • Intercourse • Wiping patterns • New sex partner • Type of underwear • Previous urinary tract infection • Hx of UTIs in a 1 st degree relative Hooton TM. Uncomplicated Urinary Tract Infection. N Engl J Med 2012;366:1028-37. Hooton TM. Uncomplicated Urinary Tract Infection. N Engl J Med 2012;366:1028-37.
Diagnosis of Cystitis Urinary Microbiome • Urgency/frequency • Urine is NOT sterile • Dysuria • 16S rRNA • Hematuria • Urinary incontinence • Expanded Quantitative Urine Culture • Suprapubic pain • Positive urine culture = • Caution • Recent UTI? Then check • Dysbiosis • Recurrent UTI? UA/Cx • Not UTI? Brubaker L, Wolfe AJ. The new world of the urinary microbiota in women. Am J Obstet Gynecol. Hooton TM. Uncomplicated Urinary Tract Infection. N Engl J Med 2012;366:1028-37. 2015 Nov;213(5):644-9. Diagnosis of Cystitis - UA Diagnosis of Cystitis - UA • Nitrite Sensitivity Specificity 0.61 1 Turner LC, et al. Utility of dipstick urinalysis in peri- and postmenopausal women with irritative bladder symptoms. Int Urogynecol J (2014) 25:493–497 • 87/148 (59%) women with pos LE or nitrite had pos UCx • 63/66 with neg UCx were given Abx. Gordon LB., et al. Overtreatment of Presumed Urinary Tract Infection in Older Women Presenting to the Emergency Department. J Am Geriatr Soc 61:788–792, 2013.
Diagnosis of Cystitis - UA Diagnosis of Cystitis - UCx • In patients with urgency/frequency • If patient is symptomatic any growth of 1 or 2 • Pyuria (>10 WBC /hpf) had negative LE in 60% bacteria should be considered a positive result • Pyuria for predicting positive Urine Culture • On ‘ Contamination ’ • Squamous cells in 99/105 cath samples but no samples Sensitivity Specificity had bacterial ‘contamination’ (mixed growth or <10K) 0.42 0.73 • Squamous cells in 101/105 clean catch samples; 21% had bacterial ‘contamination’. Walter FG, et al. Squamous cells as predictors of bacterial contamination in urine samples. Ann Emerg Med 1998;31(4):455-8 Kupelian AS, et al. Discrediting microscopic pyuria and leucocyte esterase as diagnostic surrogates for infection in patients with lower urinary tract symptoms: results from a clinical and laboratory evaluation. BJU Int. 2013 Jul;112(2):231-8 Asymptomatic Bacteriuria Asymptomatic Bacteriuria • No benefit in treating • Institutionalized Elderly • Common in older people • Ambulatory Elderly • Premenopausal Women • Not associated with decline in renal • Diabetic Women function • Renal transplant patients Meiland R, et al. Association Between Escherichia coli Bacteriuria and Renal Function in Women Long-term Follow-up. Arch Intern Med. 2007;167:253-257 • Only group in which treatment is recommended is pregnant women Zalmanovici Trestioreanu A, LadorA, et al. Antibiotics for asymptomatic bacteriuria. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD009534. Origüen J, López-Medrano F , et al. Should Asymptomatic Bacteriuria Be Systematically Treated in Kidney Foxman B. Urinary Tract Infection Syndromes Occurrence, Recurrence, Bacteriology, Risk Factors, and Disease Transplant Recipients? Results From a Randomized Controlled Trial. Am J Transplant. 2016 Oct;16(10):2943-2953 Burden. Infect Dis Clin N Am 28 (2014) 1–13
Asymptomatic Bacteriuria Treatment of Uncomplicated UTI Treatment may cause UTI? • Cai T, Mazzoli S, et al. The Role of Asymptomatic Bacteriuria in Young Women With Recurrent Urinary Tract Infections: To Treat or Not to Treat? Clinical Infectious Diseases 2012;55(6):771–7 • 673 women 18-40yo randomized to Abx vs. no Tx • At 12 months 47% in the Abx vs. 13% in no Tx had symptomatic UTI ( P<.0001 ) Treatment of Uncomplicated UTI Treatment of Uncomplicated UTI Collateral Damage: ecological adverse effects of 2 reasons to consider collateral damage in abx choosing antibiotic treatment • Selection of drug resistant bacteria • Colonization or infection with multi-drug resistant 1) minimal risk of progression (<1% progress to pyelo) bacteria spontaneous resolution in 25%–42% of women Possibly due to effect on fecal flora 2) UTI is common use for Abx • Fluoroquinolones many small increments amplify collateral damage • Broad spectrum cephalosporins • Trimethoprim International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women International Clinical Practice Guidelines for the Foxman B. Urinary Tract Infection Syndromes Occurrence, Recurrence, Bacteriology, Risk Factors, • Ampicillin Treatment of Acute Uncomplicated Cystitis and and Disease Burden . Infect Dis Clin N Am 28 (2014) 1–13 Pyelonephritis in Women
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