Faculty Disclosure Urinary Tract Infections in Women No current disclosures No past disclosures relevant to UTIs Deborah R. Erickson, M.D. Professor of Urology In the past I consulted for 2 companies University of Kentucky College of Medicine developing interstitial cystitis treatments Lexington, Kentucky Learning Objectives Educational Need/Practice Gap Discuss how to Tx uncomplicated cystitis Sx Discuss how to Tx uncomplicated cystitis Sx Need = effective evaluation and treatment for For women with frequent UTI Sx, distinguish: For women with frequent UTI Sx, distinguish: urinary tract infection symptoms in women Unresolved infection Unresolved infection Recurrent UTIs Recurrent UTIs Gap: Urinary symptoms without infection Urinary symptoms without infection Individual practices may already be optimal For women with recurrent UTIs: For women with recurrent UTIs: This presentation will review and update Describe how to treat individual episodes Describe how to treat individual episodes optimal management Discuss appropriate prevention strategies Discuss appropriate prevention strategies Identify who needs Urology consult Identify who needs Urology consult Acute Cystitis Treatment in 2016 Expected Outcome Black box warning from US FDA May 2016: Black box warning from US FDA May 2016: Optimal evaluation and treatment for UTI symptoms in women Do not Rx systemic fluoroquinolones to pts Do not Rx systemic fluoroquinolones to pts who have other options for uncomplicated UTI who have other options for uncomplicated UTI because the risks outweigh the benefits. because the risks outweigh the benefits. Most important new information: Risks include tendinitis, tendon rupture, CNS Risks include tendinitis, tendon rupture, CNS Fluoroquinolone black box warning effects, peripheral neuropathy and worsening effects, peripheral neuropathy and worsening of myesthenia gravis. of myesthenia gravis. 1
A 26 y/o healthy woman calls with acute dysuria. She Uncomplicated Cystitis Sx in Women: has no fevers, back pain or vaginal discharge. She has an IUD in place. Before receiving Abx she needs: Empiric Treatment A. Pelvic exam, UA dip Phone protocols in primary care Phone protocols in primary care & micro, urine culture Recent review: Grigoryan L, JAMA 2014 Recent review: Grigoryan L, JAMA 2014 B. UA dip & micro, urine Also Shepherd AK, Med Clin N Am 2013 Also Shepherd AK, Med Clin N Am 2013 culture C. UA dip & micro Compared with Tx based on self-Dx, Compared with Tx based on self-Dx, D. UA dip only waiting for UA or culture is not preferred waiting for UA or culture is not preferred E. Telephone evaluation Can ↑ cost Can ↑ cost is sufficient Can ↑ # of symptomatic days Can ↑ # of symptomatic days Arnold JJ, Am Fam Physician 2016 Arnold JJ, Am Fam Physician 2016 Antibiotic Choices in USA β lactam Options IDSA Guidelines Clin Inf Dis 2011 IDSA Guidelines Clin Inf Dis 2011 Preferred: Preferred: Preferred: Preferred: Nitrofurantoin macro 100 bid x 5 days Nitrofurantoin macro 100 bid x 5 days Amoxicillin/clavulanate ( not amox alone!) Amoxicillin/clavulanate ( not amox alone!) Cefaclor 2 nd gen Cefaclor 2 nd gen TMP/SMX 160/800 (DS) bid x 3 days TMP/SMX 160/800 (DS) bid x 3 days Cefdinir 3 rd gen Cefdinir 3 rd gen Fosfomycin 3 g x 1 dose (~ $75) Fosfomycin 3 g x 1 dose (~ $75) Cefpodoxime 3 rd gen Cefpodoxime 3 rd gen If allergic to above, alternates are: If allergic to above, alternates are: Cephalexin (1 st gen) is less well studied Cephalexin (1 st gen) is less well studied Fluoroquinolones (??? in 2016) Fluoroquinolones (??? in 2016) β lactam 3-7 days β lactam 3-7 days Antibiotic Choices: β lactam Options Am Fam Physician 2016 Am Fam Physician 2016 1 st line 1 st line Amox/clavulanate 500/125 mg bid x 3 days Amox/clavulanate 500/125 mg bid x 3 days Fosfomycin 3 g x 1 Fosfomycin 3 g x 1 Nitrofurantoin 100 mg bid x 5 days Nitrofurantoin 100 mg bid x 5 days Cefaclor 250 mg tid x 5 days Cefaclor 250 mg tid x 5 days Trim/sulfa 160/800 mg bid x 3 days Trim/sulfa 160/800 mg bid x 3 days Cefdinir 300 mg bid x 5 days Cefdinir 300 mg bid x 5 days 2 nd line: fluoroquinolone x 3 days 2 nd line: fluoroquinolone x 3 days (article published before FDA warning) (article published before FDA warning) Cefpodoxime 100 mg bid x 3 days Cefpodoxime 100 mg bid x 3 days 3 rd line: β lactam (see next slide) 3 rd line: β lactam (see next slide) Cephalexin 500 mg bid x 7 days Cephalexin 500 mg bid x 7 days 2
You Rx 5 days nitrofurantoin. She calls back Learning Objectives and says UTI Sx are still present. The best next step is: Discuss how to Tx uncomplicated cystitis Sx Discuss how to Tx uncomplicated cystitis Sx For women with frequent UTI Sx, distinguish: For women with frequent UTI Sx, distinguish: A. Rx a longer course of Unresolved infection Unresolved infection nitrofurantoin Recurrent UTI Recurrent UTI B. Change to trim/sulfa Urinary symptoms without infection Urinary symptoms without infection C. Add phenazopyridine D. Order UA dip and micro For women with recurrent UTIs: For women with recurrent UTIs: Describe how to treat individual episodes Describe how to treat individual episodes E. Order urine culture Discuss appropriate prevention strategies Discuss appropriate prevention strategies Identify who needs Urology consult Identify who needs Urology consult Diff Dx for our patient Urine Culture Reports No growth Unresolved infection: culture stays + Unresolved infection: culture stays + Usually means no infection May be fastidious organisms or anaerobes Recurrent UTIs Recurrent UTIs Culture becomes negative Culture becomes negative Organism with # colony forming units/ml Later, new episode with + culture Later, new episode with + culture Old dogma: > 100,000 = UTI Modern: > 100 = UTI Urinary Sx without infection Urinary Sx without infection Any other report = don’t know Culture distinguishes this from the other 2 Culture distinguishes this from the other 2 (e.g. “no significant growth” or “mixed flora”) Our patient: Alternate Scenarios culture is E. coli R to nitrofurantoin, Culture no growth S to trim/sulfa Many other possible reasons for Sx Pelvic exam +/- STD testing Diagnosis: unresolved infection UA dip & micro, repeat culture Rx: trim/sulfa Culture mixed flora Same as above but also: (> 3 days since UTI going on so long?) True UTI may be hidden in mixed skin flora Collect urine by I/O cath All Sx resolve, hooray! DE favorite: 8 Fr hydrophilic ~ painless 3
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