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Recurrent Urinary Tract Infections

Recurrent Urinary Tract Infections. Liz Albertson, M.D. Carolina Urological Associates, PA. Urinary Tract Infection. Bacterial invasion of urothelium with bacteriuria and pyuria Cystitis is the syndrome of frequency, dysuria and urgency. Classifications of UTI.

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Recurrent Urinary Tract Infections

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  1. Recurrent Urinary Tract Infections Liz Albertson, M.D. Carolina Urological Associates, PA

  2. Urinary Tract Infection • Bacterial invasion of urothelium with bacteriuria and pyuria • Cystitis is the syndrome of frequency, dysuria and urgency

  3. Classifications of UTI • Uncomplicated UTI- healthy female and structurally normal urinary system • Complicated UTI- structurally abnormal, males, children, elderly, pregnancy, indwelling catheter, immunocompromised, hospital acquired

  4. Classifications of Recurrent UTI • Relapsing- caused by same bacteria re- emerging from a focus in the urinary tract • Reinfection- variable interval to recur and can be a different bacteria • Unresolved- not responding to antibiotics

  5. Risk Factors for UTI • Anatomic abnormality of the urinary tract • Pelvic prolapse, BPH, stones, diverticulum • Decreased estrogen status • History of previous UTI • Immunosuppression • Indwelling catheter • Neurologic disease • Sexual activity

  6. Clinical history • Dysuria • Frequency • Urgency • Hematuria • Lower abdominal/back pain • Foul odor • Cloudy

  7. Diagnosis of UTI • Clinical history and symptoms • Physical exam - rule out other diseases • Urine dipstick - LE+ and nitrite + has sensitivity of 75% • Microscopic exam • Urine culture

  8. Clinical outcomes for patients with UTI symptoms 39.8% with a positive cx 42.4% with a negative cx 17.8% with a contaminated specimen

  9. When to visit the Urologist? • Persistent symptoms with negative cultures • Persistent sterile pyuria • Unresolved/relapse/reinfection • Complicated UTI • Gross hematuria • Microscopic hematuria with negative culture • 3-5 RBC/HPF seen on 2 of 3 urine specimens

  10. Urological Workup • Clinical history is very important – DETAILS • Age • Duration of symptoms • Exacerbating/associated symptoms • Past urological history • Review records and previous cultures

  11. Who needs workup? • Gross/micro hematuria • Persistent irritative symptoms • >3 UTI/yr or 2 UTI in 6 months or less • Complicated UTI • For all of the above - Catheterized specimen Cystoscopy CT scan/IVP/renal ultrasound Urodynamics

  12. EVALUATE ANATOMY AND FUNCTION

  13. MAKE SURE RECURRENT UTI IS THE CORRECT DIAGNOSIS

  14. Other diagnoses to consider • Urological cancer • Painful bladder syndrome • Gynecological pathology • Yeast infection

  15. Treatment of Recurrent UTI • Age/gender related factors • Menopausal status • Pelvic prolapse • Urinary incontinence • Voiding dysfunction • BPH

  16. Treatment of Recurrent UTI Other clinical considerations • Fluid intake • Constipation • Neurological disease • Urinary retention

  17. Behavioral Therapy Very important in young as well as elderly patients for long term and successful conservative management

  18. Behavioral Therapy • Increase fluid intake to over 70 ounces/day • Avoiding caffeine • Avoiding acidic foods/drinks • Aggressive treatment of constipation • Time/double void

  19. Treatment of UTI Important clinical considerations • Most likely uropathogens • E.coli - 80% • Staph saprophyticus, Proteus, Klebsiella, enterococci, Group B strep

  20. Antibiotic treatment • Considerations for choice of antibiotic • Bacterial sensitivities/resistance • Patient allergy • Cost • Side effects • Adjusted dosage for age/renal function • Pregnancy

  21. Antibiotic Treatment Other important considerations • Previous antibiotic treatment • Duration of treatment • Postcoital dosage • Prophylactic dosage

  22. Firstline Antibiotic therapy for Uncomplicated UTI Quinolones are not first line therapy

  23. Duration of therapy for Uncomplicated UTI • SMZ/TMP – 5 days • cephalosporins – 7 days • trimethoprim – 5 days • nitrofurantion – 7 days • fosfomycin 3 gm – single dose • quinolones – 3 days

  24. Bacterial sensitivities E. coli • nitrofurantoin – 97% • cephalexin – 95% • quinalones – 90% • SMZ/TMP – 88% • Augmentin – 72%

  25. Bacterial Sensitivities Klebsiella pneumonia • quinalones – 100% • cephalexin – 98% • SMZ/TMP – 94% • Augmentin – 90% • nitrofurantoin – 27%

  26. Bacterial Sensitivities Proteus • cephalexin – 100% • Augmentin – 99% • SMZ/TMP – 97% • quinalones – 96% • nitofurantion- 0%

  27. Bacterial Sensitivities Entercoccus • ampicillin – 99% • nitrofurantoin – 96% • quinalones – 88%

  28. Bacterial Sensitivities Staph. Aureus • nitrofurantoin- 100% • SMZ/TMP – 100% • Levaquin – 87%

  29. Don’t forget FOSFOMYCIN 3 gm ONE dose

  30. KNOWN BACTERIAL SENSITIVITIES AND DURATION OF TREATMENT ARE MOST IMPORTANT

  31. Recurrent UTI Antibiotic Therapy • Duration of therapy can vary depending on clinical situation • Previous antibiotics used to treat UTI • Consideration for QHS antibiotic prophylaxis • Consideration for postcoital antibiotics

  32. ESBL E. coli • Emergence – difficult to tell but published literature started in 2007 • Extended Spectrum Beta Lactamase producer • Most commonly identified as E coli and Klebsiella • Hospital and community acquired • High rates of relapsing infection • Pitout J et al,,Lancet Inf Dis, Mar 2008

  33. ESBL E coli Usually: • Resistant to all PO antibiotics except nitrofurantion • Resistant to 1st, 2nd, 3rd generation cephalosporins • Resistant to quinolones • Resistant to aminoglycosides

  34. ESBL E coli Treatment is with carbapenems • impenem • ertapenem • doripenem ALL ARE IV ANTIBIOTICS

  35. Common symptoms of ESBL E coli UTI • Generalized malaise • Suprapubic discomfort • Cloudy/foamy/foul smelling urine • Minimal dysuria/urgency/frequency • Can be dipstick negative for nitrites

  36. SUSPECT POSSIBLE ESBL E COLI WHEN PATIENTS FAIL TO RESPOND TO NORMAL PO THERAPY

  37. Treatment of ESBL E coli • First identify the bacteria • Most labs now test for ESBL +/- • Identify previous antibiotic regimens • Carbapenems are: • Expensive • IV only – PICC line • Usually 2 – 6 week IV therapy

  38. Forskolin • Indian coleus plant • Raises cAMP • Induces exocytosis of fusiform vesicles with trapped bacteria • Trapped bacteria “hide” and are not eliminated with voiding and can reimerge and possibly reinfect • Bishop,B:Nature Medicine 13,625-630,2007

  39. Old Wives Tales • Wiping patterns • Avoid bath tubs/hot tubs • Type of undergarments None of these has been shown to predispose women to UTI’s

  40. Summary • Correct diagnosis • do not confuse with other urogynecological diseases • Workup complete • bladder/upper tracts/urological anatomy/function • Define risk factors • Institute behavioral therapy along with appropriate antibiotic therapy • Educate patient

  41. ALWAYS INSTITUTE BEHAVIORAL THERAPY WITH FLUIDS AND ELIMINATION AS THE MOST IMPORTANT TREATMENTS

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