Prevalence of urinary tract infections UTI

1. 22.6.2000 1 Prevalence of urinary tract infections (UTI) almost half of all women will have at least one UTI in their lives. the risk of UTI in women increases after menopause after a UTI 20 - 40 % will have a recurrence the recurring infections are usually reinfections. asymptomatic bacteriuria in women occurs in 2.7% of 15 - 24 year olds 9.3% of over 65 year olds and 20 - 50% of over 80 year olds

2. 22.6.2000 2 Prevalence of UTIs 2 UTI is rare in young and middle-aged men UTI in men is often associated with catheterisation or urological procedures. bacteriuria in elderly men occurs in about 10% of those living at home, about 20% of those living in nursing homes and 30% of those who are in-patients in hospitals urinary catheter increases the risk almost ten-fold in hospitalised patients and those in other care homes. pyelonephritis is common in patients who have been catheterised for over a month.

3. 22.6.2000 3 Urinary tract infection occurs when bacteria which colonise the anal area ascend through urethra to the bladder Risk factors include reduced resistance offered by the mucous membranes (e.g. after menopause) sexual intercourse disturbances in ureteral functioning in children the re-entering of urine back into the ureters (vesicoureteral reflux), which predisposes them particularly to upper UTI’s

4. 22.6.2000 4 Other risk factors: benign prostatic hypertrophy any illness, such as diabetes, which affects the emptying of the bladder spinal injury (associated with disturbances in bladder emptying or urinary catheter) catheterisation in hospital or residential care other urological procedures

5. 22.6.2000 5 Escherichia coli most common about 80% of primary care infections about 50% of hospital-acquired infections Others: enterococci Staphylococcus saprophyticus and klebsiellas various types of pseudomonas and proteus are more rare

6. 22.6.2000 6 ‘Uncomplicated’ urinary tract infections are occasional lower urinary tract infections in women with no predisposing factors to infections ‘Complicated’ infections are all other UTIs including lower UTIs in pregnant women men children and catheter-induced infections The investigations and treatment of these entail special features

7. 22.6.2000 7 Cystitis: typical symptoms include frequency and burning sensation when passing urine. Pyelonephritis: only some patients have difficulties in micturition temperature (> 38oC) and flank or back pain nausea in the elderly or sudden collapse in health status (”off-legs”)

8. 22.6.2000 8 Symptoms of UTIs 2 incontinence or offensive urine in the elderly should not be considered as UTI as such; even though they may be indicative signs of an infection almost any signs of infection in infants may be indicative of a UTI (C) in a small child a temperature alone, without any other signs of an infection, should raise a suspicion of a UTI UTI in children and the elderly may manifest itself as incontinence or retention.

9. 22.6.2000 9 Based on the symptoms both a clinical diagnosis of a UTI and a differentiation between lower (cystitis) or upper (pyelonephritis) UTI should be made

10. 22.6.2000 10 in adults and older children a mid stream urine (MSU) sample usually reliably represents the urine in the bladder. samples collected from urinary bags or bedpans should not be used to diagnose UTI as they invariably will be contaminated the most reliable sample is obtained via a suprapubic puncture urine in bladder >4 hours (any shorter time will increase the risk of false negative findings)

11. 22.6.2000 11 Clinically significant pathogen concentrations

12. 22.6.2000 12 No need to do any urinalysis, if a female patient, who does not belong to any of the risk groups, clearly has occasional cystitis based on her symptoms Urine microscopy is not usually necessary to diagnose cystitis

13. 22.6.2000 13 Diagnosis algorithm

14. 22.6.2000 14 Bacterial culture of urine should be carried out in all cases, except in uncomplicated cystitis, even though the results will not be available when medication is commenced (B) In early pregnancy bacterial culture should be carried out in all pregnant women if only to diagnose asymptomatic bacteriuria (A) In adult febrile infections with generalised symptoms, and in children’s infections, C-reactive protein (CRP) concentration above 40 mg/l is suggestive of a kidney infection (C)

15. 22.6.2000 15 Results of urine culture have repeatedly shown bacterial growth above 105 bacteria/ml possible pyuria does not affect interpretation if several bacterial strains are grown on culture; contamination of the sample is the likely cause investigations and treatment of asymptomatic bacteriuria should be instigated only in pregnant women

16. 22.6.2000 16 Acute uncomplicated cystitis: patient with typical symptoms, not belonging to any of the risk groups, is treated without laboratory investigations if the symptoms are atypical, a strip test urinalysis may be carried out to support diagnosis if the strip test is negative, the urine should be cultured and other reasons for the symptoms should be considered First choices: trimethoprim for 3-5 days nitrofurantoin for 5-7 days or pivmecillinam for 5-7 or 3 days Antimicrobial therapy in UTIs 1

17. 22.6.2000 17 Reserve drugs: Quinolones (norfloxacin, ofloxacin or ciprofloxacin) for 3 days if first choice drugs are not suitable or if the infection has not responded to first choice drugs or recurrent infection within 4 weeks if there is a relapse, urine must be cultured and the treatment should be continued for 7 days In special cases: cefalexin or cefadroxil for 5 days (if the above are contraindicated) sulphatrimethoprim for 3 days (particularly if the level of infection is unclear) amoxicillin for 5 days (particularly in enterococcal infections)

18. 22.6.2000 18 single-dose therapy is slightly less effective than conventional therapy effective in infections caused by E. coli, but less so in S. saprophyticus infections recommended particularly when practical reasons warrant its use (e.g. self-care) Preparations: phosphomycin 3 g norfloxacin 800 mg ciprofloxacin 500 - 750 mg ofloxacin 200 mg as a single dose

19. 22.6.2000 19 Uncomplicated pyelonephritis: A pyelonephritis patient who is not unduly ill can be looked after at home (C) Treatment with either a fluoroquinolone or sulphatrimethoprim orally for 10-14 days

20. 22.6.2000 20 Treatment of pyelonephritis 2 An unwell pyelonephritis patient with or without high temperature should be admitted to hospital in hospital the treatment is commenced with cefuroxime i.v. 0.75-1.5g every 8 hours or with an fluoroquinolone orally it is usually possible to change over to oral medication with first-generation cephalosporins in 2-3 days, when response to treatment is obvious third-generation cephalosporins are usually not recommended for the treatment of uncomplicated pyelonephritis, but ceftriaxone may be chosen as the initial therapy, if either once a day or intramuscular administration are considered beneficial aminoglycosides have shown no additional benefits over other forms of treatment

21. 22.6.2000 21 Bacteriuria during pregnancy is associated with increased risk of premature labour and pyelonephritis asymptomatic bacteriuria and cystitis are treated in the same way single-dose treatment is not recommended drugs of choice nitrofurantoin 75 mg twice daily for 5 - 7 days or beta-lactamase (mecillinam, amoxicillin or first-generation cephalosporins) for 5 – 7 days. due to foetal risk fluoroquinolones should be avoided during the whole of pregnancy, and sulphatrimethoprim during the latter part of pregnancy

22. 22.6.2000 22 treatment principles are the same as for adults little evidence to support short term treatment in children (C) drugs of choice nitrofurantoin 5 mg/kg/day or trimethoprim 8 mg/kg/day treatment to continue for 5 days (C)

23. 22.6.2000 23 treated so that any possible infection of the kidney is also covered, i.e. with antibiotics with high tissue penetrability oral medication acceptable drugs of choice sulphatrimethoprim (trimethoprim 8 mg/kg/day) cefalexin 30 - 50 mg/kg/day in 3 divided doses cefuroxime axetil 20 mg/kg/day in 2 divided doses or mecillinam 20 - 40 mg/kg/day in 3 divided doses treatment to continue for 7 days (C)

24. 22.6.2000 24 all infants with febrile UTI should be admitted to hospital drugs of choice cefuroxime (100 mg/kg/day in 3 divided doses) or ceftriaxone (80 mg/kg/day daily) intravenous therapy until obvious response when obvious response to treatment is observed, medication is changed over to oral until the total course of treatment, i.e. 10 days, is completed follow-up treatment according to culture and sensitivity results, with an antibiotic with good tissue penetrability (e.g. sulphatrimethoprim or a cephalosporin)

25. 22.6.2000 25 a UTI in men can be associated with either acute or chronic bacterial prostatitis prostatitis or epididymitis may play a part particularly in febrile UTI it is advisable to palpate both the prostate and scrotum chronic bacterial prostatitis, or at least the retention of bacteria in the prostatic ducts, should be suspected in relapses with the same causative bacteria

26. 22.6.2000 26 Afebrile lower urinary tract infection in men: if the infection is not associated with urinary stricture or prostatitis,it is treated with the same drugs as cystitis in women, but the treatment should continue for 7 - 10 days nitrofurantoin should not be used in men as adequate prostatic concentrations are not achieved (D) Febrile urinary tract infection in men is treated with a long course of antibiotics with good prostatic and epididymal penetration first choice: a fluoroquinolone for 2 weeks

27. 22.6.2000 27 UTIs in men 3 UTI in men associated with acute bacterial prostatitis treatment for 4 - 6 weeks (depending how quickly patient responds to treatment) to be followed up with low dose prophylaxis with e.g. trimethoprim or nitrofurantoin Chronic bacterial prostatitis recurrent UTI’s and calcifications in prostate oral quinolones for 2 – 3 months (D) to be followed up with prophylactic medication

28. 22.6.2000 28 Cystitis in diabetics drugs of choice for initial treatment are same as for uncomplicated UTI antibiotic treatment must always be based on the results of urine culture treatment to continue for 7 days Acute pyelonephritis in diabetics treatment is the same as for uncomplicated pyelonephritis consider urological imaging earlier than normal, if there is no response to appropriately chosen medication the causative agents of recurrent UTI’s in diabetics are often unusual, resistant microbes (species of pseudomonas, enterococci and enterobacter) and various candida species.

29. 22.6.2000 29 prophylaxis should be considered when more than 3 infections per year prophylaxis to continue for 6 months if infections recur after prophylactic treatment, the prophylaxis is re-commenced for 6 – 12 months (D)

30. 22.6.2000 30 First choice: trimethoprim 100 mg in the evenings nitrofurantoin 50 - 75 mg in the evenings Second choice: methenamine hippurate 1 g twice daily norfloxacin 200 mg daily or on 3 evenings per week nitrofurantoin (not if serum creatinine is above 150 µmol/l) quinolones (in cases where there is no response with other prophylactic medication or tolerance to other medications is poor) During pregnancy: nitrofurantoin 50 mg daily or methenamine hippurate 1 g daily for the rest of the pregnancy particularly if recurrent bacteriuria is diagnosed in early pregnancy

31. 22.6.2000 31 A single-dose prophylaxis taken after intercourse is effective in women whose UTI’s are clearly associated with sexual intercourse (A) First choice: trimethoprim 100-300 mg as a single dose nitrofurantoin 50-75 mg as a single dose Second choice: norfloxacin 200 mg, ofloxacin 100 mg or ciprofloxacin 100-250 mg sulphatrimethoprim (1 single-strength tablet)

32. 22.6.2000 32 The main quality criteria for the treatment of UTI’s urine sample to be collected appropriately when infection is suspected unnecessary culturing of urine samples to be avoided the investigation and treatment of asymptomatic bacteriuria to be reserved for risk groups diagnosing structural anomalies of the urinary tract in children rational use of antibiotics

33. 22.6.2000 33 the treatment of UTI in a catheterised patient should always be based on the identity and sensitivity of the causative microbe the catheter should always be removed, at least for the duration of treatment, as otherwise the bacteria will not be eradicated if this is not feasible, the recommendation is to continue treatment for 7 - 10 days even in lower UTI’s

34. 22.6.2000 34 In the following patient groups antibiotics can prevent serious infective complications caused by long-term catheterisation : after renal transplant (for 3 months) granulocytopenic patients and possibly in diabetics it is recommended that drugs which could be of benefit in serious infections (beta-lactamases and fluoroquinolones) are not used for prophylaxis Antibiotic prophylaxis is not recommended: for repeat catheterisations for the insertion of long-term catheter for pyuria and bacteriuria in a patient with a long-term catheter but no obvious infection

35. 22.6.2000 35 Antimicrobial therapy in association with a urinary catheter 3 Fungal bladder infection in a catheterised patient: systemic fluconazole is slightly more effective than topical amphotericin B removal of the catheter will improve the eradication of the microbe during therapy Suprapubic catheter: its use is associated with a lower incidence of bacteriuria in postoperative care any infections are treated as any other infections associated with urinary catheters

36. 22.6.2000 36 Infections associated with impaired urine outflow and neurological illnesses it is recommended not to treat asymptomatic bacteriuria acute episodes of infections are treated according to urine microbiology depending on response, treatment is to continue 7 - 14 days if the underlying condition is treatable prophylaxis should be provided, after the infection has been cleared, until the urological condition has been treated if the risk factor is permanent no prophylaxis should be provided, after the infection has been cleared, whether bacteriuria is present or not 6 months’ prophylaxis may be considered if infections are frequent no prophylaxis is recommended for the elderly in care who are either incontinent or regularly use incontinence pads

37. 22.6.2000 37 UTI in dialysis patients: UTI often has few symptoms or is totally asymptomatic and often remains undiagnosed the significance of pyuria in a dialysis patient is unclear if UTI is diagnosed, it should be treated according to culture results

38. 22.6.2000 38 UTI in polycystic kidney disease UTI with the symptoms of cystitis can be treated with oral medication chosen according to culture results in febrile UTI a cyst infection is common, but difficult to diagnose antibiotics with best possible penetrability into renal tissue and cyst fluid, such as fluoroquinolones, are recommended

39. 22.6.2000 39 Post renal transplant 1 febrile UTI’s are common during the first few months (35 - 79% will get an infection during the first 3 - 4 months) UTI’s after this stage are less serious and easier to treat treatment according to culture results with usual drugs is adequate the treatment of symptomatic infection in women is to continue for 1-2 weeks and in men for 4 weeks urological investigations should be carried out to rule out any predisposing anomalies there is neither study data nor consensus about the benefits of treating bacteriuria post transplant. If the decision favours treatment, at least a week’s treatment is recommended

40. 22.6.2000 40 UTI’s in special situations 5 Post renal transplant 2 fluoroquinolones or sulphatrimethoprim are both suitable follow-up treatment consists of prophylaxis with either trimethoprim or nitrofurantoin for 3 - 6 months Restrictions in antibiotic therapy: nitrofurantoin should be avoided if serum creatinine is above 150 µmol/l the use of trimethoprim and sulpha should also be avoided in severe renal impairment (creatinine > 350 µmol/l) or their concentration should at least be monitored during prolonged use if fluoroquinolones are used, their dose should be reduced aminoglycosides should be avoided in those using cyclosporin due to the risk of renal damage