Urinary Tract Infection in Women

Transcription

1 C H A P T E R 1 8 Urinry Trct Infection in Women Toms L. Griebling, MD Associte Professor & Vice Chir of Urology University of Knss Knss City, Knss

2 Contents INTRODUCTION DEFINITION AND DIAGNOSIS RISK FACTORS PREVALENCE AND INCIDENCE MORBIDITY AND MORTALITY TRENDS IN HEALTHCARE RESOURCE UTILIZATION Medictions Inptient Cre Outptient Cre Emergency Room Cre Nursing Home Cre ECONOMIC IMPACT SPECIAL CONSIDERATIONS CONCLUSIONS RECOMMENDATIONS

3 Urinry Trct Infection in Women Toms L. Griebling, MD INTRODUCTION Urinry trct infection is n extremely common condition tht occurs in both mles nd femles of ll ges. The prevlence nd incidence of urinry trct infection is higher in women thn in men, which is likely the result of severl clinicl fctors including ntomic differences, hormonl effects, nd behvior ptterns. DEFINITION AND DIAGNOSIS Urinry trct infection (UTI) is cused by pthogenic invsion of the urinry trct, which leds to n inflmmtory response of the urothelium. Infections my be cute or chronic. The clinicl mnifesttions of UTI depend on the portion of the urinry trct involved, the etiologic orgnism(s), the severity of the infection, nd the ptient s bility to mount n immune response to it. Signs nd symptoms my include fever, chills, dysuri, urinry urgency, frequency, nd cloudy or mlodorous urine. Bcteriuri refers to the presence of bcteri in the urine, but this is not equivlent to UTI. A UTI includes the inflmmtory response nd the ssocited signs nd symptoms tht result from the presence of the bcteri. Bcteriuri my be symptomtic, prticulrly in elderly dults. Pyuri refers to the presence of white blood cells in the urine. It is mrker of inflmmtion in response to bcteril infection. Infections in the urinry system re often clssified by the ntomic site or orgn involved, lthough the entire urinry trct my be ffected. Pyelonephritis refers to urinry trct infection involving the kidney. This my be n cute or chronic process. Acute pyelonephritis is chrcterized by fever, chills, nd flnk pin. Ptients my lso experience nuse nd vomiting, depending on the severity of the infection nd whether there is ny obstruction to the flow of urine out of the renl collecting system. The risk of renl dmge in most ptients with uncomplicted UTI is low, even in those with uncomplicted cute pyelonephritis. Chronic pyelonephritis implies recurrent renl infections nd my be ssocited with the development of renl scrring nd impired function if obstruction is present. A perinephric bscess my develop in severe cses of pyelonephritis. The clinicl distinction between upper nd lower UTI my be difficult, prticulrly in women. Cystitis is n inflmmtory process of the urinry bldder, typiclly cused by bcteril infection. It my be cute or chronic in nture. Urethritis refers to n inflmmtion or infection of the urethr. This often occurs in combintion with cystitis nd my be difficult to differentite. Isolted bcteril urethritis is rre in women. Vginitis nd cervicitis, often relted to sexully trnsmitted orgnisms, my lso cuse symptoms ttributed to cystitis or urethritis. Recurrent UTIs involve reinfection from source outside the urinry trct or from bcteril persistence within it. In ech cse, the infections my be cused by the sme or different orgnisms. The vst mjority of recurrent UTIs in women re due to reinfection. The stndrd ICD-9 dignostic codes for UTI (Tble 1) were used for the nlyses presented in this chpter. These codes re ctegorized primrily on the 589

4 Urologic Diseses in Americ Tble 1. Codes used in the dignosis nd mngement of femle urinry trct infection Femles 18 yers or older with one of the following ICD-9 dignosis codes: Cystitis Cndidisis of other urogenitl sites Schistosomisis, unspecified Acute cystitis Chronic interstitil cystitis Other chronic cystitis Trigonitis Other specified types of cystitis Cystitis, unspecified Infections of genitourinry trct in pregnncy Mternl renl nd urinry trct diseses ffecting fetus or newborn Pyelonephritis Chronic pyelonephritis Chronic pyelonephritis without lesion of renl medullry necrosis Chronic pyelonephritis with lesion of renl medullry necrosis Acute pyelonephritis Acute pyelonephritis without lesion of medullry necrosis Acute pyelonephritis with lesion of renl medullry necrosis Renl nd perinephric bscess Pyeloureteritis cystic Other pyelonephritis or pyonephrosis, not specified s cute or chronic Infection of kidney, unspecified Other specified disorders of kidney nd ureter Other Other urethritis Urinry trct infection site not specified Asymptomtic bcteriuri in pregnncy 590

5 Urinry Trct Infection in Women bsis of the site nd type of infection involved. The primry ctegories include cystitis, pyelonephritis, nd other infections. Common definitions re used here to permit comprisons mong dtsets. The dignosis of UTI my be mde presumptively on the bsis of clinicl signs nd symptoms in combintion with urinlysis results. A urinlysis tht revels both bcteriuri nd pyuri is considered cliniclly dignostic of UTI. Trditionlly, confirmtory cultures hve been obtined to verify the infection nd identify the specific orgnism(s) involved; however, this stndrd is evolving. If culture is obtined, the presence of t lest 10 5 colony-forming units (CFU) of bcteri on voided specimen hs clssiclly been used s the culture-bsed definition of UTI. Lower colony counts (100 CFU) my be used to estblish clinicl dignosis in ctheterized or spirted specimens from symptomtic ptients. Bcteril coloniztion of indwelling ctheters is common, nd it my be difficult to distinguish between this phenomenon nd symptomtic UTI requiring therpy. Drug susceptibility dt re typiclly obtined to verify tht pproprite therpy hs been selected. The incresed prevlence of drug-resistnt bcteri hs mde susceptibility testing prticulrly importnt. RISK FACTORS Reserch hs identified number of risk fctors for UTI in women. Women re t greter risk for UTI thn men, prtly becuse of the reltively short, stright ntomy of the urethr. Retrogrde scent of bcteri from the perineum is the most common cuse of cute cystitis in women. Host fctors such s chnges in norml vginl flor my lso ffect the risk of UTI. Genetic fctors, including expression of HLA-A3 nd Lewis blood group Le(-b-) or Le(+b-), my lso put women t higher risk for recurrent UTI. Sexully ctive women re t greter risk for UTI thn women who do not engge in sexul intercourse. Simple hygiene hbits, including voiding before nd fter sexul intercourse nd wiping from nterior to posterior, re often dvocted to decrese the risk of UTI; however, recent review found no dvntge to these behviorl techniques (1). Contrceptive use my ffect the rte of UTI, which ppers to be greter in women who use certin types of spermicides. Hemtogenous nd lymphtic spred of bcteri to the urinry trct is uncommon in helthy ptients. Vesicoureterl reflux hs been identified s risk fctor for the development of pyelonephritis. This is most commonly dignosed in children, but it my lso be identified in dults. Ptients with recurrent pyelonephritis wrrnt ntomic evlution, usully with voiding cystourethrogrm to identify evidence of reflux. A foreign body in the urinry system my ct s nidus for infection nd my be ssocited with recurrent infections. Common exmples include urinry clculi nd indwelling ctheters. Indwelling urinry ctheters re ssocited with chronic bcteril coloniztion, which occurs in lmost ll ptients fter five to seven dys. This coloniztion significntly increses the risk for symptomtic UTI. Ctheter modifictions with ntibiotic nd silver impregntion hve been developed in n effort to decrese the rte of infection in ptients with indwelling ctheters (2). Ure-splitting orgnisms re often ssocited with UTI in the presence of stones. Post-menopusl women re t higher risk for UTI thn younger women re, becuse they lck estrogen, which is essentil to mintin the norml cidity of vginl fluid. This cidity is criticl to permit the growth of Lctobcillus in the norml vginl flor, which cts s nturl host defense mechnism ginst symptomtic UTI. Restortion of the norml hormonl milieu in the vgin is not effective tretment for ctive urinry trct infections, but it my be useful for prevention. Other urologic fctors potentilly ssocited with n incresed risk of UTI in post-menopusl women include urinry incontinence, cystocele, nd elevted volumes of postvoid residul urine. Urinry trct infections re often chrcterized s uncomplicted if they involve only the bldder nd re not ssocited with the presence of foreign bodies or ntomic bnormlities. Complicted UTIs my include pyelonephritis, urosepsis nd the presence of foreign bodies or ntomic disorders. Significnt UTIs in elderly ptients re often clssified s complicted due to the incresed risk of ssocited morbidity nd mortlity in this popultion. Urinry trct infections my be cused by vriety of different orgnisms, most commonly bcteri. The most frequent bcteril cuse of UTI in dult women 591

6 Urologic Diseses in Americ is Escherichi coli, which is prt of the norml gut flor. This orgnism ccounts for pproximtely 85% of community-cquired UTIs nd 50% of hospitlcquired UTIs. Other common orgnisms include Enterococcus feclis, Klebsiell pneumonie, nd Stphylococcus sprophyticus. Nosocomil infections nd those ssocited with foreign bodies my involve more ggressive orgnisms such s Pseudomons eruginos, Serrti, Enterobcter, nd Citrobcter species. Nonbcteril infections re less common nd tend to occur more often in immunosuppressed individuls or those with dibetes mellitus. Fungl infections with Cndid spp re the most common nonbcteril infections. Other less common urinry trct pthogens include Mycobcterium tuberculosis nd vriety of nerobic orgnisms. The overll role of nerobic urinry infections is controversil; however, nerobes my be especilly dngerous in immunocompromised ptients due to n incresed risk of severe infections such s emphysemtous pyelonephritis or cystitis. Bilhrzil cystitis is uncommon in the United Sttes but my be seen in ptients who hve recently immigrted or trveled to res of the world where schistosomes re endemic. Reserch on the physiology nd microbiology of urinry trct infections hs identified number of orgnism nd host fctors tht my increse the risk for UTI. Disruption of the urothelium due to trum or other irrittion my increse the bility of orgnisms to dhere to tissue nd cuse infection. Bcteri my develop number of mechnisms such s pili, fimbrie, nd chemicl dhesins tht increse their bility to dhere to host tissues. PREVALENCE AND INCIDENCE Urinry trct infection is n extremely common dignosis in women, nd tretment incurs substntil costs. It is estimted tht t lest one-third of ll women in the United Sttes re dignosed with UTI by the time they rech 24 yers of ge (3). In rndomdigit-diling telephone survey of 2,000 women, Foxmn nd collegues found tht 10.8% of women 18 yers of ge or older self-reported t lest one UTI in the previous 12 months (95% CI, ) (Figure UTI in pst First UTI % with UTI Figure 1. Self-reported incidence of physicin-dignosed urinry trct infection during the previous 12 months by ge nd history of urinry trct infection mong 2000 United Sttes women prticipting in rndom digit diling survey. The verge stndrd error for the totl incidences in ech of the ge groups is 2.3%. SOURCE: Adpted from Annls of Epidemiology, 10, Foxmn B, Brlow R, D Arcy H, Gillespie B, nd Sobel JD, Urinry trct infection: self-reported incidence nd ssocited costs, , Copyright 2000, with permission from Elsevier Science. 592

7 Urinry Trct Infection in Women Tble 2. Femle lifetime prevlence of urinry trct infections, by sociodemogrphic group, count, rte Count Incidence Rte Totl count b 50,810,018 53, bldder infections ever 26,871,194 28, bldder infections ever 23,938,824 25,002 Men number of infections in the lst 12 months of those ever hving UTI Rce/ethnicity White non-hispnic 41,641,569 55,937 Blck non-hispnic 5,129,383 45,976 Hispnic 3,195,829 45,550 Other 843,238 26,937 Midwest 12,081,920 52,335 Northest 9,508,670 47,039 South 18,116,413 54,924 West 11,103,015 57,048 Urbn/rurl MSA 24,236,785 34,135 Non-MSA 26,573, ,393 MSA, metropolitn sttisticl re. Rte per 100,000 bsed on 1991 popultion estimtes from Current Popultion Survey (CPS), CPS Utilities, Unicon Reserch Corportion, for relevnt demogrphic ctegories of US femle dult civilin non-institutionlized popultion. b The dt in this tble re bsed on the weighted number of persons who responded 1 or more to question HAK4: How mny times hve you hd bldder infection, lso clled urinry trct infection, UTI or cystitis? NOTE: Counts my not sum to totl due to rounding. SOURCE: Ntionl Helth nd Nutrition Exmintion Survey III, Tble 3. Femle incidence of UTIs in pst 12 months, by sociodemogrphic group, count, rte Incidence Count Rte Totl count b 12,753,035 13,320 1 or more bldder infections in the lst 12 months 12,753,035 13,320 Men number of infections in the lst 12 months ,741,548 21, ,274,713 15, ,338,316 11, ,531,348 11, ,129,215 10, ,627 9, ,903 10, ,365 11,770 Rce/ethnicity White non-hispnic 9,949,997 13,366 Blck non-hispnic 1,572,606 14,096 Hispnic 1,017,401 14,501 Other 213,032 6,805 Midwest 2,518,030 10,907 Northest 2,346,347 11,607 South 5,037,597 15,273 West 2,851,061 14,649 Urbn/rurl MSA 6,425,838 9,050 Non-MSA 6,327,198 25,571...dt not vilble. MSA, metropolitn sttisticl re. Rte per 100,000 bsed on 1991 popultion estimtes from Current Popultion Survey (CPS), CPS Utilities, Unicon Reserch Corportion, for relevnt demogrphic ctegories of US femle dult civilin non-institutionlized popultion. b The dt in this tble re bsed on the weighted number of persons who responded 1 or more to question HAK5: How mny of these infections did you hve during the pst 12 months? NOTE: Counts my not sum to totl due to rounding. SOURCE: Ntionl Helth nd Nutrition Exmintion Survey III,

8 Urologic Diseses in Americ Tble 4. Frequency of urinry trct infection (including cystitis, pyelonephritis, orchitis, nd other) s dignosis in VA ptients seeking outptient cre, rte Sub-Conditions Primry Dignosis Any Dignosis Primry Dignosis Any Dignosis Primry Dignosis Any Dignosis Mle UTI b 2,082 2,705 1,963 2,591 1,719 2,334 Cystitis Pyelonephritis Orchitis Other 1,649 2,187 1,555 2,097 1,351 1,868 Femle UTI b 4,793 6,015 4,589 5,904 4,265 5,552 Cystitis Pyelonephritis Other 4,378 5,521 4,187 5,409 3,883 5,075 Rte is defined s the number of unique ptients with ech condition (unweighted frequency or # of cses) divided by the bse popultion in the sme fiscl yer (# unique SSNs per strt) x 100,000 to clculte the rte per 100,000 (# cses per 100,000 unique outptients). b Represents unique cses of UTI (i.e., ptients with more thn one UTI subtype re counted only once). SOURCE: Outptient Clinic File (OPC), VA Austin Automtion Center, ). Using this informtion, the uthors clculted the lifetime risk for UTI in their smple to be 60.4% (95% CI, ). Using these dt, the uthors estimted tht t lest 11.3 million women in the United Sttes hd t lest one UTI in 1995, nd the overll cost of prescriptions to tret UTIs tht yer ws more thn $218 million. Similrly, between 1988 nd 1994, the overll lifetime prevlence of UTI ws estimted to be 53,067 cses per 100,000 dult women, bsed on the Ntionl Helth nd Nutrition Exmintion Survey (NHANES-III) (Tble 2). The prevlence in women ws significntly higher thn tht estimted in men (13,689 cses per 100,000) in this study (Chpter 7, Tble 2). Dt from NHANES-III lso shows the incidence of UTI in the pst 12 months to be 13,320 per 100,000 dult women (Tble 3). Dt from US Veterns Helth Administrtion (VA) fcilities reveled similr disprity in the numbers of women nd men seeking cre for UTIs (Tble 4). In 2001, the rte of women seeking outptient cre for cystitis ws 626 cses per 100,000 (with 469 s the primry dignosis), compred with 161 cses per 100,000 (111 s the primry dignosis) in men. In contrst to cystitis, the overll prevlence of women seeking outptient cre for pyelonephritis ws only slightly higher in women thn in men: 78 cses per 100,000 (64 s the primry dignosis) vs 60 cses per 100,000 (40 s the primry dignosis). In the three yers for which dt re vilble (1999 to 2001), the overll frequency of n outptient primry dignosis of UTI in US femle VA outptient clinic ptients grdully declined, from 4,793 per 100,000 to 4,265 per 100,000 (Tble 5). Also, note tht the prevlence rtes in the VA dt re much lower thn those in NHANES becuse the VA identifies only UTIs for which ptients sought medicl ttention in one yer, wheres NHANES relies on self-reported UTI over lifetime nd hence presents true popultion prevlence. MORBIDITY AND MORTALITY Urinry trct infections my be ssocited with significnt morbidity nd even mortlity. This is prticulrly true in the fril elderly nd in those with ssocited urinry incontinence, where UTI my be relted to skin brekdown nd ulcertion. Complicted UTIs my led to urosepsis nd deth; however, the risk of UTI-relted mortlity in the elderly nd comorbid popultion is unknown. It is generlly believed tht symptomtic bcteriuri in elderly ptients does not need to be treted, lthough this issue is controversil (4). More commonly, UTI is ssocited with bothersome urinry symptoms tht 594

9 Urinry Trct Infection in Women Tble 5. Frequency of urinry trct infection s dignosis in femle VA ptients seeking outptient cre, rte b Primry Dignosis Any Dignosis Primry Dignosis Any Dignosis Primry Dignosis Any Dignosis Totl 4,793 6,015 4,589 5,904 4,265 5, ,396 5,154 4,852 5,878 4,431 5, ,969 5,840 4,726 5,705 5,051 6, ,547 5,634 4,370 5,525 3,909 5, ,624 5,841 4,451 5,717 4,127 5, ,543 6,081 4,645 6,320 4,273 5, ,097 6,843 4,887 6,677 4,040 5, ,546 7,395 4,818 6,598 4,229 5, ,484 6,567 5,269 7,446 5,088 6,416 Rce/ethnicity White 6,094 7,697 5,764 7,484 5,322 6,937 Blck 5,735 7,182 5,280 6,664 4,942 6,403 Hispnic 6,672 8,556 5,801 7,605 5,666 6,922 Other 4,787 6,080 6,722 7,665 3,630 13,299 Unknown 3,255 4,038 3,209 4,111 3,048 3,976 Estern 4,008 4,965 3,781 4,823 3,623 4,591 Centrl 4,640 5,871 4,696 5,939 4,195 5,456 Southern 5,313 6,747 4,888 6,489 4,482 6,002 Western 4,778 5,887 4,720 5,865 4,512 5,707 Insurnce sttus No insurnce/self-py 4,792 5,957 4,658 5,928 4,375 5,576 Medicre/Medicre supplementl 6,064 7,828 5,308 7,192 4,791 6,692 Medicid 5,229 6,536 5,482 6,360 5,915 6,839 Privte insurnce/hmo/ppo 4,001 5,146 3,829 4,914 3,428 4,559 Other insurnce 4,174 4,973 3,697 4,736 3,512 4,484 Unknown 5,594 6,993 1,493 1,493 1,914 1,914 HMO, helth mintennce orgniztion; PPO, preferred provider orgniztion. Represents dignosis codes for femle urinry trct infections (including cystitis, pyelonephritis, nd other UTIs). b Rte is defined s the number of unique ptients with ech condition (unweighted frequency or # of cses) divided by the bse popultion in the sme fiscl yer (# unique SSNs per strt) x 100,000 to clculte the rte per 100,000 (# cses per 100,000 unique outptients). NOTE: Rce/ethnicity dt from clinicl observtion only, not self-report; note lrge number of unknown vlues. SOURCE: Outptient Clinic File (OPC), VA Austin Automtion Center,

10 Urologic Diseses in Americ Tble 6. Prescribing trends from 1989 through 1998 Antibiotic Prescribed Adjusted Odds Rtio (95% Confidence Intervl) for Predictor, Yer (per decde) b Trimethoprim-sulfmethoxzole ( ) Recommended fluoroquinolones c ( ) Nitrofurntoin ( ) Overll non-recommended ntibiotics d ( ) No. of visits per 2-yer period n/ Unless otherwise indicted, dt re percentges of ptients. b In ll models, ntibiotic prescribing ws the dependent vrible. All trends djusted for ge younger thn 45 yers nd history of urinry trct infection. c Recommended fluoroquinolones were defined s ciprofloxcin, ofloxcin, lomefloxcin, enoxcin, nd fleroxcin. d Non-recommended ntibiotics were defined s ll ntibiotics other thn trimethoprim or trimethoprim-sulfmethoxzole or recommended fluoroquinolones. SOURCE: Reprinted from Hung ES, Stfford RS, Ntionl ptterns in the tretment of urinry trct infections in women by mbultory cre physicins, Archives Internl Medicine, 162, 41 47, Copyright 2002, with permission from the Americn Medicl Assocition. All rights reserved. cn led to work bsence nd decresed bility to engge in ctivities of dily living. TRENDS IN HEALTHCARE RESOURCE UTILIZATION Medictions Antimicrobil therpy remins the minsty of tretment for ptients with UTIs. Bcteril urine cultures with pproprite drug susceptibility dt should guide the selection of ntimicrobils. However, most symptomtic ptients require selection of therpy prior to the identifiction of the etiologic orgnism. Initil therpy is usully empiric, with subsequent modifictions mde on the bsis of urine culture nd susceptibility results s necessry. The need for urine culture is lso n re of debte. Mny experts dvocte empiric therpy for most ptients, with urine cultures reserved for those who fil to respond to tretment or hve recurrent infections. The Infectious Disese Society of Americ published guidelines in 1999 tht recommended the use of trimethoprim-sulfmethoxzole (TMP-SMX) s first-line therpy for ptients without n llergy to this compound (5). Specific fluoroquinolones were recommended s second-line gents. In geogrphic Tble 7. Expenditures for femle urinry trct infection nd shre of costs, by site of service (% of totl) Site of Service Totl $1,885,000,000 $1,944,300,000 $2,211,900,000 $2,474,000,000 Inptient $1,168,700,000 (62.0%) $1,254,100,000 (64.5%) $1,322,700,000 (59.8%) $1,360,700,000 (55.0%) Physicin Office $309,100,000 (16.4%) $295,500,000 (15.2%) $404,800,000 (18.3%) $536,800,000 (21.7%) Hospitl Outptient $126,300,000 (6.7%) $105,000,000 (5.4%) $165,900,000 (7.5%) $163,300,000 (6.6%) Emergency Room $280,900,000 (14.9%) $289,700,000 (14.9%) $318,500,000 (14.4%) $413,200,000 (16.7%) Totl undjusted expenditures exclude spending on outptient prescription drugs for the tretment of urinry trct infection. Averge drug spending for UTI-relted conditions (both mle nd femle) is estimted t $96 million to $146 million nnully for the period 1996 to SOURCES: Ntionl Ambultory Medicl Cre Survey, Ntionl Hospitl Ambultory Medicl Cre Survey, Helthcre Cost nd Utiliztion Project, nd Medicl Expenditure Pnel Survey, 1994, 1996, 1998,

11 Urinry Trct Infection in Women Tble 8. Inptient stys by femle Medicre beneficiries with urinry trct infection listed s primry dignosis, count, rte b (95% CI) Count Rte Count Rte Count Rte Totl c 114, ( ) 127, ( ) 128, ( ) Totl < 65 8, ( ) 9, ( ) 11, ( ) Totl , ( ) 118, ( ) 117, ( ) , ( ) 27, ( ) 24, ( ) , ( ) 46, ( ) 46, ( ) ,700 1,527 (1,510 1,544) 37,660 1,694 (1,677 1,711) 39,460 1,774 (1,756 1,791) 95+ 4,400 1,706 (1,656 1,757) 6,120 2,161 (2,108 2,215) 6,480 2,088 (2,038 2,139) Rce/ethnicity White 94, ( ) 105, ( ) 104, ( ) Blck 13, ( ) 17, ( ) 17, ( ) Asin ( ) ( ) Hispnic 1, ( ) 3, ( ) N. Americn Ntive 200 1,238 (1,064 1,411) 380 1,457 (1,311 1,603) Midwest 28, ( ) 31, ( ) 31, ( ) Northest 21, ( ) 23, ( ) 23, ( ) South 50, ( ) 56, ( ) 57, ( ) West 12, ( ) 14, ( ) 14, ( ) dt not vilble. Unweighted counts multiplied by 20 to rrive t vlues in the tble. b Rte per 100,000 Medicre beneficiries in the sme demogrphic strtum. c Persons of other rces, unknown rce nd ethnicity, nd other region re included in the totls. NOTE: Counts less thn 600 should be interpreted with cution. SOURCE: Centers for Medicre nd Medicid Services, MedPAR nd 5% Crrier File, 1992, 1995, Physicin Office Inptient Inptient Emergency Room Hospitl Ou Emergency Physicin 10000O Rte per 100, Hospitl Outptient Figure 2. Trends in visits by femles with urinry trct infection listed s primry dignosis, by site of service nd yer. SOURCE: Centers for Medicre nd Medicid Services, 1992, 1995,

12 Urologic Diseses in Americ res where resistnce to TMP-SMX is high (>20%), fluoroquinolones re recommended s first-line therpy. The recommendtion to use older gents such s TMP-SMX s initil therpy hs strong merit. These medictions cost less thn newer ntimicrobils such s fluoroquinolones. In ddition, reserving fluoroquinolones nd brod-spectrum ntimicrobils for complicted infections or cses with documented resistnce to first-line therpy my help reduce the incidence of bcteril resistnce. However, recent study on the ntionl trends in prescribing ptterns for UTI in women mong mbultory cre physicins reveled tht the use of TMP-SMX is decresing nd the use of fluoroquinolones is incresing (6). The proportion of TMP-SMX use dropped from 48% in to 24% in (djusted OR, 0.33; 95% CI, per decde). At the sme time, fluoroquinolone use incresed from 19% to 29% (djusted OR, 2.28; 95% CI, per decde) (Tble 6). This indictes tht there is trend towrd using more-expensive ntimicrobils such s fluoroquinolones s initil therpy. This trend my be due in prt to incresed rtes of outptient cre nd incresed vilbility nd mrketing of these products. However, it hs the potentil to increse both overll costs nd ntimicrobil resistnce. Inptient Cre Severe UTIs, prticulrly those ssocited with cute pyelonephritis, my require inptient hospitliztion for tretment with intrvenous ntimicrobils. In 2000, inptient services constituted 55% of ll expenditures for the tretment of UTI (Tble 7). According to dt from the Centers for Medicre nd Medicid Services (CMS), there ws grdul overll increse in the ge-undjusted rte of inptient hospitliztion for tretment of UTI in dult women between 1992 (579 per 100,000) nd 1998 (674 per 100,000) (Tble 8 nd Figure 2). While the overll rte of inptient stys for women 84 yers of ge nd younger hs remined reltively constnt, there hs been drmtic increse in the rte of inptient hospitl stys for very elderly women. The rte for women 85 to 94 yers of ge incresed from 1,527 per 100,000 in 1992 (95% CI, 1,510 1,544) to 1,774 per 100,000 in 1998 (95% CI, 1,756 1,791). The rte ws even higher for women over 95, incresing from 1,706 per 100,000 in 1992 to 2,088 in Urinry trct infections my be more severe in fril elderly women due to dditionl comorbidity, nd this my necessitte more ggressive tretment with inptient hospitliztion nd intrvenous ntimicrobil therpy. Africn Americn women hd higher rtes of inptient tretment thn did other ethnic groups (1.1 to 2.95 times higher). Ptients living in the South hd higher rtes of inptient cre thn did women living in other regions. Dt from the Helthcre Cost nd Utiliztion Project (HCUP) for the yers from 1994 to 2000 indicte tht the rte of inptient hospitliztion for primry dignosis of UTI hs been generlly decresing for young nd middle-ged women (18 to 54 yers of ge) nd hs been reltively stble overll for those ged 55 to 74 (Tble 9). In ddition, the overll rte of inptient hospitliztion is reltively low for young women, incresing pproximtely twofold when women rech the 65 to 74 ge group. However, these dt lso demonstrte tht there hs been grdul increse in the rte of inptient hospitliztions for women 75 to 84 yers of ge when UTI is the primry dmitting dignosis. The most striking finding in the dt is tht women 85 nd older hd inptient hospitliztion rtes 2.82 to 3.27 times higher thn those of women in the 75 to 84 ge rnge. This my be reflection of the degree of ssocited morbidity nd potentil helth impirment cused by UTI in elderly women. Nosocomil infections my lso influence the rtes of hospitliztion in this ptient group. It is uncler why estimted inptient utiliztion rtes re lower in HCUP dt thn in CMS dt. Acute pyelonephritis is serious UTI often treted with intrvenous ntimicrobils, historiclly requiring inptient cre, lthough newer pproches include primry mngement with orl ntimicrobils. Anlysis of HCUP dt for women dmitted to the hospitl for primry dignosis of pyelonephritis indictes tht there ws grdul decline in the rte of dmissions between 1994 nd 2000 (Tble 10). Pyelonephritis ccounted for 28% of the femle UTI hospitliztions in 1994 nd 21% in The overll rte of dmissions for pyelonephritis mong women grdully declined from 65 per 100,000 (95% CI, 62 68) in 1994 to 49 per 100,000 (95% CI, 46 51) in This trend is reflected cross essentilly ll ge strt nlyzed. It likely reflects incresed use of orl 598

13 Urinry Trct Infection in Women Tble 9. Inptient hospitl stys by dult femles with urinry trct infection (ny ntomic loction) listed s primry dignosis, count, rte (95% CI) Count Rte Count Rte Count Rte Count Rte Totl b 223, ( ) 235, ( ) 243, ( ) 245, ( ) , ( ) 15, ( ) 13, ( ) 12, (87 99) , (99 113) 20, (92 105) 17, (83 94) 15, (76 87) , (80 90) 18, (80 89) 17, (75 84) 17, (71 79) , (93 105) 15, (88 100) 15, (85 94) 16, (85 93) , ( ) 17, ( ) 17, ( ) 18, ( ) , ( ) 34, ( ) 36, ( ) 34, ( ) , ( ) 59, ( ) 64, ( ) 66, ( ) ,844 2,593 (2,477 2,709) 54,984 2,844 (2,725 2,962) 60,618 3,162 (3,038 3,286) 64,584 3,078 (2,975 3,182) Rce/ethnicity White 131, ( ) 139, ( ) 136, ( ) 137, ( ) Blck 26, ( ) 28, ( ) 24, ( ) 23, ( ) Asin/Pcific Islnder 1, (55 80) 1, (48 64) 2, (48 80) 3, (73 92) Hispnic 12, ( ) 14, ( ) 15, ( ) 16, ( ) MSA Midwest 48, ( ) 51, ( ) 54, ( ) 52, ( ) Northest 47, ( ) 44, ( ) 47, ( ) 47, ( ) South 92, ( ) 98, ( ) 101, ( ) 103, ( ) West 34, ( ) 39, ( ) 40, ( ) 42, ( ) Rurl 52, ( ) 55, ( ) 55, ( ) 57, ( ) Urbn 170, ( ) 178, ( ) 187, ( ) 187, ( ) MSA, metropolitn sttisticl re. Rte per 100,000 bsed on 1994, 1996, 1998, 2000 popultion estimtes from Current Popultion Survey (CPS), CPS Utilities, Unicon Reserch Corportion, for relevnt demogrphic ctegories of US femle dult civilin non-institutionlized popultion. b Persons of other rces, missing or unvilble rce nd ethnicity, nd missing MSA re included in the totls. NOTE: Counts my not sum to totls due to rounding. SOURCE: Helthcre Cost nd Utiliztion Project Ntionwide Inptient Smple, 1994, 1996, 1998,

14 Urologic Diseses in Americ Tble 10. Inptient hospitl stys by dult femles with pyelonephritis listed s primry dignosis, count, rte (95% CI) Count Rte Count Rte Count Rte Count Rte Totl b 62, (62 68) 61, (59 65) 54, (51 56) 50, (46 51) , (90 104) 11, (83 95) 9, (71 82) 8, (60 70) , (67 76) 13, (61 70) 11, (52 60) 9, (46 54) , (45 51) 10, (44 50) 9, (39 45) 8, (36 41) , (41 49) 7, (40 47) 6, (34 39) 6, (32 36) , (44 52) 5, (44 53) 4, (38 43) 4, (37 43) , (59 71) 6, (58 69) 5, (53 62) 5, (49 58) , (79 94) 5, (80 96) 5, (74 87) 4, (66 79) 85+ 2, ( ) 2, ( ) 2, ( ) 2, ( ) Rce/ethnicity White 34, (45 51) 33, (43 47) 28, (36 40) 25, (32 35) Blck 7, (60 74) 7, (59 70) 5, (40 48) 4, (33 40) Asin/Pcific Islnder (22 33) (15 22) (15 29) (18 28) Hispnic 4, (50 64) 5, (47 72) 5, (44 61) 5, (42 55) MSA Midwest 14, (56 66) 13, (54 65) 11, (46 55) 11, (44 52) Northest 11, (51 61) 10, (46 56) 9, (41 53) 8, (36 43) South 24, (67 81) 24, (62 73) 21, (55 63) 19, (50 58) West 12, (55 68) 13, (57 74) 12, (50 60) 11, (44 54) Rurl 15, (56 70) 14, (58 71) 13, (54 63) 12, (49 57) Urbn 46, (62 68) 47, (57 64) 41, (49 55) 38, (45 50) MSA, metropolitn sttisticl re. Rte per 100,000 bsed on 1994, 1996, 1998, 2000 popultion estimtes from Current Popultion Survey (CPS), CPS Utilities, Unicon Reserch Corportion, for relevnt demogrphic ctegories of US femle dult civilin non-institutionlized popultion. b Persons of other rces, missing or unvilble rce nd ethnicity, nd missing MSA re included in the totls. NOTE: Counts my not sum to totls due to rounding. SOURCE: Helthcre Cost nd Utiliztion Project Ntionwide Inptient Smple, 1994, 1996, 1998,

15 Urinry Trct Infection in Women Tble 11. Trends in men inptient length of sty (dys) for dult femles hospitlized with urinry trct infection listed s primry dignosis Length of Sty Totl Rce/ethnicity White Blck Asin/Pcific Islnder Hispnic Other MSA Midwest Northest South West Rurl Urbn Primry pyor Medicre Medicid Privte insurnce/hmo Self-py No chrge * Other *Figure does not meet stndrd for relibility or precision. MSA, metropolitn sttisticl re; HMO, helth mintennce orgniztion. SOURCE: Helthcre Cost nd Utiliztion Project Ntionwide Inptient Smple, 1994, 1996, 1998, ntimicrobils nd home-bsed intrvenous therpy in the tretment of women with pyelonephritis. The decline in ge-undjusted rtes of hospitliztion for women with pyelonephritis ws most noticeble in Africn Americn nd Cucsin women. Rtes were reltively stble in Hispnic nd Asin women. Rtes of hospitliztion declined in ll geogrphic res, nd no distinct regionl differences were noted. The overll length of hospitl sty of women who require inptient hospitliztion for the mngement of UTI hs decresed, consistent with the generl trend towrd decresed length of sty (LOS) for ll conditions (Tble 11). Ntionwide HCUP dt revel tht the men LOS for women with UTI decresed from 6.2 dys in 1994 to 4.9 dys in This trend ws seen cross ll ge groups, lthough elderly women continued to hve somewht greter LOS thn younger women, probbly due to the moresevere infections or ssocited comorbidity in older dults. The decrese in LOS ws more pronounced for women who hve Medicre or Medicid s their primry insurer thn it ws for women with either privte insurnce or HMO coverge. Outptient Cre Outptient cre for UTI is provided in vriety of settings, which re nlyzed seprtely below. Hospitl Outptient Cre The overll rte of hospitl outptient visits for women with UTI generlly incresed from 1994 to 2000, ccording to dt from the Ntionl Hospitl Ambultory Medicl Cre Survey (NHAMCS), both when UTI ws listed s the primry dignosis (Tble 12) nd when UTI ws listed s one of ny dignoses t the time of visit (Tble 13). The most striking increses were observed in young women 18 to 34 yers of ge. Overll rtes of hospitl outptient visits by young women for ny reson were 1.64 times greter in 2000 thn they were in Rce/ethnicity ppers to ply some role in the rte of outptient visits for UTI: Hispnic nd Africn Americn women hd higher ge-undjusted visit rtes where relible estimtes re vilble. Some regionl fluctutions were noted, but no consistent trends were observed. Rtes of outptient hospitl visits for femle UTI hve been generlly stble in metropolitn sttisticl res (MSAs), tht is, urbn settings, but hve been 601

16 Urologic Diseses in Americ Tble 12. Hospitl outptient visits by dult femles with urinry trct infection listed s primry reson for visit, count, rte (95% CI) Count Rte Count Rte Count Rte Count Rte Totl b 432, ( ) 358, ( ) 563, ( ) 559, ( ) , ( ) 135, ( ) 181, ( ) 233, ( ) , ( ) 128, ( ) 228, ( ) 212, ( ) 65+ * * * 517 (73 961) 152, (497 1,152) 113, ( ) Rce/ethnicity White 279, ( ) 250, ( ) 420, ( ) 445, ( ) Blck * * * 386 ( ) * * * * Hispnic * * 60, (294 1,041) 62, (269 1,006) * * MSA Midwest 181, (403 1,180) * * * * 194, (494 1,139) Northest 52, ( ) 69, ( ) 160, (488 1,094) 102, ( ) South 147, ( ) 69, ( ) 252, ( ) 181, ( ) West 50, ( ) 64, ( ) * * * * MSA 318, ( ) 293, ( ) 372, ( ) 309, ( ) Non-MSA * * * * 190, (568 1,092) 250,006 1,084 (690 1,479) *Figure does not meet stndrd for relibility or precision. MSA, metropolitn sttisticl re. Rte per 100,000 bsed on 1994, 1996, 1998, 2000 popultion estimtes from Current Popultion Survey (CPS), CPS Utilities, Unicon Reserch Corportion, for relevnt demogrphic ctegories of US femle dult civilin non-institutionlized popultion. b Persons of other rces re included in the totls. NOTE: Counts my not sum to totls due to rounding. SOURCE: Ntionl Hospitl Ambultory Medicl Cre Survey Outptient, 1994, 1996, 1998,

17 Urinry Trct Infection in Women Tble 13. Hospitl outptient visits by dult femles with urinry trct infection listed s ny reson for visit, count, rte (95% CI) Count Rte Count Rte Count Rte Count Rte Totl b 568, ( ) 566, ( ) 784, ( ) 816, ( ) , ( ) 215, ( ) 296, (673 1,161) 349,866 1,079 (776 1,382) , ( ) 213, ( ) 281, ( ) 282, ( ) , ( ) * * 206,512 1,113 (714 1,512) 184, (537 1,428) Rce/ethnicity White 375, ( ) 361, ( ) 564, ( ) 613, ( ) Blck 75, ( ) 92, (425 1,114) 92, (371 1,108) 110, (377 1,345) Hispnic * * 103,775 1,151 (614 1,687) 115,176 1,179 (664 1,694) 85, (330 1,264) MSA Midwest 236,759 1,031 (610 1,452) 245,751 1,045 (571 1,520) 128, ( ) 281,994 1,183 (787 1,580) Northest 80, ( ) 133, ( ) 233,853 1,154 (787 1,521) 177, (467 1,248) South 195, ( ) 104, ( ) 313, (623 1,106) 238, ( ) West 55, ( ) 83, ( ) 108, ( ) 118, ( ) MSA 432, ( ) 470, ( ) 566, ( ) 496, ( ) Non-MSA 135, ( ) * * 217, (669 1,230) 319,806 1,387 (950 1,824) *Figure does not meet stndrd for relibility or precision. MSA, metropolitn sttisticl re. Rte per 100,000 bsed on 1994, 1996, 1998, 2000 popultion estimtes from Current Popultion Survey (CPS), CPS Utilities, Unicon Reserch Corportion, for relevnt demogrphic ctegories of US femle dult civilin non-institutionlized popultion. b Persons of other rces re included in the totls. NOTE: Counts my not sum to totl due to rounding. SOURCE: Ntionl Hospitl Ambultory Medicl Cre Survey Outptient, 1994, 1996, 1998,

18 Urologic Diseses in Americ Tble 14. Outptient hospitl visits by femle Medicre beneficiries with urinry trct infection listed s primry dignosis, count, rte b (95% CI) Count Rte Count Rte Count Rte Totl 78, ( ) 157, ( ) 204,360 1,072 (1,068 1,077) Totl < 65 8, ( ) 21, ( ) 28,620 1,030 (1,019 1,042) Totl , ( ) 135, ( ) 175,740 1,080 (1075 1,085) , ( ) 64, ( ) 74, ( ) , ( ) 50, ( ) 70,680 1,210 (1,201 1,219) , ( ) 18, ( ) 28,000 1,259 (1,244 1,273) ( ) 1, ( ) 2, ( ) Rce/ethnicity White 60, ( ) 126, ( ) 169,320 1,047 (1,042 1,052) Blck 11, ( ) 20,240 1,100 (1,085 1,115) 20,080 1,138 (1,123 1,154) Asin ( ) ( ) Hispnic 2,760 1,374 (1,323 1,424) 6,240 1,698 (1,656 1,740) N. Americn Ntive 1,360 8,416 (7,989 8,843) 2,320 8,896 (8,551 9,241) Midwest 23, ( ) 42, ( ) 59,980 1,216 (1,206 1,226) Northest 15, ( ) 20, ( ) 25, ( ) South 27, ( ) 72,820 1,008 (1,001 1,015) 90,520 1,290 (1,282 1,298) West 11, ( ) 21, ( ) 27,640 1,017 (1,005 1,029) dt not vilble. Unweighted counts multiplied by 20 to rrive t vlues in the tble. b Rte per 100,000 Medicre beneficiries in the sme demogrphic strtum. c Persons of other rces, unknown rce nd ethnicity, nd other region re included in the totls. NOTE: Counts less thn 600 should be interpreted with cution. SOURCE: Centers for Medicre nd Medicid Services, 5% Crrier nd Outptient Files, 1992, 1995, ,000,000 6,000,000 5,000, Count 4,000,000 3,000,000 2,000,000 1,000, Hospitl Outptient Physicin Office Emergency Room Figure 3. Trends in visits by femles for urinry trct infection by ptient ge nd site of service. SOURCE: Ntionl Hospitl Ambultory Medicl Cre Survey (hospitl outptient nd emergency room); Ntionl Ambultory Medicl Cre Survey (physicin office). 604

19 Urinry Trct Infection in Women Tble 15. Physicin office visits by dult femles with urinry trct infection listed s primry reson for visit, count, rte (95% CI) Count Rte Count Rte Count Rte Totl 5,665,211 5,867 (4,766 6,968) 5,205,024 5,403 (4,513 6,292) 4,340,795 4,324 (3,493 5,156) ,167,103 6,431 (4,314 8,549) 1,502,309 4,562 (3,255 5,869) 895,243 2,718 (1,749 3,687) ,171,942 4,819 (3,391 6,248) 2,147,659 4,691 (3,413 5,969) 1,983,960 4,045 (2,874 5,217) 65+ 1,326,166 7,454 (4,906 10,001) 1,555,056 8,819 (6,236 11,403) 1,461,592 7,943 (5,146 10,741) MSA Midwest 1,200,957 5,206 (3,157 7,255) 841,952 3,667 (2,385 4,948) 1,013,390 4,310 (2,460 6,159) Northest 864,968 4,280 (2,362 6,199) 981,042 4,838 (2,927 6,750) 769,391 3,827 (2,271 5,383) South 2,437,343 7,295 (5,264 9,326) 2,042,634 6,231 (4,656 7,806) 1,386,711 3,889 (2,626 5,152) West 1,161,943 5,848 (3,112 8,584) 1,339,396 6,590 (4,227 8,953) 1,171,303 5,550 (3,392 7,707) MSA 3,985,675 5,535 (4,377 6,694) 4,447,400 6,164 (5,074 7,253) 3,340,574 4,293 (3,351 5,235) Non-MSA 1,679,536 6,841 (4,157 9,525) * * 1,000,221 4,432 (2,662 6,202) Specilty Urology 1,103,291 1,143 (929 1,356) 731, ( ) 780, ( ) GFP 2,357,447 2,441 (1,599 3,284) 2,277,566 2,364 (1,702 3,026) 1,861,398 1,854 (1,261 2,447) All others 2,204,473 2,283 (1,623 2,943) 2,195,587 2,279 (1,711 2,847) 1,699,374 1,693 (1,151 2,234) Totl 5,288,958 5,169 (4,050 6,288) 6,300,754 6,013 (4,840 7,186) * * 1,361,644 4,200 (2,479 5,921) ,738,069 5,325 (3,672 6,978) 3,015,698 5,624 (4,046 7,201) 65+ 1,313,974 7,081 (4,056 10,105) 1,923,412 10,265 (6,551 13,979) MSA Midwest * * 1,377,591 5,781 (3,377 8,186) Northest * * 1,344,803 6,514 (3,837 9,192) South 2,158,702 5,948 (4,030 7,865) 1,963,660 5,290 (3,449 7,131) West * * 1,614,700 6,963 (4,202 9,724) MSA 3,879,002 4,888 (3,640 6,136) 4,630,497 5,666 (4,388 6,944) Non-MSA 1,409,956 6,143 (3,642 8,645) 1,670,257 7,245 (4,437 10,053) Specilty Urology 547, ( ) 783, ( ) GFP 2,388,058 2,334 (1,569 3,099) 2,821,067 2,692 (1,815 3,569) All others 2,352,946 2,300 (1,505 3,094) 2,696,298 2,573 (1,826 3,320) GFP, generl nd fmily prctice; MSA, metropolitn sttisticl re. *Figure does not meet stndrd for relibility or precision. Rte per 100,000 bsed on 1992, 1994, 1996, 1998, 2000 popultion estimtes from Current Popultion Survey (CPS), CPS Utilities, Unicon Reserch Corportion, for relevnt demogrphic ctegories of US femle dult civilin non-institutionlized popultion. NOTE: Counts my not sum to totls due to rounding. SOURCE: Ntionl Ambultory Medicl Cre Survey, 1992, 1994, 1996, 1998,

20 Urologic Diseses in Americ Tble 16. Physicin office visits by dult femles with urinry trct infection listed s ny reson for visit, count, rte (95% CI) Count Rte Count Rte Count Rte Totl 7,302,802 7,563 (6,307 8,819) 6,505,167 6,752 (5,757 7,747) 6,295,860 6,272 (5,276 7,268) ,564,452 7,610 (5,280 9,941) 1,800,179 5,466 (3,963 6,970) 1,737,586 5,275 (3,765 6,786) ,775,830 6,159 (4,523 7,795) 2,591,923 5,662 (4,286 7,037) 2,509,412 5,117 (3,817 6,417) 65+ 1,962,520 11,030 (7,900 14,161) 2,113,065 11,984 (8,999 14,969) 2,048,862 11,135 (7,941 14,329) MSA Midwest 1,462,687 6,341 (4,114 8,567) 1,264,608 5,507 (3,746 7,269) 1,562,287 6,644 (4,413 8,876) Northest 1,232,828 6,101 (3,698 8,503) 1,247,926 6,155 (3,936 8,373) 939,584 4,673 (2,873 6,473) South 2,909,465 8,708 (6,485 10,931) 2,357,740 7,193 (5,516 8,869) 2,301,628 6,455 (4,806 8,104) West 1,697,822 8,545 (5,284 11,805) 1,634,893 8,044 (5,583 10,504) 1,492,361 7,071 (4,715 9,427) MSA 5,010,454 6,958 (5,651 8,266) 5,526,106 7,659 (6,438 8,880) 4,828,440 6,205 (5,086 7,325) Non-MSA 2,292,348 9,337 (6,223 12,451) 979,061 4,047 (2,488 5,607) 1,467,420 6,502 (4,329 8,675) Specilty Urology 1,280,128 1,326 (1,104 1,547) 849, (731 1,031) 895, (696 1,089) GFP 3,022,128 3,130 (2,185 4,075) 2,840,667 2,948 (2,210 3,686) 2,629,808 2,620 (1,915 3,324) Intern. Med. 1,208,039 1,251 (720 1,782) 1,442,635 1,497 (986 2,009) 1,344,616 1,340 (842 1,837) All other 1,792,507 1,856 (1,286 2,427) 1,372,789 1,425 (1,046 1,804) 1,425,731 1,420 (981 1,859) Totl 7,645,826 7,473 (6,146 8,800) 8,150,279 7,778 (6,464 9,093) ,025,391 6,263 (4,184 8,342) 1,875,092 5,784 (3,776 7,792) ,431,071 6,673 (4,874 8,472) 3,693,141 6,887 (5,146 8,628) 65+ 2,189,364 11,798 (7,849 15,747) 2,582,046 13,780 (9,635 17,925) MSA Midwest 1,689,897 7,111 (4,244 9,979) 1,572,822 6,601 (4,145 9,057) Northest * * 1,615,468 7,826 (4,949 10,702) South 3,401,109 9,371 (6,980 11,762) 2,486,626 6,699 (4,670 8,728) West 1,812,256 8,241 (5,090 11,391) 2,475,363 10,674 (7,242 14,106) MSA 6,001,991 7,563 (6,033 9,092) 6,242,476 7,638 (6,116 9,113) Non-MSA 1,643,835 7,162 (4,509 9,816) 1,907,803 8,275 (5,380 11,170) Specilty Urology 704, ( ) 1,077,581 1,028 (785 1,272) GFP 3,377,733 3,301 (2,396 4,207) 3,569,977 3,407 (2,437 4,377) Intern. Med. 2,335,343 2,283 (1,494 3,071) 1,914,448 1,827 (1,171 2,483) All other * * 1,588,273 1,516 (1,001 2,031) GFP, generl nd fmily prctice; MSA, metropolitn sttisticl re. *Figure does not meet stndrd for relibility or precision. Rte per 100,000 bsed on 1992, 1994, 1996, 1998, 2000 popultion estimtes from Current Popultion Survey (CPS), CPS Utilities, Unicon Reserch Corportion, for relevnt demogrphic ctegories of US femle dult civilin non-institutionlized popultion. NOTE: Counts my not sum to totls due to rounding. SOURCE: Ntionl Ambultory Medicl Cre Survey, 1992, 1994, 1996, 1998,

21 Urinry Trct Infection in Women Tble 17. Physicin office visits by femle Medicre beneficiries with urinry trct infection listed s primry dignosis, count, rte b (95% CI) Count Rte Count Rte Count Rte Totl c 1,568,800 7,918 (7,907 7,930) 1,740,660 8,625 (8,613 8,638) 1,585,360 8,319 (8,307 8,332) Totl < ,780 4,303 (4,277 4,329) 145,780 5,425 (5,398 5,453) 144,520 5,204 (5,177 5,230) Totl 65+ 1,466,020 8,414 (8,401 8,427) 1,594,880 9,117 (9,103 9,130) 1,440,840 8,851 (8,837 8,865) ,880 7,843 (7,826 7,861) 767,800 8,530 (8,512 8,548) 641,100 8,113 (8,094 8,132) ,020 9,681 (9,657 9,705) 619,480 10,348 (10,324 10,373) 599,440 10,261 (10,236 10,285) ,460 7,970 (7,933 8,007) 197,260 8,871 (8,834 8,909) 189,900 8,536 (8,499 8,573) 95+ 8,660 3,359 (3,289 3,428) 10,340 3,652 (3,582 3,721) 10,400 3,352 (3,288 3,415) Rce/ethnicity White 1,403,820 8,363 (8,350 8,377) 1,555,680 8,965 (8,952 8,979) 1,403,340 8,674 (8,660 8,688) Blck 95,360 5,655 (5,621 5,690) 102,840 5,590 (5,557 5,624) 91,440 5,183 (5,150 5,216) Asin 8,480 8,983 (8,801 9,165) 12,740 7,200 (7,080 7,321) Hispnic 26,300 13,090 (12,942 13,237) 42,340 11,520 (11,417 11,623) N. Americn Ntive 1,080 6,683 (6,300 7,067) 1,400 5,368 (5,096 5,640) Midwest 364,120 7,255 (7,232 7,278) 394,540 7,652 (7,629 7,675) 358,200 7,261 (7,238 7,284) Northest 250,720 5,532 (5,511 5,553) 270,300 6,015 (5,993 6,037) 244,060 6,230 (6,206 6,253) South 710,66010,170 (10,148 10,193) 782,420 10,829 (10,807 10,852) 717,800 10,229 (10,206 10,251) West 218,240 7,654 (7,623 7,685) 257,100 8,979 (8,946 9,012) 228,500 8,407 (8,374 8,440) dt not vilble. Unweighted counts multiplied by 20 to rrive t vlues in the tble. b Rte per 100,000 Medicre beneficiries in the sme demogrphic strtum. c Persons of other rces, unknown rce nd ethnicity, nd other region re included in the totls. NOTE: Counts less thn 600 should be interpreted with cution. SOURCE: Centers for Medicre nd Medicid Services, 5% Crrier nd Outptient Files, 1992, 1995, incresing cutely in non-msa, or rurl, settings. This my reflect incresed vilbility of hospitl-bsed outptient services in nonmetropolitn res. An nlysis of Medicre dt for the yers 1992, 1995, nd 1998 lso reflects the trend towrd incresed hospitl outptient utiliztion for the mngement of femle UTIs (Tble 14). The overll utiliztion rte cross ll ges ws 395 per 100,000 (95% CI, ) in It rose to 780 per 100,000 (95% CI, ) in 1995, nd to 1,072 per 100,000 (95% CI, 1,068 1,077) in These trends were similr when strtified by ge (< 65 or 65 yers). Very elderly women ( 95 yers) hd the smllest overll increse in hospitl outptient utiliztion, which corresponds to the lrger increse in inptient hospitliztion previously described for this ge group. Physicin Office Cre The outptient physicin office is the most widely utilized site of service for the tretment of femle UTIs (Figure 3). According to dt from the Ntionl Ambultory Medicl Cre Survey (NAMCS), there were more thn 6,300,000 physicin office visits for primry dignosis of femle UTI in the United Sttes in 2000 (Tble 15). The rtes of utiliztion hve remined reltively stble for ll ptients when UTI is mong ny of the resons listed for the visit (Tble 16), but they incresed between 1996 nd 2000 when UTI ws the primry dignosis (Tble 15). These increses in physicin outptient services occurred in the 35 to 64 nd 65 yer old ge groups, but not in 18- to 34- yer-old groups. l vritions were observed during the yers nlyzed, with generlly higher 607