Evidence-Based Evaluation and Treatment of UTI UTI Prevalence Leslee L. Subak, MD Associate Professor Obstetrics, Gynecology & RS Epidemiology & Biostatistics University of California, San Francisco 50% of women 0.5 UTI s / sexually active woman / year 8 million physician visits/year > 1 million hospitalizations / year $2 billion / year UTI Risk Factors Think UTI Younger women: Sexual intercourse Spermicide use +/- diaphragm use Recent UTI Pregnancy Older women: Diabetes, insulin Rx Lifetime h/o UTI Nursing home functional/mental status Bladder catheter Neurogenic bladder > 90% probability UTI Dysuria, frequency No vaginal discharge Unlikely UTI Vaginal discharge / irritation Bent JAMA 2002 1
UTI Microbiology Ascending infection E. coli (85%) Staph. saprophyticus (5-20%) Older women non - E. coli Dipstick Urine Analysis Leukocytes - most valuable Blood - common LE + or Nitrite + Sensitivity: 75% Specificity: 85% LE - and Nitrite - Neg predictive value: 95% Hurlbut 1991; Deville 2004; Wilson 2004 UTI Diagnosis Cost-effectiveness analysis Empiric Abx, dipstick UA, Cx Empiric Abx most cost-effective Dipstick UA if: Cost of Abx > $74 Prior probability of UTI < 30% Barry 1997; Fenwick 2000 Urine Culture Usually not needed Atypical symptoms Persistent symptoms/new Rx Fever, chills, flank pain Pregnancy Positive if 10 2 + symptoms Post treatment TOC not needed 2
Urine Culture Technique 242 women with UTI Sx randomized - Simple urination, clean container - Clean-catch, midstream urination - Above plus tampon in vagina Contamination rates for 3 groups the same (30%) Lifshitz 2000 Telephone Management RCT 72 women with suspected UTI - Telephone group: empiric Rx (N=36) - Office group: seen by MD (N=36) All had UA and culture TMP/SMZ (nitrofuratoin) x 7 days Barry et al. J Fam Pract 2001 Exclusion Criteria Sx or Hx of pyelonephritis New vaginal discharge Diabetes STI UTI or ABX within 1 month Sx > 14 days Hx kidney disease, renal surgery or chemotherapy Barry et al. J Fam Pract 2001 Outcomes Office Telephone Urine Culture + 68% 61% UTI Score - baseline 30 30 - day 3 7 7 - day 10 3 2 Barry et al. J Fam Pract 2001 3
UTI Treatment Symptomatic, uncomplicated UTI 1. Empiric TMP-SMX DS x 3 days If TMP/SMX resistance > 20% 2. Nitrofurantoin (Macrobid) x 7 days 3. Ciprofloxacin 250 mg BID x 3 days Warren 1999; Hooton 2003 TMP-SMX Resistance Western US: 22% Eastern US: 10% Consider TMP-SMX: No prior failure Call if no change Consider Fluoroquinolone-sparing: Nitrofurantoin Gupta 2001; Hooton 2004; Warren 1999 UCSF Antibiotic Resistance Outpatient urine samples E. Coli resistance: 2001 2005 TMP-SMZ 25% 30% Ciprofloxaxin 10% 20% Cefazolin 5% 11% Nitrofurantoin 5% 2% UTI Treatment Literature review of effectiveness 3 d more effective than 1 dose 3 d and > 7 d are similar Nitrofurantoin - 7 d course Warren 1999; Cochrane 2005; Katchman 2005 4
UTI Treatment UTI Treatment LITERATURE REVIEW OF EFFECTIVENESS Rx (3 d course) Eradication Recurrence Adverse Effects TMP/SMZ DS 94 13 28 Ciprofloxacin 95 14 23 Norfloxacin 95 14 17-29 Ofloxacin 95 8 23 Cefadroxil 100 34* 30 Amoxicilin 86* 19 25 * p < 0.05 compared to TMP/SMZ, fluoroquinolones Older women: 7-day course Complicated: 7-day fluoroquinolone sx or h/o pyelo, DM, pregnancy, immunosupression, sx > 14 days, urinary tract anomaly Pyridium 200 mg TID x 3 d for dysuria Hydration - no evidence Cranberry juice - no evidence Warren 1999 Recurrent UTI 3 infections per year 4% of women Re-infection rather than relapse > 2 weeks Does not lead to health problems Reassure patient Urologic Work Up Rarely indicated Proteus: Think stones R/O nephrolithiasis Spiral CT or renal U/S 5
Etiology Vaginal colonization Adherence to uroepi cells Genetic determinants Spermicide New sexual partner Recurrent UTI Pathology: same as acute cystitis Diagnosis: urine culture Rarely serious, easy treatment Recurrent UTI Treatment Treat infection for 7 days Key: Prevent recurrent infections Patient-initiated initiated therapy for Sx Abx prophylaxis with coitus Low dose, continuous abx prophylaxis What would you like to do? Post Coital Rx Discontinue spermicidal agents Prophylaxis after intercourse RCT of post-coital vs. daily Cipro Equal efficacy Post-coital Rx used 2/3 less drug Melekos 1997 6
Daily Prophylaxis Long-term prophylaxis x 6 months Decreased UTI vs. placebo TMP/SMZ SS Nitrofurantoin 50 mg Cephalexin 125 mg Can consider 1-2 yrs Recurrent UTI - Older women Postmenopausal intravaginal estrogen Effective prophylaxis Improved cytologic maturation Acidifies vagina Changes vaginal flora Stapelton 1997 Griebling 1997 Postmenopausal Vaginal Estrogen RCT, Recurrent UTI, N=93 E3 Vaginal Cream Placebo Cream UTIs/woman / year 0.5 5.9 Days Abx use/woman 6.9 32.0 Vaginal lactobacililli 61% 0% Mean vaginal ph 3.8 5.5 Vaginal E. coli 31% 63% Raz NEJM 1993 Vaginal Estrogen RCT of Estring, 108 women, recurrent UTI Significantly fewer UTI s More women UTI-free Lower vaginal ph Eriksen 1999 7
Asymptomatic Bacteriuria 3-6% sexually active women risk with age, diabetes, catheter 2 consecutive clean catch specimens > 10 5 cfu/ml Same strain of bacteria Asymptomatic Bacteriuria Screening is NOT recommended - Including older age, DM, institutionalized, spinal cord injury, indwelling catheter DO Screen: Pregnant women Nicolle 2005 Nicolle 2005 Asymptomatic Bacteriuria No treatment needed Rx doesn t: Prevent symptomatic UTI Improve urinary function Improve survival Treat in pregnancy, diabetes ISDA 2005 Summary UTI: Think STI. Diagnosis by history Consider nitrofurantoin Recurrent UTI: Reassure Patient preference for Rx Asymptomatic bacteriuria No screening or Rx 8