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AUA & CUA Recurrent UTI (2019): Difference between revisions

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'''See [https://pubmed.ncbi.nlm.nih.gov/31042112/ Original Guideline]'''
'''See [https://pubmed.ncbi.nlm.nih.gov/31042112/ Original Guideline]'''
*This guideline only describes diagnosis and treatment of recurrent episodes of UNCOMPLICATED cystitis in women.
** “Uncomplicated” means that the patient has no known factors that would make her more susceptible to develop a UTI, while '''“complicated” indicates infection with multi-drug resistant bacteria or presence of risk factor(s)''' for UTI and decreased treatment efficacy.
*** '''See from [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202002/table/t1-cuaj-5-316/ Table 1] from 2011 CUA Guideline on Recurrent UTI for host factors that classify a urinary tract infection as complicated'''
* '''The index patient for this guideline is an otherwise healthy adult female with an uncomplicated rUTI'''. The infection is culture-proven and associated with acute-onset symptoms. This guideline does not apply to complicated UTI or those exhibiting signs or symptoms of systemic bacteremia, such as fever and flank pain.


== Background ==
== Background ==
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* ≈60% of females will experience at least 1 symptomatic episode of acute bacterial cystitis in their lifetime. Of these, 20-40% will experience at least 1 other episode, of which 25-50% of whom will experience multiple recurrent episodes.
* ≈60% of females will experience at least 1 symptomatic episode of acute bacterial cystitis in their lifetime. Of these, 20-40% will experience at least 1 other episode, of which 25-50% of whom will experience multiple recurrent episodes.


== Definitions ==
== Acute Bacterial Cystitis ==
* '''<span style="color:#ff0000">Diagnosis of acute bacterial cystitis requires (2):</span>'''
 
=== Definition ===
*'''<span style="color:#ff0000">Diagnosis of acute bacterial cystitis requires (2):</span>'''
*# '''<span style="color:#ff0000">Laboratory confirmation of significant bacteriuria AND</span>'''
*# '''<span style="color:#ff0000">Laboratory confirmation of significant bacteriuria AND</span>'''
*# '''<span style="color:#ff0000">Acute-onset symptoms (lower urinary tract symptoms).</span>'''
*# '''<span style="color:#ff0000">Acute-onset symptoms (lower urinary tract symptoms)</span>'''
** '''<span style="color:#ff0000">Laboratory confirmation</span>'''
*In this guideline, the term UTI will refer to culture-proven acute bacterial cystitis and associated symptoms unless otherwise specified.
*** '''Urine culture remains the mainstay of diagnosis of an episode of acute cystitis'''
 
**** '''Clinical judgment is needed to determine when a culture result represents clinically significant bacteriuria''' considering the patient presentation, urine collection method, and the presence of other suggestive factors such as pyuria.
=== Diagnosis and Evaluation ===
***** '''<span style="color:#ff0000">The definition for clinically significant bacteriuria of >10<sup>5</sup> colony forming units (CFU)/mL represents an arbitrary cut-off.</span>'''
 
***** '''Although > 10<sup>5</sup> CFU/mL for bacterial growth on midstream voided urine''' '''may help distinguish bladder bacteriuria from contamination in asymptomatic, pre-menopausal women,''' '''<span style="color:#ff0000">a lower 10<sup>2</sup> CFU/mL threshold may be appropriate in symptomatic individuals</span>'''
==== History and Physical Exam ====
* '''History'''
** '''<span style="color:#ff0000">Symptoms</span>'''
** '''<span style="color:#ff0000">Symptoms</span>'''
*** '''<span style="color:#ff0000">Urinary tract infection symptoms include dysuria, central to the diagnosis of UTI, with variable degrees of:</span>'''
*** '''<span style="color:#ff0000">Urinary tract infection symptoms include dysuria, central to the diagnosis of UTI, with variable degrees of:</span>'''
**** <span style="color:#ff0000">Increased urinary urgency and frequency</span>
***# <span style="color:#ff0000">'''Increased urinary urgency and frequency'''</span>
**** <span style="color:#ff0000">Hematuria</span>
***# <span style="color:#ff0000">'''Hematuria'''</span>
**** <span style="color:#ff0000">Suprapubic pain</span>
***# <span style="color:#ff0000">'''Suprapubic pain'''</span>
**** <span style="color:#ff0000">New or worsening incontinence</span>
***# <span style="color:#ff0000">'''New or worsening incontinence'''</span>
*** '''<span style="color:#ff0000">In older adults, the symptoms of UTI may be less clear.</span>'''
*** '''<span style="color:#ff0000">In older adults, the symptoms of UTI may be less clear.</span>'''
**** Given the subjective nature of these symptoms, '''careful evaluation of their chronicity becomes an important consideration.'''
**** Given the subjective nature of these symptoms, '''careful evaluation of their chronicity becomes an important consideration.'''
***** Older females frequently have nonspecific symptoms that may be perceived as a UTI, such as dysuria, cloudy urine, vaginal dryness, vaginal/perineal burning, bladder or pelvic discomfort, urinary frequency and urgency, or urinary incontinence, but these tend to be more chronic
***** Older females frequently have nonspecific symptoms that may be perceived as a UTI, such as dysuria, cloudy urine, vaginal dryness, vaginal/perineal burning, bladder or pelvic discomfort, urinary frequency and urgency, or urinary incontinence, but these tend to be more chronic
***** '''Acute-onset dysuria, particularly when associated with new or worsening storage symptoms, remains a reliable diagnostic criterion in older females''' living both in the community and in long-term care facilities.
***** '''Acute-onset dysuria, particularly when associated with new or worsening storage symptoms, remains a reliable diagnostic criterion in older females''' living both in the community and in long-term care facilities.
*** '''Without symptoms, bacteriuria of any magnitude is considered asymptomatic bacteriuria'''
**** '''DO NOT treat asymptomatic bacteriuria'''
***** No evidence that treatment of asymptomatic bacteriuria improves outcomes
***** '''Indications for screening/treatment of asymptomatic bacteriuria (2):'''
*****# '''Pregnant women'''
*****# '''Patients undergoing elective urologic surgery'''
*****# '''[Neonatal candiduria, not technically bacteruria but should be treated even if asymptomatic]'''
***** '''Asymptomatic bacteriuria and struvite stones'''
****** '''Routine treatment of urease-producing bacteriuria in the absence of UTI symptoms or documented urinary tract stones is not recommended'''
****** There is no clear evidence that identification and treatment of asymptomatic bacteriuria caused by urease-producing organisms (recall that urease-producing organisms include proteus, pseudomonas, klebsiella, mycoplasma, and staphylococcus) prevents struvite stone formation. However, '''in certain patients with recurrent struvite stones, screening for and treating urease-producing bacteriuria may be indicated if other measures have not been able to prevent stone formation.'''
* In this guideline, the term UTI will refer to culture-proven acute bacterial cystitis and associated symptoms unless otherwise specified.
*This guideline only describes diagnosis and treatment of recurrent episodes of UNCOMPLICATED cystitis in women.
** “Uncomplicated” means that the patient has no known factors that would make her more susceptible to develop a UTI, while '''“complicated” indicates infection with multi-drug resistant bacteria or presence of risk factor(s)''' for UTI and decreased treatment efficacy.
*** '''See from Table 1 from 2011 CUA Guideline on Recurrent UTI'''
* '''The index patient for this guideline is an otherwise healthy adult female with an uncomplicated rUTI'''. The infection is culture-proven and associated with acute-onset symptoms. This guideline does not apply to complicated UTI or those exhibiting signs or symptoms of systemic bacteremia, such as fever and flank pain.


== Definition of recurrent UTI ==
==== Labs ====
*'''<span style="color:#ff0000">Urine culture/laboratory confirmation of significant bacteriuria</span>'''
** '''Urine culture remains the mainstay of diagnosis of an episode of acute cystitis'''
*** '''Clinical judgment is needed to determine when a culture result represents clinically significant bacteriuria''' considering the patient presentation, urine collection method, and the presence of other suggestive factors such as pyuria.
**** '''<span style="color:#ff0000">The definition for clinically significant bacteriuria of >10<sup>5</sup> colony forming units (CFU)/mL represents an arbitrary cut-off.</span>'''
**** '''Although > 10<sup>5</sup> CFU/mL for bacterial growth on midstream voided urine''' '''may help distinguish bladder bacteriuria from contamination in asymptomatic, pre-menopausal women,''' '''<span style="color:#ff0000">a lower 10<sup>2</sup> CFU/mL threshold may be appropriate in symptomatic individuals</span>'''
**'''Obtain repeat urine studies when an initial urine specimen is suspect for contamination, with consideration for obtaining a catheterized specimen'''
*** '''Urine culture contamination should be suspected when (3):'''
***# '''Mixed cultures containing ≥2 organisms'''
***# '''Low quantities (<103 CFU/mL) of a pathogenic organism in an asymptomatic patient'''
***# '''Specimen exhibits growth of normal vaginal flora (e.g. Lactobacilli, Group B Streptococci, Corynebacteria, or non-saprophyticus coagulase-negative Staphylococci)'''
***#* '''Growth of these organisms are thought to be contaminant and generally do not require treatment'''
*** '''Concomitant urinalysis can also be useful (presence of epithelial cells or mucus on microscopic urinalysis may also suggest contaminant).'''
*** When there is high suspicion for contamination, consider obtaining a catheterized specimen for further evaluation prior to treatment.
*** '''Urine specimens should not sit at room temperature for > 30 minutes''' to facilitate lab diagnosis of UTI.
=== Differential Diagnosis ===
*'''<span style="color:#ff0000">Differential Diagnosis of UTI (10):</span>'''
*# '''<span style="color:#ff0000">Interstitial cystitis/bladder pain syndrome</span>'''
*# '''<span style="color:#ff0000">Overactive Bladder</span>'''
*# '''<span style="color:#ff0000">Urinary calculi</span>'''
*# '''<span style="color:#ff0000">Infectious bacterial or fungal vaginitis</span>'''
*# '''<span style="color:#ff0000">Vulvar dermatitis</span>'''
*# '''<span style="color:#ff0000">Non-infectious vulvovestibulitis</span>'''
*# '''<span style="color:#ff0000">Vulvodynia</span>'''
*# '''<span style="color:#ff0000">Hypertonic pelvic floor muscle dysfunction</span>'''
*# '''<span style="color:#ff0000">Genitourinary syndrome of menopause</span>'''
*# '''<span style="color:#ff0000">CIS of the bladder</span>''' (less commonly)
* A lack of correlation between microbiological data and symptomatic episodes should prompt a diligent consideration of alternative/comorbid diagnoses (many females with gross hematuria may be incorrectly treated for a UTI when they should be evaluated for bladder cancer; a negative culture would prompt further investigation of GH)
 
== Asymptomatic Bacteruria ==
* '''<span style="color:#ff0000">Definition: bacteriuria of any magnitude without symptoms</span>'''
*'''<span style="color:#ff0000">Management</span>'''
**'''<span style="color:#ff0000">DO NOT routinely treat asymptomatic bacteriuria</span>'''
*** No evidence that treatment of asymptomatic bacteriuria improves outcomes
** '''<span style="color:#ff0000">Indications for screening/treatment of asymptomatic bacteriuria (2):</span>'''
**# '''<span style="color:#ff0000">Pregnant females</span>'''
**# '''<span style="color:#ff0000">Patients undergoing elective urologic surgery</span>'''
**# '''[Neonatal candiduria, not technically bacteruria but should be treated even if asymptomatic]'''
** '''Asymptomatic bacteriuria and struvite stones'''
*** '''Routine treatment of urease-producing bacteriuria in the absence of UTI symptoms or documented urinary tract stones is not recommended'''
*** There is no clear evidence that identification and treatment of asymptomatic bacteriuria caused by urease-producing organisms (recall that urease-producing organisms include proteus, pseudomonas, klebsiella, mycoplasma, and staphylococcus) prevents struvite stone formation. However, '''in certain patients with recurrent struvite stones, screening for and treating urease-producing bacteriuria may be indicated if other measures have not been able to prevent stone formation.'''
 
== Recurrent UTI ==
 
=== Definitions ===
*'''<span style="color:#ff0000">Definition of Recurrent UTI: Either (2):</span>'''
*#'''<span style="color:#ff0000">≥2 episodes of acute bacterial cystitis within 6 months or</span>'''
*# '''<span style="color:#ff0000">≥3 episodes within 1 year</span>'''
*#* These episodes are considered to be separate infections with resolution of symptoms between episodes, and do not include those who require >1 course of antibiotics for symptomatic resolution, as can occur with inappropriate initial or empiric treatment
*#* '''<span style="color:#ff0000">For diagnosis of recurrent UTI, each symptomatic episode must be associated with a document positive urine culture'''
*Patients with a long history of culture-proven symptomatic episodes of cystitis that occur at a lower frequency than this definition will likely benefit from management strategy similar to that for patients with rUTI.
 
=== Diagnosis and Evaluation ===
 
==== UrologySchool.com Summary ====
 
* '''<span style="color:#ff0000">Mandatory (1):</span>'''
*# '''<span style="color:#ff0000">History and Physical Exam</span>'''
* '''<span style="color:#ff0000">Optional (1):</span>'''
*# '''<span style="color:#ff0000">PVR</span>'''
* '''Not recommended'''
** '''Cystoscopy'''
** '''Upper tract imaging'''
 
==== Mandatory ====


* '''≥2 episodes of acute bacterial cystitis within 6 months or'''
===== History and Physical Exam =====
* '''≥3 episodes within 1 year'''
* '''<span style="color:#ff0000">History'''
** These episodes are considered to be separate infections with resolution of symptoms between episodes, and do not include those who require >1 course of antibiotics for symptomatic resolution, as can occur with inappropriate initial or empiric treatment
** '''Characterize current LUTS''' (dysuria, frequency, urgency, nocturia, incontinence, hematuria, pneumaturia, fecaluria)
** Patients with a long history of culture-proven symptomatic episodes of cystitis that occur at a lower frequency than this definition will likely benefit from management strategy similar to that for patients with rUTI.
***'''Characterize baseline symptoms between infections'''
* '''For diagnosis of rUTI, each symptomatic episode must be associated with a document positive urine culture'''
**Back or flank pain; catheter usage; vaginal discharge or irritation
** '''Many non-UTI disorders have significant symptoms overlap with UTI, including (10):'''
**'''UTI history''': frequency of UTI, antimicrobial usage, and documentation of positive cultures and the type of cultured microorganisms, responses to treatment for each episode, the symptoms the patient considers indicative of a UTI, the relationship of acute episode to infectious triggers (e.g. sexual intercourse for post-coital UTIs), relationship of infections to hormonal influences (e.g., menstruation, menopause, exogenous hormone use), results of any prior diagnostic investigations
**# '''Interstitial cystitis/bladder pain syndrome'''
**'''Bowel symptoms''' such as diarrhea, accidental bowel leakage, or constipation
**# '''OAB'''
** '''Menopausal status; contraceptive method; and use of spermicides or estrogen- or progesterone-containing products'''
**# '''Urinary calculi'''
** '''Risk factors for complicated UTI (see [[Urinary Tract Infections|Urinary Tract Infections Chapter Notes]])'''
**# '''Infectious bacterial or fungal vaginitis'''
** '''Medications''' (immunosuppressive meds, recent use of antibiotics for any medical condition), '''PMHx, PSHx''' (may suggest complicated UTI), '''allergies, travel history'''
**# '''Vulvar dermatitis'''
* '''<span style="color:#ff0000">Physical Exam'''
**# '''Non-infectious vulvovestibulitis'''
** '''<span style="color:#ff0000">Abdominal and pelvic examination'''
**# '''Vulvodynia'''
***'''Prolapse, urethral tenderness, urethral diverticulum, Skene’s gland cyst, or other enlarged or infected vulvar or vaginal cysts'''
**# '''Hypertonic pelvic floor muscle dysfunction'''
***'''Any other infectious and inflammatory conditions (vaginitis, vulvar dermatitis, and vaginal atrophy''' (genitourinary syndrome of menopause)
**# '''Genitourinary syndrome of menopause'''
***'''Pelvic floor musculature''' for tone, tenderness, and trigger points
**# '''CIS of the bladder''' (less commonly)
** '''Focused neurological exam'''  
** A lack of correlation between microbiological data and symptomatic episodes should prompt a diligent consideration of alternative/comorbid diagnoses (many females with gross hematuria may be incorrectly treated for a UTI when they should be evaluated for bladder cancer; a negative culture would prompt further investigation of GH)
***'''May also be considered''' to rule out occult neurologic defects
* '''Obtain repeat urine studies when an initial urine specimen is suspect for contamination, with consideration for obtaining a catheterized specimen'''
** '''Urine culture contamination should be suspected when (3):'''
**# '''Mixed cultures containing ≥2 organisms'''
**# '''Low quantities (<103 CFU/mL) of a pathogenic organism in an asymptomatic patient'''
**# '''Specimen exhibits growth of normal vaginal flora (e.g. Lactobacilli, Group B Streptococci, Corynebacteria, or non-saprophyticus coagulase-negative Staphylococci)'''
**#* '''Growth of these organisms are thought to be contaminant and generally do not require treatment'''
** '''Concomitant urinalysis can also be useful (presence of epithelial cells or mucus on microscopic urinalysis may also suggest contaminant).'''
** When there is high suspicion for contamination, consider obtaining a catheterized specimen for further evaluation prior to treatment.
** '''Urine specimens should not sit at room temperature for > 30 minutes''' to facilitate lab diagnosis of UTI.


== Diagnosis and Evaluation ==
==== Optional ====
*'''<span style="color:#ff0000">Post-void Residual'''
** '''<span style="color:#ff0000">Indications</span>'''
***'''<span style="color:#ff0000">Can be considered for all patients'''
***'''<span style="color:#ff0000">Should be performed in any patient with suspicion of incomplete emptying, such as those with (4):</span>'''
***# '''<span style="color:#ff0000">Significant anterior vaginal wall prolapse</span>'''
***# '''<span style="color:#ff0000">Underlying neurologic disease</span>'''
***# '''<span style="color:#ff0000">Diabetes</span>'''
***# '''<span style="color:#ff0000">Subjective sensation of incomplete emptying</span>'''.


* '''Mandatory (1): H+P'''
==== Not recommended (2): ====
** '''History and Physical Exam'''
*'''Cystoscopy and upper tract imaging'''
*** '''History'''
**** '''Characterize LUTS''' (dysuria, frequency, urgency, nocturia, incontinence, hematuria, pneumaturia, fecaluria)
**** '''Baseline genitourinary symptoms between infections'''
**** '''UTI history''': frequency of UTI, antimicrobial usage, and documentation of positive cultures and the type of cultured microorganisms, responses to treatment for each episode, the symptoms the patient considers indicative of a UTI, the relationship of acute episode to infectious triggers (e.g. sexual intercourse for post-coital UTIs), relationship of infections to hormonal influences (e.g., menstruation, menopause, exogenous hormone use), results of any prior diagnostic investigations
**** '''Bowel symptoms''' such as diarrhea, accidental bowel leakage, or constipation
**** '''Menopausal status; contraceptive method; and use of spermicides or estrogen- or progesterone-containing products'''
**** Back or flank pain; catheter usage; vaginal discharge or irritation
**** '''Risk factors for complicated UTI (see Urinary Tract Infections Chapter Notes)'''
**** '''Medications''' (immunosuppressive meds, recent use of antibiotics for any medical condition), '''PMHx, PSHx''' (may suggest complicated UTI), '''allergies, travel history'''
*** '''Physical exam'''
**** '''Abdominal and pelvic examination (prolapse, urethral tenderness, urethral diverticulum, Skene’s gland cyst, or other enlarged or infected vulvar or vaginal cysts), any other infectious and inflammatory conditions (vaginitis, vulvar dermatitis, and vaginal atrophy''' (genitourinary syndrome of menopause)''', pelvic floor musculature''' for tone, tenderness, and trigger points
**** '''A focused neurological exam''' '''may also be considered''' to rule out occult neurologic defects
* '''[Optional (1): PVR]'''
** '''Post-void residual can be considered for all patients, but should be performed in any patient with suspicion of incomplete emptying, such as those with (4):'''
**# '''Significant anterior vaginal wall prolapse'''
**# '''Underlying neurologic disease'''
**# '''Diabetes'''
**# '''Subjective sensation of incomplete emptying'''.
* '''Not recommended (2): cystoscopy and upper tract imaging'''
** '''Low yield of anatomical abnormalities with cystoscopy and upper tract imaging in patients with uncomplicated rUTI.'''
** '''Low yield of anatomical abnormalities with cystoscopy and upper tract imaging in patients with uncomplicated rUTI.'''
*** '''However, if a patient does not respond appropriately to treatment of uncomplicated UTI, particularly rapid recurrence with the same organism repeatedly, the patient should be considered to have a complicated UTI, thereby necessitating further investigations of the urinary tract'''
*** '''However, if a patient does not respond appropriately to treatment of uncomplicated UTI, particularly rapid recurrence with the same organism repeatedly, the patient should be considered to have a complicated UTI, thereby necessitating further investigations of the urinary tract'''
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*** '''If any risk factors are present, cystoscopy should be performed.'''
*** '''If any risk factors are present, cystoscopy should be performed.'''


== Management ==
==== Management ====
 
===== Conservative =====
*'''<span style="color:#ff0000">Options (2):</span>'''
*#'''<span style="color:#ff0000">Education</span>'''
*#'''<span style="color:#ff0000">Behavior modification</span>'''
 
====== Education and Informed Decision Making ======
* '''Discuss the option of delaying antibiotics while awaiting culture results as there is minimal risk of progression to tissue invasion or pyelonephritis for uncomplicated patients with episodes of acute cystitis.'''
** '''Antibiotic treatment for acute cystitis results in mildly faster symptomatic improvement but only modestly decrease the risk of pyelonephritis'''.
** Patients with urosepsis or pyelonephritis often do not have UTI-related symptoms.
 
====== <span style="color:#ff0000">Behavior modification (2):</span> ======
# '''<span style="color:#ff0000">Changing mode of contraception (avoid barrier contraceptives and spermicidal products</span>''' (has deleterious effect on lactobacillus colonization and/or the vaginal microbiome))
# '''<span style="color:#ff0000">Increasing water intake in those consuming < 1.5L/day</span>'''
#* Unclear if there is a benefit in women that normally consume over this amount
 
====== '''Changes that DO NOT play a role in rUTI prevention''' ======
# '''Hygiene practices (e.g., front to back wiping)'''
# '''Pre- and post-coital voiding'''
# '''Avoidance of hot tubs'''
# '''Tampon use'''
# '''Douching'''


* '''Conservative (2): education, behaviour modification'''
===== Intervention =====
*# '''Education''' and Informed Decision Making
*'''<span style="color:#ff0000">Options (3):</span>'''  
*#* '''Discuss the option of delaying antibiotics while awaiting culture results as there is minimal risk of progression to tissue invasion or pyelonephritis for uncomplicated patients with episodes of acute cystitis.'''
**'''<span style="color:#ff0000">Antibiotics</span>'''
*#** '''Antibiotic treatment for acute cystitis results in mildly faster symptomatic improvement but only modestly decrease the risk of pyelonephritis'''.
**'''<span style="color:#ff0000">Non-antibiotic prophylaxis</span>'''
*#** Patients with urosepsis or pyelonephritis often do not have UTI-related symptoms.
***'''<span style="color:#ff0000">Cranberry</span>'''
*# '''Behaviour modification (2):'''
***'''<span style="color:#ff0000">Vaginal estrogen (if post-menopausal)</span>'''
*## '''Changing mode of contraception (avoid barrier contraceptives and spermicidal products''' (has deleterious effect on lactobacillus colonization and/or the vaginal microbiome))
*## '''Increasing water intake in those consuming < 1.5L/day'''
*##* Unclear if there is a benefit in women that normally consume over this amount
*# '''Changes that DO NOT play a role in rUTI prevention:'''
*## '''Hygiene practices (e.g., front to back wiping)'''
*## '''Pre- and post-coital voiding'''
*## '''Avoidance of hot tubs'''
*## '''Tampon use'''
*## '''Douching'''


* '''Intervention (3): antibiotics, cranberry, vaginal estrogen (if post-menopausal)'''
====== Antibiotics ======
** '''Antibiotics'''
* '''<span style="color:#ff0000">Acute cystitis episodes in patients with recurrent UTI'''
*** '''Acute cystitis'''
** '''<span style="color:#ff0000">Obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs'''
**** '''Obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs'''
*** Continued documentation of cultures during symptomatic periods prior to starting antibiotics helps to provide a baseline against which interventions can be evaluated, to determine the appropriate pathway within the treatment algorithm, and to allow for the tailoring of therapy based on bacterial sensitivities.
***** Continued documentation of cultures during symptomatic periods prior to starting antibiotics helps to provide a baseline against which interventions can be evaluated, to determine the appropriate pathway within the treatment algorithm, and to allow for the tailoring of therapy based on bacterial sensitivities.
*** '''In select patients with rUTIs with symptoms of recurrence, presumptive treatment with antibiotics can be initiated prior to finalization of the culture''' based on prior speciation, susceptibilities, and local antibiogram
***** '''In select patients with rUTIs with symptoms of recurrence, presumptive treatment with antibiotics can be initiated prior to finalization of the culture''' based on prior speciation, susceptibilities, and local antibiogram
** '''Use first-line therapy (See [https://www.auanet.org/guidelines-and-quality/guidelines/recurrent-uti Table 3] (statement 9, no direct link) from Original Guideline) dependent on the local antibiogram for treatment of symptomatic UTIs in women'''
**** '''Use first-line therapy (See Table 3 (statement 9, no direct link) from Original Guideline) dependent on the local antibiogram for treatment of symptomatic UTIs in women'''
*** <span style="color:#ff0000">'''Options (3):'''</span>
***** A systematic review found no differences between fluoroquinolones, β-lactams (e.g., penicillins and its derivatives, cephalosporins), nitrofurantoin or TMP-SMX in the efficacy or risk of discontinuation due to adverse events
****<span style="color:#ff0000">'''Fosfomycin 3g PO x 1'''</span>
***** TMP-SMX is not recommended for empiric use in areas where local resistance rates > 20%
****<span style="color:#ff0000">'''TMP-SMX one tab DS PO BID x 3 days'''</span>
****<span style="color:#ff0000">'''Nitrofurantoin 100mg PO BID x 5 days'''</span>
***A systematic review found no differences between fluoroquinolones, β-lactams (e.g., penicillins and its derivatives, cephalosporins), nitrofurantoin or TMP-SMX in the efficacy or risk of discontinuation due to adverse events
*** TMP-SMX is not recommended for empiric use in areas where local resistance rates > 20%]
***'''Table 3 from guideline suggests that nitrofurantoin does not cover enterococcus but CW11 Table 12-5/CW12 Table 55-6 suggests that it does'''
** '''Clinicians should treat rUTI patients experiencing acute cystitis episodes with as short a duration of antibiotics as reasonable, generally < 7 days'''
*** '''In patients with rUTIs experiencing acute cystitis episodes associated with urine cultures resistant to oral antibiotics''', clinicians may treat with culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than 7 days. '''Many such infections will be caused by organisms producing ESBLs.'''
**** '''Generally, such organisms are susceptible only to carbapenems. However, clinicians should order fosfomycin susceptibility testing, as many MDR uropathogens, including ESBL-producing bacteria, retain susceptibility to Fosfomycin thereby providing an oral option'''.
** '''Do not perform a post-treatment test of cure (urinalysis or urine culture) in asymptomatic patients'''
*** Extrapolating from the asymptomatic bacteruria literature, repeat urine culture after successful UTI treatment may lead to overtreatment
*** '''Omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs.'''
**** While pregnant women and patients undergoing invasive urologic procedures do benefit from treatment, substantial evidence supports that other populations, including women with diabetes mellitus and long-term care facility residents, do not require or benefit from additional evaluation or antibiotic treatment
** '''Repeat urine cultures to guide further management when UTI symptoms persist following antibiotic therapy'''
*** '''After initiating antibiotic therapy for UTI, clinical cure (i.e. UTI symptom resolution) is expected within 3-7 days.''' Although there is no evidence, it is reasonable to '''repeat a urine culture if symptoms persist > 7 days'''
* '''<span style="color:#ff0000">Antibiotics to reduce UTI episodes in patients with rUTI (self-start vs. prophylaxis)</span>'''
*# '''<span style="color:#ff0000">Self-start antibiotics: patient-initiated treatment for acute episodes while awaiting urine cultures.'''</span>
*#* '''For reliable patients, consider shared decision-making with regards to deferring therapy prior to obtaining results from the urine culture.'''
*#* Despite the original concept behind self-start therapy that allowed for women to treat their UTI without obtaining a culture. given more recent goals to reduce overuse of antibiotics and the development of antibacterial resistance, '''obtaining culture data for symptomatic recurrences is recommended''', when feasible.
*# '''<span style="color:#ff0000">Antibiotic prophylaxis (continuous vs. post-coital)</span>'''
*## '''Continuous:''' After discussion of the risks and benefits, clinicians may prescribe continuous antibiotic prophylaxis to decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs.
*##* '''Antibiotic prophylaxis reduces the number of clinical recurrences but increases risk of adverse events. Once the antibiotics are stopped, UTIs recur at the baseline rate.'''
*##* '''The dosing options for continuous prophylaxis include the following:'''
*##** Nitrofurantoin monohydrate/macrocrystals 50mg daily
*##** '''Nitrofurantoin''' monohydrate/macrocrystals '''100mg daily'''
*##** Cephalexin 125mg once daily
*##** '''Cephalexin 250mg once daily'''
*##** TMP 100mg once daily
*##** '''TMP-SMX''' '''40mg/200mg once daily'''
*##** TMP-SMX 40mg/200mg thrice weekly
*##** '''Fosfomycin 3g every 10 days'''
*##* '''Potential adverse effects of gastrointestinal disturbances and skin rash are commonly associated with antibiotics, including TMP, TMP-SMX, cephalexin, and Fosfomycin'''
*##* '''<span style="color:#ff0000">Potentially serious risks with nitrofurantoin include pulmonary and hepatic toxicity.</span>'''
*##** The rate of possible serious pulmonary or hepatic adverse events has been reported to be 0.001% and 0.0003%, respectively.
*##* '''<span style="color:#ff0000">The use of fluoroquinolones (e.g. ciprofloxacin) for prophylactic antibiotic use is not recommended in current clinical practice.</span>'''
*##** '''<span style="color:#ff0000">Fluoroquinolone agents have potentially adverse side effects including QTc prolongation, tendon rupture, and increased risk of aortic rupture</span>'''
*##* '''The duration of prophylaxis can vary from 3-12 months''', with periodic assessment
*## '''Post-coital'''
*##* '''In women with UTIs temporally related to sexual activity, a single dose of antibiotic prophylaxis taken before or after sexual intercourse is effective and safe'''
*##** Options:
*##*** TMP-SMX 40mg/200mg
*##*** TMP-SMX 80mg/400mg
*##*** Nitrofurantoin 50-100mg
*##*** Cephalexin 250mg


***** '''Table 3 from guideline suggests that nitrofurantoin does not cover enterococcus but CW11 Table 12-5/CW12 Table 55-6 suggets that it does'''
====== <span style="color:#ff0000">Non-antibiotic prophylaxis (2):</span> ======
**** '''Clinicians should treat rUTI patients experiencing acute cystitis episodes with as short a duration of antibiotics as reasonable, generally < 7 days'''
# '''<span style="color:#ff0000">Cranberry prophylaxis</span>'''
***** '''In patients with rUTIs experiencing acute cystitis episodes associated with urine cultures resistant to oral antibiotics''', clinicians may treat with culture-directed parenteral antibiotics for as short a course as reasonable, generally no longer than 7 days. '''Many such infections will be caused by organisms producing ESBLs.'''
#* MOA: thought to be related to proanthocyanidins present in cranberries and their ability to prevent the adhesion of bacteria to the urothelium
****** '''Generally, such organisms are susceptible only to carbapenems. However, clinicians should order fosfomycin susceptibility testing, as many MDR uropathogens, including ESBL-producing bacteria, retain susceptibility to Fosfomycin thereby providing an oral option'''.
#* '''<span style="color:#ff0000">Indications</span>'''
**** '''Do not perform a post-treatment test of cure (urinalysis or urine culture) in asymptomatic patients'''
#**'''<span style="color:#ff0000">Can be offered for women with rUTIs</span>'''
***** Extrapolating from the asymptomatic bacteruria literature, repeat urine culture after successful UTI treatment may lead to overtreatment
#*Oral juice and tablet formulations are available
***** '''Omit surveillance urine testing, including urine culture, in asymptomatic patients with rUTIs.'''
# '''<span style="color:#ff0000">Vaginal estrogen</span>'''
****** While pregnant women and patients undergoing invasive urologic procedures do benefit from treatment, substantial evidence supports that other populations, including women with diabetes mellitus and long-term care facility residents, do not require or benefit from additional evaluation or antibiotic treatment
#* '''<span style="color:#ff0000">Indications</span>'''
**** '''Repeat urine cultures to guide further management when UTI symptoms persist following antibiotic therapy'''
#**'''<span style="color:#ff0000">Recommended in peri-and post-menopausal women with rUTIs,</span>''' if there is no contraindication to estrogen.
***** '''After initiating antibiotic therapy for UTI, clinical cure (i.e. UTI symptom resolution) is expected within 3-7 days.''' Although there is no evidence, it is reasonable to '''repeat a urine culture if symptoms persist > 7 days'''
#*** '''Oral or other formulations of systemic estrogen therapy have not been shown to reduce UTI and are associated with different risks and benefits.'''
*** '''Antibiotics to reduce UTI episodes in patients with rUTI (self-start vs. prophylaxis)'''
#*** Given low systemic absorption, risks generally associated with systemic estrogen (cardiovascular disease, thrombosis, breast cancer) are minimal with vaginal estrogen.
***# '''Self-start antibiotics:''' patient-initiated treatment for acute episodes while awaiting urine cultures.
#* '''Patients with rUTI and are already on systemic estrogen therapy should still be placed on vaginal estrogen. There is no substantially increased risk of adverse events.'''
***#* '''For reliable patients, consider shared decision-making with regards to deferring therapy prior to obtaining results from the urine culture.'''
#* '''Vaginal estrogen therapy has not been shown to increase risk of cancer recurrence in women undergoing treatment for or with a personal history of breast cancer'''. Therefore, vaginal estrogen therapy should be considered in prevention of UTI women with a personal history of breast cancer in coordination with the patient’s oncologist.
***#* Despite the original concept behind self-start therapy that allowed for women to treat their UTI without obtaining a culture. given more recent goals to reduce overuse of antibiotics and the development of antibacterial resistance, '''obtaining culture data for symptomatic recurrences is recommended''', when feasible.
* '''Lactobacillus is not recommended''' as a prophylactic agent for rUTI given the lack of data
***# '''Antibiotic prophylaxis (continuous vs. post-coital)'''
***## '''Continuous:''' After discussion of the risks and benefits, clinicians may prescribe continuous antibiotic prophylaxis to decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs.
***##* '''Antibiotic prophylaxis reduces the number of clinical recurrences but increases risk of adverse events. Once the antibiotics are stopped, UTIs recur at the baseline rate.'''
***##* '''The dosing options for continuous prophylaxis include the following:'''
***##** Nitrofurantoin monohydrate/macrocrystals 50mg daily
***##** '''Nitrofurantoin''' monohydrate/macrocrystals '''100mg daily'''
***##** Cephalexin 125mg once daily
***##** '''Cephalexin 250mg once daily'''
***##** TMP 100mg once daily
***##** '''TMP-SMX''' '''40mg/200mg once daily'''
***##** TMP-SMX 40mg/200mg thrice weekly
***##** '''Fosfomycin 3g every 10 days'''
***##* '''Potential adverse effects of gastrointestinal disturbances and skin rash are commonly associated with antibiotics, including TMP, TMP-SMX, cephalexin, and Fosfomycin'''
***##* '''Potentially serious risks with nitrofurantoin include pulmonary and hepatic toxicity.'''
***##** The rate of possible serious pulmonary or hepatic adverse events has been reported to be 0.001% and 0.0003%, respectively.
***##* '''The use of fluoroquinolones''', such as ciprofloxacin, '''for prophylactic antibiotic use is not recommended in current clinical practice.'''
***##** '''Fluoroquinolone agents have potentially adverse side effects including QTc prolongation, tendon rupture, and increased risk of aortic rupture'''
***##* '''The duration of prophylaxis can vary from 3-12 months''', with periodic assessment
***## '''Post-coital'''
***##* '''In women with UTIs temporally related to sexual activity, a single dose of antibiotic prophylaxis taken before or after sexual intercourse is effective and safe'''
***##** Options:
***##*** TMP-SMX 40mg/200mg
***##*** TMP-SMX 80mg/400mg
***##*** Nitrofurantoin 50-100mg
***##*** Cephalexin 250mg
** '''Non-antibiotic prophylaxis (2):'''
**# '''Cranberry prophylaxis can be offered for women with rUTIs.'''
**#* MOA: thought to be related to proanthocyanidins present in cranberries and their ability to prevent the adhesion of bacteria to the urothelium
**#* Oral juice and tablet formulations are available
**# '''Vaginal estrogen'''
**#* '''In peri-and post-menopausal women with rUTIs, vaginal estrogen therapy is recommended to reduce the risk of future UTIs''' if there is no contraindication to estrogen.
**#** '''Oral or other formulations of systemic estrogen therapy have not been shown to reduce UTI and are associated with different risks and benefits.'''
**#** Given low systemic absorption, risks generally associated with systemic estrogen (cardiovascular disease, thrombosis, breast cancer) are minimal with vaginal estrogen.
**#* '''Patients with rUTI and are already on systemic estrogen therapy should still be placed on vaginal estrogen. There is no substantially increased risk of adverse events.'''
**#* '''Vaginal estrogen therapy has not been shown to increase risk of cancer recurrence in women undergoing treatment for or with a personal history of breast cancer'''. Therefore, vaginal estrogen therapy should be considered in prevention of UTI women with a personal history of breast cancer in coordination with the patient’s oncologist.
*** '''Lactobacillus is not recommended''' as a prophylactic agent for rUTI given the lack of data


== Questions ==
== Questions ==
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