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

(21 intermediate revisions by the same user not shown)

Line 5:

*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'''

*** '''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.

Line 21:

=== Diagnosis and Evaluation ===

* '''History and Physical Exam'''

** '''History'''

*** '''Symptoms'''

**** '''Urinary tract infection symptoms include dysuria, central to the diagnosis of UTI, with variable degrees of:'''

****# '''Increased urinary urgency and frequency'''

****# '''Hematuria'''

****# '''Suprapubic pain'''

****# '''New or worsening incontinence'''

**** '''In older adults, the symptoms of UTI may be less clear.'''

***** 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

****** '''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.

* '''Labs'''

**'''Urine culture/laboratory confirmation of significant bacteriuria'''

*** '''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.

***** '''The definition for clinically significant bacteriuria of >105 colony forming units (CFU)/mL represents an arbitrary cut-off.'''

***** '''Although > 105 CFU/mL for bacterial growth on midstream voided urine''' '''may help distinguish bladder bacteriuria from contamination in asymptomatic, pre-menopausal women,''' '''a lower 102 CFU/mL threshold may be appropriate in symptomatic individuals'''

***'''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 ====

==== History and Physical Exam ====

* '''History'''

** '''Symptoms'''

*** '''Urinary tract infection symptoms include dysuria, central to the diagnosis of UTI, with variable degrees of:'''

***# '''Increased urinary urgency and frequency'''

***# '''Hematuria'''

***# '''Suprapubic pain'''

***# '''New or worsening incontinence'''

*** '''In older adults, the symptoms of UTI may be less clear.'''

**** 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

***** '''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.

==== Labs ====

*'''Urine culture/laboratory confirmation of significant bacteriuria'''

** '''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.

**** '''The definition for clinically significant bacteriuria of >105 colony forming units (CFU)/mL represents an arbitrary cut-off.'''

**** '''Although > 105 CFU/mL for bacterial growth on midstream voided urine''' '''may help distinguish bladder bacteriuria from contamination in asymptomatic, pre-menopausal women,''' '''a lower 102 CFU/mL threshold may be appropriate in symptomatic individuals'''

**'''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 ===

*'''Differential Diagnosis of UTI (10):'''

*# '''Interstitial cystitis/bladder pain syndrome'''

Line 83:

Line 84:

*# '''≥3 episodes within 1 year'''

*#* 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

*#* '''For diagnosis of ~~rUTI~~, each symptomatic episode must be associated with a document positive urine culture'''

*#* '''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.

Line 94:

Line 95:

* '''Optional (1):'''

*# '''PVR'''

* Not recommended

* '''Not recommended'''

** Cystoscopy

** '''Cystoscopy'''

** Upper tract imaging

** '''Upper tract imaging'''

==== Mandatory ====

*'''History and Physical Exam~~'''~~

** '''History'''

===== History and Physical Exam =====

*** '''Characterize LUTS''' (dysuria, frequency, urgency, nocturia, incontinence, hematuria, pneumaturia, fecaluria)

* '''History'''

*** '''~~Baseline genitourinary~~ symptoms between infections'''

** '''Characterize current LUTS''' (dysuria, frequency, urgency, nocturia, incontinence, hematuria, pneumaturia, fecaluria)

*** '''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

***'''Characterize baseline symptoms between infections'''

*** '''Bowel symptoms''' such as diarrhea, accidental bowel leakage, or constipation

**Back or flank pain; catheter usage; vaginal discharge or irritation

*** '''Menopausal status; contraceptive method; and use of spermicides or estrogen- or progesterone-containing products'''

**'''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

*** Back or flank pain; catheter usage; vaginal discharge or irritation

**'''Bowel symptoms''' such as diarrhea, accidental bowel leakage, or constipation

*** '''Risk factors for complicated UTI (see Urinary Tract Infections Chapter Notes)'''

** '''Menopausal status; contraceptive method; and use of spermicides or estrogen- or progesterone-containing products'''

*** '''Medications''' (immunosuppressive meds, recent use of antibiotics for any medical condition), '''PMHx, PSHx''' (may suggest complicated UTI), '''allergies, travel history'''

** '''Risk factors for complicated UTI (see [[Urinary Tract Infections|Urinary Tract Infections Chapter Notes]])'''

** '''Physical ~~exam~~'''

** '''Medications''' (immunosuppressive meds, recent use of antibiotics for any medical condition), '''PMHx, PSHx''' (may suggest complicated UTI), '''allergies, travel history'''

*** '''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

* '''Physical Exam'''

*** '''~~A focused~~ neurological exam''' '''~~may~~ also be considered''' to rule out occult neurologic defects

** '''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

** '''Focused neurological exam'''

***'''May also be considered''' to rule out occult neurologic defects

==== Optional ====

*'''Post-void Residual'''

*'''Post-void Residual'''

** '''~~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):'''

** '''Indications'''

**# '''Significant anterior vaginal wall prolapse'''

***'''Can be considered for all patients'''

**# '''Underlying neurologic disease'''

***'''Should be performed in any patient with suspicion of incomplete emptying, such as those with (4):'''

**# '''Diabetes'''

***# '''Significant anterior vaginal wall prolapse'''

**# '''Subjective sensation of incomplete emptying'''.

***# '''Underlying neurologic disease'''

***# '''Diabetes'''

***# '''Subjective sensation of incomplete emptying'''.

==== ~~'''~~Not recommended (2):~~'''~~ ====

==== Not recommended (2): ====

*'''Cystoscopy and upper tract imaging'''

** '''Low yield of anatomical abnormalities with cystoscopy and upper tract imaging in patients with uncomplicated rUTI.'''

Line 130:

Line 138:

==== Management ====

===== ~~'''~~Conservative~~'''~~ =====

===== Conservative =====

*'''Options (2): ~~education, behaviour modification~~'''

*'''Options (2):'''

*# '''Education''' and Informed Decision Making

*#'''Education'''

*#* '''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.'''

*#'''Behavior modification'''

*#** '''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.

====== Education and Informed Decision Making ======

*# '''Behaviour modification (2):'''

* '''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.'''

*## '''Changing mode of contraception (avoid barrier contraceptives and spermicidal products''' (has deleterious effect on lactobacillus colonization and/or the vaginal microbiome))

** '''Antibiotic treatment for acute cystitis results in mildly faster symptomatic improvement but only modestly decrease the risk of pyelonephritis'''.

*## '''Increasing water intake in those consuming < 1.5L/day'''

** Patients with urosepsis or pyelonephritis often do not have UTI-related symptoms.

*##* 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~~''' =====

====== Behavior modification (2): ======

*'''Options (3):'''

# '''Changing mode of contraception (avoid barrier contraceptives and spermicidal products''' (has deleterious effect on lactobacillus colonization and/or the vaginal microbiome))

**'''Antibiotics'''

# '''Increasing water intake in those consuming < 1.5L/day'''

**'''Non-antibiotic prophylaxis'''

#* Unclear if there is a benefit in women that normally consume over this amount

***'''Cranberry'''

***'''Vaginal estrogen (if post-menopausal)'''

====== '''Changes that DO NOT play a role in rUTI prevention''' ======

~~'''~~Antibiotics~~'''~~

# '''Hygiene practices (e.g., front to back wiping)'''

* '''Acute cystitis'''

# '''Pre- and post-coital voiding'''

** '''Obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs'''

# '''Avoidance of hot tubs'''

# '''Tampon use'''

# '''Douching'''

===== Intervention =====

*'''Options (3):'''

**'''Antibiotics'''

**'''Non-antibiotic prophylaxis'''

***'''Cranberry'''

***'''Vaginal estrogen (if post-menopausal)'''

====== Antibiotics ======

* '''Acute cystitis episodes in patients with recurrent UTI'''

** '''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.

*** '''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 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 [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'''

*** 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

*** '''Options (3):'''

****'''Fosfomycin 3g PO x 1'''

****'''TMP-SMX one tab DS PO BID x 3 days'''

****'''Nitrofurantoin 100mg PO BID x 5 days'''

***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 ~~suggets~~ that it does'''

***'''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.'''

Line 171:

Line 189:

** '''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'''

* '''Antibiotics to reduce UTI episodes in patients with rUTI (self-start vs. prophylaxis)'''

* '''Antibiotics to reduce UTI episodes in patients with rUTI (self-start vs. prophylaxis)'''

*# '''Self-start antibiotics:~~'''~~ patient-initiated treatment for acute episodes while awaiting urine cultures.

*# '''Self-start antibiotics: patient-initiated treatment for acute episodes while awaiting urine cultures.'''

*#* '''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.

*# '''Antibiotic prophylaxis (continuous vs. post-coital)'''

*# '''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.'''

Line 188:

Line 206:

*##** '''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.'''

*##* '''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.'''

*##* '''The use of fluoroquinolones (e.g. 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'''

*##** '''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'''

Line 200:

Line 218:

*##*** Nitrofurantoin 50-100mg

*##*** Cephalexin 250mg

~~'''~~Non-antibiotic prophylaxis (2):~~'''~~

# '''Cranberry prophylaxis ~~can be offered for women with rUTIs.~~'''

====== Non-antibiotic prophylaxis (2): ======

# '''Cranberry prophylaxis'''

#* 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

#* '''Indications'''

# '''Vaginal estrogen'''

#**'''Can be offered for women with rUTIs'''

#* '''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 juice and tablet formulations are available

#** '''Oral or other formulations of systemic estrogen therapy have not been shown to reduce UTI and are associated with different risks and benefits.'''

# '''Vaginal estrogen'''

#** Given low systemic absorption, risks generally associated with systemic estrogen (cardiovascular disease, thrombosis, breast cancer) are minimal with vaginal estrogen.

#* '''Indications'''

#**'''Recommended in peri-and post-menopausal women with rUTIs,''' 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.

@@ Line 5: / Line 5: @@
 *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'''
+*** '''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.
@@ Line 21: / Line 21: @@
 === Diagnosis and Evaluation ===
-* '''History and Physical Exam'''
-** '''History'''
-*** '''<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">'''Increased urinary urgency and frequency'''</span>
-****# <span style="color:#ff0000">'''Hematuria'''</span>
-****# <span style="color:#ff0000">'''Suprapubic pain'''</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>'''
-***** 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
-****** '''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.
-* '''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 ====
+==== History and Physical Exam ====
+* '''History'''
+** '''<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">'''Increased urinary urgency and frequency'''</span>
+***# <span style="color:#ff0000">'''Hematuria'''</span>
+***# <span style="color:#ff0000">'''Suprapubic pain'''</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>'''
+**** 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
+***** '''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.
+==== 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>'''
@@ Line 83: / Line 84: @@
 *# '''<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
-*#* '''For diagnosis of rUTI, each symptomatic episode must be associated with a document positive urine culture'''
+*#* '''<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.
@@ Line 94: / Line 95: @@
 * '''<span style="color:#ff0000">Optional (1):</span>'''
 *# '''<span style="color:#ff0000">PVR</span>'''
-* Not recommended
+* '''Not recommended'''
-** Cystoscopy
+** '''Cystoscopy'''
-** Upper tract imaging
+** '''Upper tract imaging'''
 ==== Mandatory ====
-*'''History and Physical Exam'''
-** '''History'''
+===== History and Physical Exam =====
-*** '''Characterize LUTS''' (dysuria, frequency, urgency, nocturia, incontinence, hematuria, pneumaturia, fecaluria)
+* '''<span style="color:#ff0000">History'''
-*** '''Baseline genitourinary symptoms between infections'''
+** '''Characterize current LUTS''' (dysuria, frequency, urgency, nocturia, incontinence, hematuria, pneumaturia, fecaluria)
-*** '''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
+***'''Characterize baseline symptoms between infections'''
-*** '''Bowel symptoms''' such as diarrhea, accidental bowel leakage, or constipation
+**Back or flank pain; catheter usage; vaginal discharge or irritation
-*** '''Menopausal status; contraceptive method; and use of spermicides or estrogen- or progesterone-containing products'''
+**'''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
-*** Back or flank pain; catheter usage; vaginal discharge or irritation
+**'''Bowel symptoms''' such as diarrhea, accidental bowel leakage, or constipation
-*** '''Risk factors for complicated UTI (see Urinary Tract Infections Chapter Notes)'''
+** '''Menopausal status; contraceptive method; and use of spermicides or estrogen- or progesterone-containing products'''
-*** '''Medications''' (immunosuppressive meds, recent use of antibiotics for any medical condition), '''PMHx, PSHx''' (may suggest complicated UTI), '''allergies, travel history'''
+** '''Risk factors for complicated UTI (see [[Urinary Tract Infections|Urinary Tract Infections Chapter Notes]])'''
-** '''Physical exam'''
+** '''Medications''' (immunosuppressive meds, recent use of antibiotics for any medical condition), '''PMHx, PSHx''' (may suggest complicated UTI), '''allergies, travel history'''
-*** '''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
+* '''<span style="color:#ff0000">Physical Exam'''
-*** '''A focused neurological exam''' '''may also be considered''' to rule out occult neurologic defects
+** '''<span style="color:#ff0000">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
+** '''Focused neurological exam'''
+***'''May also be considered''' to rule out occult neurologic defects
 ==== Optional ====
-*'''Post-void Residual'''
+*'''<span style="color:#ff0000">Post-void Residual'''
-** '''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):'''
+** '''<span style="color:#ff0000">Indications</span>'''
-**# '''Significant anterior vaginal wall prolapse'''
+***'''<span style="color:#ff0000">Can be considered for all patients'''
-**# '''Underlying neurologic disease'''
+***'''<span style="color:#ff0000">Should be performed in any patient with suspicion of incomplete emptying, such as those with (4):</span>'''
-**# '''Diabetes'''
+***# '''<span style="color:#ff0000">Significant anterior vaginal wall prolapse</span>'''
-**# '''Subjective sensation of incomplete emptying'''.
+***# '''<span style="color:#ff0000">Underlying neurologic disease</span>'''
+***# '''<span style="color:#ff0000">Diabetes</span>'''
+***# '''<span style="color:#ff0000">Subjective sensation of incomplete emptying</span>'''.
-==== '''Not recommended (2):''' ====
+==== Not recommended (2): ====
 *'''Cystoscopy and upper tract imaging'''
 ** '''Low yield of anatomical abnormalities with cystoscopy and upper tract imaging in patients with uncomplicated rUTI.'''
@@ Line 130: / Line 138: @@
 ==== Management ====
-===== '''Conservative''' =====
+===== Conservative =====
-*'''Options (2): education, behaviour modification'''
+*'''<span style="color:#ff0000">Options (2):</span>'''
-*# '''Education''' and Informed Decision Making
+*#'''<span style="color:#ff0000">Education</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">Behavior modification</span>'''
-*#** '''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.
+====== Education and Informed Decision Making ======
-*# '''Behaviour modification (2):'''
+* '''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.'''
-*## '''Changing mode of contraception (avoid barrier contraceptives and spermicidal products''' (has deleterious effect on lactobacillus colonization and/or the vaginal microbiome))
+** '''Antibiotic treatment for acute cystitis results in mildly faster symptomatic improvement but only modestly decrease the risk of pyelonephritis'''.
-*## '''Increasing water intake in those consuming < 1.5L/day'''
+** Patients with urosepsis or pyelonephritis often do not have UTI-related symptoms.
-*##* 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''' =====
+====== <span style="color:#ff0000">Behavior modification (2):</span> ======
-*'''Options (3):'''
+# '''<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))
-**'''Antibiotics'''
+# '''<span style="color:#ff0000">Increasing water intake in those consuming < 1.5L/day</span>'''
-**'''Non-antibiotic prophylaxis'''
+#* Unclear if there is a benefit in women that normally consume over this amount
-***'''Cranberry'''
-***'''Vaginal estrogen (if post-menopausal)'''
+====== '''Changes that DO NOT play a role in rUTI prevention''' ======
-'''Antibiotics'''
+# '''Hygiene practices (e.g., front to back wiping)'''
-* '''Acute cystitis'''
+# '''Pre- and post-coital voiding'''
-** '''Obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs'''
+# '''Avoidance of hot tubs'''
+# '''Tampon use'''
+# '''Douching'''
+===== Intervention =====
+*'''<span style="color:#ff0000">Options (3):</span>'''
+**'''<span style="color:#ff0000">Antibiotics</span>'''
+**'''<span style="color:#ff0000">Non-antibiotic prophylaxis</span>'''
+***'''<span style="color:#ff0000">Cranberry</span>'''
+***'''<span style="color:#ff0000">Vaginal estrogen (if post-menopausal)</span>'''
+====== Antibiotics ======
+* '''<span style="color:#ff0000">Acute cystitis episodes in patients with recurrent UTI'''
+** '''<span style="color:#ff0000">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.
 *** '''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 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 [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'''
-*** 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">'''Options (3):'''</span>
+****<span style="color:#ff0000">'''Fosfomycin 3g PO x 1'''</span>
+****<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 suggets that it does'''
+***'''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.'''
@@ Line 171: / Line 189: @@
 ** '''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'''
-* '''Antibiotics to reduce UTI episodes in patients with rUTI (self-start vs. prophylaxis)'''
+* '''<span style="color:#ff0000">Antibiotics to reduce UTI episodes in patients with rUTI (self-start vs. prophylaxis)</span>'''
-*# '''Self-start antibiotics:''' patient-initiated treatment for acute episodes while awaiting urine cultures.
+*# '''<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.
-*# '''Antibiotic prophylaxis (continuous vs. post-coital)'''
+*# '''<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.'''
@@ Line 188: / Line 206: @@
 *##** '''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.'''
+*##* '''<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.
-*##* '''The use of fluoroquinolones''', such as ciprofloxacin, '''for prophylactic antibiotic use is not recommended in current clinical practice.'''
+*##* '''<span style="color:#ff0000">The use of fluoroquinolones (e.g. ciprofloxacin) for prophylactic antibiotic use is not recommended in current clinical practice.</span>'''
-*##** '''Fluoroquinolone agents have potentially adverse side effects including QTc prolongation, tendon rupture, and increased risk of aortic rupture'''
+*##** '''<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'''
@@ Line 200: / Line 218: @@
 *##*** Nitrofurantoin 50-100mg
 *##*** Cephalexin 250mg
-'''Non-antibiotic prophylaxis (2):'''
-# '''Cranberry prophylaxis can be offered for women with rUTIs.'''
+====== <span style="color:#ff0000">Non-antibiotic prophylaxis (2):</span> ======
+# '''<span style="color:#ff0000">Cranberry prophylaxis</span>'''
 #* 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
+#* '''<span style="color:#ff0000">Indications</span>'''
-# '''Vaginal estrogen'''
+#**'''<span style="color:#ff0000">Can be offered for women with rUTIs</span>'''
-#* '''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 juice and tablet formulations are available
-#** '''Oral or other formulations of systemic estrogen therapy have not been shown to reduce UTI and are associated with different risks and benefits.'''
+# '''<span style="color:#ff0000">Vaginal estrogen</span>'''
-#** Given low systemic absorption, risks generally associated with systemic estrogen (cardiovascular disease, thrombosis, breast cancer) are minimal with vaginal estrogen.
+#* '''<span style="color:#ff0000">Indications</span>'''
+#**'''<span style="color:#ff0000">Recommended in peri-and post-menopausal women with rUTIs,</span>''' 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.