AUA & CUA Recurrent UTI (2019): Difference between revisions
Urology4all (talk | contribs) |
Urology4all (talk | contribs) |
||
| (9 intermediate revisions by the same user not shown) | |||
| Line 5: | Line 5: | ||
*This guideline only describes diagnosis and treatment of recurrent episodes of UNCOMPLICATED cystitis in women. | *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. | ** “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. | * '''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 50: | Line 50: | ||
*** When there is high suspicion for contamination, consider obtaining a catheterized specimen for further evaluation prior to treatment. | *** 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. | *** '''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">Differential Diagnosis of UTI (10):</span>''' | ||
*# '''<span style="color:#ff0000">Interstitial cystitis/bladder pain syndrome</span>''' | *# '''<span style="color:#ff0000">Interstitial cystitis/bladder pain syndrome</span>''' | ||
| Line 84: | Line 84: | ||
*# '''<span style="color:#ff0000">≥3 episodes within 1 year</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 | *#* 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 | *#* '''<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. | *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 95: | Line 95: | ||
* '''<span style="color:#ff0000">Optional (1):</span>''' | * '''<span style="color:#ff0000">Optional (1):</span>''' | ||
*# '''<span style="color:#ff0000">PVR</span>''' | *# '''<span style="color:#ff0000">PVR</span>''' | ||
* Not recommended | * '''Not recommended''' | ||
** Cystoscopy | ** '''Cystoscopy''' | ||
** Upper tract imaging | ** '''Upper tract imaging''' | ||
==== Mandatory ==== | ==== Mandatory ==== | ||
===== History and Physical Exam ===== | |||
* '''<span style="color:#ff0000">History''' | |||
*** ''' | ** '''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''' | ||
**Back or flank pain; catheter usage; vaginal discharge or irritation | |||
**'''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''' | |||
** '''Risk factors for complicated UTI (see [[Urinary Tract Infections|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''' | |||
* '''<span style="color:#ff0000">Physical Exam''' | |||
** '''<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 ==== | ==== Optional ==== | ||
*'''<span style="color:#ff0000">Post-void Residual''' | *'''<span style="color:#ff0000">Post-void Residual''' | ||
** '''<span style="color:#ff0000">Indications</span>''' | ** '''<span style="color:#ff0000">Indications</span>''' | ||
***'''Can be considered for all patients''' | ***'''<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">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">Significant anterior vaginal wall prolapse</span>''' | ||
| Line 140: | Line 141: | ||
*'''<span style="color:#ff0000">Options (2):</span>''' | *'''<span style="color:#ff0000">Options (2):</span>''' | ||
*#'''<span style="color:#ff0000">Education</span>''' | *#'''<span style="color:#ff0000">Education</span>''' | ||
*#'''<span style="color:#ff0000"> | *#'''<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''' | |||
===== Intervention ===== | ===== Intervention ===== | ||
| Line 164: | Line 168: | ||
====== Antibiotics ====== | ====== Antibiotics ====== | ||
* '''Acute cystitis''' | * '''<span style="color:#ff0000">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''' | ** '''<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. | *** 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 | ||
| Line 175: | Line 179: | ||
***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 | ***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%] | *** 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 | ***'''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''' | ** '''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.''' | *** '''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.''' | ||