AUA & CUA Recurrent UTI (2019)
- 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
- “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.
- 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
- ≈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.
Acute Bacterial Cystitis
Definition
- Diagnosis of acute bacterial cystitis requires (2):
- Laboratory confirmation of significant bacteriuria AND
- Acute-onset symptoms (lower urinary tract symptoms)
- In this guideline, the term UTI will refer to culture-proven acute bacterial cystitis and associated symptoms unless otherwise specified.
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.
- Given the subjective nature of these symptoms, careful evaluation of their chronicity becomes an important consideration.
- Urinary tract infection symptoms include dysuria, central to the diagnosis of UTI, with variable degrees of:
- Symptoms
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
- 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.
- 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.
- Urine culture contamination should be suspected when (3):
- Urine culture remains the mainstay of diagnosis of an episode of acute cystitis
Differential Diagnosis
- Differential Diagnosis of UTI (10):
- Interstitial cystitis/bladder pain syndrome
- Overactive Bladder
- Urinary calculi
- Infectious bacterial or fungal vaginitis
- Vulvar dermatitis
- Non-infectious vulvovestibulitis
- Vulvodynia
- Hypertonic pelvic floor muscle dysfunction
- Genitourinary syndrome of menopause
- CIS of the bladder (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
- Definition: bacteriuria of any magnitude without symptoms
- Management
- DO NOT routinely treat asymptomatic bacteriuria
- No evidence that treatment of asymptomatic bacteriuria improves outcomes
- Indications for screening/treatment of asymptomatic bacteriuria (2):
- Pregnant females
- 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.
- DO NOT routinely treat asymptomatic bacteriuria
Recurrent UTI
Definitions
- Definition of Recurrent UTI: Either (2):
- ≥2 episodes of acute bacterial cystitis within 6 months or
- ≥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 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
- Mandatory (1):
- History and Physical Exam
- Optional (1):
- PVR
- Not recommended
- Cystoscopy
- Upper tract imaging
Mandatory
- History and Physical Exam
- 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
- Focused neurological exam
- May also be considered to rule out occult neurologic defects
- Abdominal and pelvic examination
- History
Optional
- Post-void Residual
- Indications
- Can be considered for all patients
- 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.
- Indications
Not recommended (2):
- Cystoscopy and upper tract imaging
- 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
- In patients with gross hematuria in the presence of a positive urine culture and no risk factors for urothelial malignancy (e.g., age under 40, non-smoker, no environmental risk), cystoscopy is not necessary.
- If any risk factors are present, cystoscopy should be performed.
- Low yield of anatomical abnormalities with cystoscopy and upper tract imaging in patients with uncomplicated rUTI.
Management
Conservative
- Options (2):
- Education
- Behaviour modification
- 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.
- 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.
- Behaviour modification (2):
- 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
- Education and Informed Decision Making
Intervention
- Options (3):
- Antibiotics
- Non-antibiotic prophylaxis
- Cranberry
- Vaginal estrogen (if post-menopausal)
Antibiotics
- Acute cystitis
- 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
- 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
- Options (3):
- 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.
- 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.
- 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
- Obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs
- 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.
- 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)
- 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 (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
- 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
- Options:
- 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
- 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.
- Self-start antibiotics: patient-initiated treatment for acute episodes while awaiting urine cultures.
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
- Indications
- Can be offered for women with rUTIs
- Oral juice and tablet formulations are available
- 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.
- Recommended in peri-and post-menopausal women with rUTIs, if there is no contraindication to 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.
- Indications
- Lactobacillus is not recommended as a prophylactic agent for rUTI given the lack of data
Questions
- What is the definition of recurrent UTIs?
- What is an uncomplicated UTI?
- List 10 factors that classify a UTI as complicated.
- What are the 3 antibiotic regimens to treat recurrent UTIs?
- Urine culture demonstrating growth of which bacteria would be considered contaminant?
- What is the workup of a patient with recurrent UTIs?
- What is the differential diagnosis of a UTI?
- Take a history and describe the physical exam in a patient with recurrent UTI
- What are the indications to treat asymptomatic bacteriuria?
- When should a urine culture be repeated in patients that have started treatment for UTI?
- What conservative recommendations can be made to reduce risk of recurrent UTI?
- Describe 3 first-line antibiotic therapies for uncomplicated symptomatic UTI
- Describe 3 options for continuous antibiotic prophylaxis in the context of recurrent UTI
- What are drug-specific adverse events related to fluoroquinolone use?
- What is the role of cranberry or lactobacillus in the treatment of recurrent UTI?
Answers
- What is the definition of recurrent UTIs?
- ≥2 UTI within 6 months or ≥3 UTI within 12 months
- What is an uncomplicated UTI?
- A UTI in a female patient has no known factors that would make her more susceptible to develop a UTI
- List 10 factors that classify a UTI as complicated.
- UTI with multidrug resistant bacteria
- Anatomic abnormality: cystocele, diverticulum, fistula
- Iatrogenic: indwelling catheter, nosocomial infection, surgery
- Voiding dysfunction: VUR, neurologic disease, pelvic floor dysfunction, high PVR, incontinence
- Obstruction: Bladder outlet obstruction, ureteral stricture, UPJO
- Other: pregnant, urolithiasis, diabetes, immunosuppression, UTI in men
- What are the 3 antibiotic regimens to treat recurrent UTIs?
- Self-start
- Prophylaxis
- Post-coital
- Urine culture demonstrating growth of which bacteria would be considered contaminant?
- Lactobacilli
- Corynebacteria
- Group B Streptococci
- Non-saprophyticus coagulase-negative Staphylococci
- What is the workup of a patient with recurrent UTIs?
- History, physical exam (no role for cystoscopy or imaging in initial workup)
- What is the differential diagnosis of a UTI?
- Interstitial cystitis/bladder pain syndrome
- OAB
- Genitourinary syndrome of menopause
- Urinary calculi
- Infectious bacterial or fungal vaginitis
- Vulvar dermatitis
- Non-infectious vulvovestibulitis
- Vulvodynia
- Hypertonic pelvic floor muscle dysfunction
- CIS of the bladder
- Take a history and describe the physical exam in a patient with recurrent UTI
- History: characterize LUTS, baseline GU symptoms between infections, UTI history, bowel symptoms, menopausal status, contraceptive method
- Physical exam: abdominal and pelvic exam, focused neurologic exam, +/- PVR
- What are the indications to treat asymptomatic bacteriuria?
- Pregnant women
- Patient undergoing elective urologic surgery
- When should a urine culture be repeated in patients that have started treatment for UTI?
- If symptoms persist > 7 days
- What conservative recommendations can be made to reduce risk of recurrent UTI?
- Avoid barrier contraceptives and spermicidal products
- Drink >1.5L water/day
- 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, and douching
- Describe 3 first-line antibiotic therapies for uncomplicated symptomatic UTI
- Nitrofurantoin 100mg BID x 5 days
- TMP-SMX 1 tab DS BID x 3 days
- Fosfomycin 3g x 1 dose
- Note that ciprofloxacin is not considered first-line
- Describe 3 options for continuous antibiotic prophylaxis in the context of recurrent UTI
- Nitrofurantoin 100mg daily
- Cephalexin 250mg daily
- Fosfomycin 3g q10days
- What are drug-specific adverse events related to fluoroquinolone use?
- Prolonged QT syndrome
- Aortic rupture
- Tendon rupture
- What is the role of cranberry or lactobacillus in the treatment of recurrent UTI?
- Cranberry can be offered, lactobacillus is not recommended