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Treating Students with Urinary Tract Infections. Sara Mackenzie, MD, MPH Regional Health Specialist October 18, 2012. After this presentation, you will be able to:. Describe the prevalence of UTI in men and women Describe how to assess for uncomplicated UTI

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Treating Students with Urinary Tract Infections

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Treating Students with Urinary Tract Infections

Sara Mackenzie, MD, MPH

Regional Health Specialist

October 18, 2012


After this presentation, you will be able to:

  • Describe the prevalence of UTI in men and women

  • Describe how to assess for uncomplicated UTI

  • List common antibiotics and indications for treatment of uncomplicated UTI

  • Identify red flags for complicated UTI or other infections (such as STI)


Can I get a sense of who is on call?

  • Center physician?

  • Center health and wellness manager?

  • Center nurse or LPN?

  • TEAP/CMHC?

  • Other?


Terminology:

UTI = urinary tract infection

Lower urinary tract: UTI=cystitis= bladder infection

Upper urinary tract: pyelonephritis=

kidney infection


Why discuss?

  • Global:

    > 250 million UTIs/yr

    > $7 billion direct costs

  • United States, annual figures:

    > 7 million uncomplicated UTIs

    > 250,000 acute pyelonephritis

    > 4 million UTIs in pregnancy

    > 1 million catheter-associated UTIs


In women:

  • Acute, uncomplicated UTI:

    • 3% of all women visit ≥ once a year

    • ≥ 50% report at least one per lifetime

  • Recurrent UTI:

    • 20-40% develop frequent (≥ 3/yr.)


In men:

  • Incidence significantly lower

    • 5 to 8 UTI per year per 10,000 men

  • Longer urethral length, drier periurethral environment, less frequent colonization with bacteria around urethra, and antibacterial substances in prostatic fluid


Mechanism of infection:


Complicated

  • A UTI is said to be “complicated” UTI if:

    • Diabetes

    • Pregnancy

    • History of pyelo in last year

    • Antibiotic resistance

    • Symptoms more than 7 days before seeking care

    • Hospital acquired infection

    • Functional or structural abnormality (such as stones, anatomical)

    • Immunosuppression

    • Male

  • Important to identify as higher risk of failing therapy


Uncomplicated

  • To say another way—a UTI is said to be “uncomplicated” if:

    • Female

    • Non-pregnant

    • Otherwise healthy

    • Normal urinary tract


Case 1:

22-year-old female who is otherwise healthy comes in to Health and Wellness complaining that “it hurts when I pee, I feel like I have to go right away, and I have to pee all the time”.

  • Uncomplicated UTI

  • Complicated UTI

  • Need more information


Presentation lower UTI

  • Dysuria, urgency and frequency [Suprapubic pain +/- hematuria (blood in urine)]

  • The probability of cystitis in a woman with one of the first three symptoms is 50%

  • The probability of cystitis in a woman with dysuria, frequency and NO vaginal discharge or irritation is 90%


Evaluation:

  • Review clinical history – up to date problem list 

  • Review recent antibiotic use

  • Ask about recent new sexual partners (STI risk) and pregnancy risk

  • Physical exam: assess for fever, costovetebral angle tenderness and abdominal exam

  • Pelvic not usually indicated


Evaluation (continued):

  • Do you need to do urinalysis:

    • Leukocyte esterase detects white blood cells

    • Nitrite detects enterobacteriaceae

    • Hematuria common in UTI

  • Dipstick most accurate for predicting UTI if positive for either leukocyte esterase or nitrite

    ***Results of dipstick provide little additional useful information if history strongly suggestive of UTI!


Back to the Case

  • 22 Y/O with dysuria, frequency, urgency,

  • No prior medical history, antibiotic use, previous UTI or risk for STI or pregnancy

  • No fever, no CVA tenderness

  • Do you need to do a urine culture?

    • Yes

    • No

    • Need more information


Urine Culture

  • Empiric treatment usually indicated as pathogens are predictable


Microbiology

*Uncomplicated UTI and pyelo 75-95% e.coli


Urine culture

Culture indicated if:

  • Symptoms not characteristic

  • Persist or recur within 3 months of prior infection or antibiotic use

  • If not responding to empiric treatment within 24 to 48 hours

  • If suspect complicated infection

  • In all women with suspected pyelonephritis

  • All men suspected to have UTI


What antibiotic for uncomplicated cystitis?

  • Target for e. coli

  • Weigh cost, availability, allergy profile

  • Nitrofurantoin 100mg twice daily for 7 days

    OR

  • Trimethaprimsulfamethoxazole (Bactrim DS) 1 pill twice daily for 3 days


What antibiotic should be used?

  • Consider local resistance patterns

  • Local public health department or hospital should have information on resistance patterns in community


E. coli resistance (UW Hall Health N=1,284)

Empiric bactrim treatment should be avoided if local resistance patterns exceed 20%


Fluoroquinolones:

  • Not recommended as first line by IDSA 2011 guidelines

    • Selection of more drug resistant organisms

    • Colonization with multidrug resistant organisms

    • Reserve for more serious infections


UTI Prevention

  • 20 to 40% of women will develop recurrent (>3/year)

  • Frequency of sexual intercourse strong risk factor

  • Review contraceptive options – avoid spermicides

  • Discuss urination after sex and increase fluids

  • Cranberry juice ??


UTI Prevention

  • Consider antibiotic prophylaxis

    • Prophylaxis advocated if 2 or more in 6 months or 3 or more over 12 months

      • After sex – single post coital dose

      • Daily – proven reduction in recurrence; take for 6 to 12 months;

      • Nitrofurantoin or bactrim or cipro can be used


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