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”.

A. Uncomplicated UTI

B. Complicated UTI

C. 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• Trimethaprim sulfamethoxazole

(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