1. Treating Students with Urinary Tract Infections
Sara Mackenzie, MD, MPH
Regional Health Specialist
October 18, 2012

2. 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)

3. Can I get a sense of who is on call?
Center physician?
Center health and wellness manager?
Center nurse or LPN?
TEAP/CMHC?
Other?

4. Terminology:
UTI = urinary tract infection Lower urinary tract: UTI=cystitis= bladder infection Upper urinary tract: pyelonephritis= kidney infection

5. Why discuss? Global: United States, annual figures:
> 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

6. In women: Acute, uncomplicated UTI: Recurrent UTI:
3% of all women visit ≥ once a year
≥ 50% report at least one per lifetime
Recurrent UTI:
20-40% develop frequent (≥ 3/yr.)

7. 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

9. Mechanism of infection:

10. 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

11. Uncomplicated
To say another way—a UTI is said to be “uncomplicated” if:
Female
Non-pregnant
Otherwise healthy
Normal urinary tract

12. 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

13. 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%

14. 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

15. 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!

16. 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

17. Urine Culture
Empiric treatment usually indicated as pathogens are predictable

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

19. 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

20. 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

21. What antibiotic should be used?
Consider local resistance patterns
Local public health department or hospital should have information on resistance patterns in community

22. E. coli resistance (UW Hall Health N=1,284)
Empiric bactrim treatment should be avoided if local resistance patterns exceed 20%

23. 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

25. 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 ??

26. 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