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Genitourinary Tract Infections: An Evidence-Based Approach Ralph Gonzales, MD, MSPH Associate Professor of Medicine; Epidemiology & Biostatistics.

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Presentation on theme: "Genitourinary Tract Infections: An Evidence-Based Approach Ralph Gonzales, MD, MSPH Associate Professor of Medicine; Epidemiology & Biostatistics."— Presentation transcript:

1 Genitourinary Tract Infections: An Evidence-Based Approach Ralph Gonzales, MD, MSPH Associate Professor of Medicine; Epidemiology & Biostatistics

2 Self-Assessment Questions -35 yo woman calls with 2-3 days of painful urination, increased urinary frequency and urgency. a) What are the key questions that will help determine if she can be treated by telephone? b) If she fulfills criteria for telephone treatment, what is her probability of having a true UTI? c) If she happened to stop by your office, is there any value to performing a urinalysis? d) What would you treat her with? e) Does she need follow-up appointment or urine culture? f) Patient doesnt get better, dysuria continues. Other causes?

3 Self-Assessment Questions -35 yo woman calls with 4-5 days of new, foul-smelling vaginal discharge. a) What are the key questions that will help determine if she can be treated by telephone? b) What is her probability of having a candidal vaginitis (ie, available OTC therapy)? c) How helpful are findings on history and physical examination in establishing an etiology? d) How helpful is microscopy? e) What management options should be considered for recurrent yeast infections?

4 Background: Acute Uncomplicated UTI is Common Uncomplicated UTI is an extremely common disorder in women Over 7 million office visits annually Affects half of women at least once during their lifetime Direct costs attributed to these infections in the US: $1 billion yearly

5 Background: Microbiology and Pathogenesis of Cystitis Organisms: E. coli, S. saprophyticus, Proteus, Klebsiella Pathogenesis: Fecal flora Vaginal introitus Urethra Bladder

6 Important Risk Factors for Cystitis in Women Past history of cystitis, especially if recurrent Recent sexual intercourse Recent diaphragm and/or spermicide use Unmarried Lack of urination after sexual intercourse Presence of asymptomatic bacteruria

7 Clinical Manifestations of UTI Clinical features of cystitis Dysuria +/- frequency, urgency, suprapubic pain Clinical features of pyelonephritis Fever, flank pain, CVA tenderness, nausea, vomiting Differential Diagnosis For cystitis: urethritis or vaginitis For pyelonephritis: an abdominal process

8 Clinical Features of Complicated UTIs recent UTI structural abnormalities –Genetic/surgical/nephrolithiasis diabetes immunosuppression pregnancy urethral instrumentation

9 How Good is History for the Diagnosis of Cystitis (vs. vaginitis)?

10 Positive Predictive Values for Combinations of Symptoms Prob UTI, %Summary LR -Dysuria Present -Frequency Present -Vaginal Discharge Absent -Vaginal Irritation Absent Overall 77% Dysuria Absent -Vag D/C or Irritation Present Overall 4% 0.3 -Dysuria or Frequency Present -Vag D/C or Irritation Absent Overall 9% 0.7 Bent et al, JAMA 2002

11 How Good are Lab Tests for the Diagnosis of Cystitis (vs. vaginitis)?

12 How Effective is Treatment of Cystitis? Pooled Results from RCTs

13 Irritable Voiding Symptoms 35 yo woman c/o 2-3 d painful urination, increased frequency, urgency. Denies fever, back pain. Question #1: When should I perform urinalysis?

14 Urinary Tract Infections -Test Characteristics (Bent et al) Likelihood Ratios positive negative Dysuria 1.5 ( )0.5 ( ) Frequency 1.8 ( )0.6 ( ) Hematuria 2.0 ( )0.9 ( ) Fever 1.6 ( )0.9 ( ) Flank Pain 1.1 ( )0.9 ( ) Vaginal Discharge (Hx) 0.3 ( )3.1 ( ) Vaginal Irritation 0.2 ( )2.7 ( ) Back Pain 1.6 ( )0.8 ( ) Vaginal Discharge (PEx) 0.7 ( )1.1 ( ) CVAT 1.7 ( )0.9 ( ) Urinalysis

15 Goal of Diagnostic Testing Probability of Disease 0% 50% 100% Treatment Threshold Diagnostic Threshold

16 Goal of Diagnostic Testing Probability of Disease 0% 50% 100% Treatment Threshold Diagnostic Threshold

17 Dysuria Case UTI Prob 1.5 dys *1.8 freq *3.1 d/c- *2.7 irr- =23 Step 1: -12/88 = Step 2: x 23 = Step 3: /4.2 2 = 76%

18 UTI Post-Test Probabilities Bent et al. PreTest Prob

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20 Voiding symptoms cont. Question #1: Why perform urinalysis? –Positive test: ppv = 93% –Negative test:npv = 49% You diagnose uncomplicated UTI and refrain from performing UA –… what are your treatment options?

21 Uncomplicated UTI Rx TMP-sulfa DS bid x 3 days ciprofloxacin, bid x 3 days keflex 250 tid x 7 days macrobid 100 bid x 7 days amoxicillin 500 tid x 7 days Follow-up: No visit or Cx if asymptomatic after 3 days, else return for re-eval. Prevention: avoid spermicides; sexual activity ?Cranberry

22 Suspected UTI Algorithm Woman > 1 UTI Sx Risk Factors? Fever, Back Pain, N/V? Vaginitis Sx? Multiple UTI Sx Present High Prob UTI, Rx w/o Testing About 20% UTI Perform Pelvic Consider UCx, Empirial Rx Perform Urinalysis yes Adapted from Bent et al

23 When should we consider STD Testing?

24 STDs can present with dysuria: -gonorrhea, chlamydia, trichomonas Shapiro et al. Bronx, NY, ED setting ( Acad Emerg Med. 2005) –All women had straight cath urine cultures and pelvic exams –Used low bacteria count criteria for UTI in symptomatic women (100 cfu) –Excluded if new vaginal D/C or other reasons to suspect STD present –Mean duration of symptoms: 6.8 days RESULTS Urine culture (+) = 57% Chlamydia (+) = 10%; GC (+) = 1% (n=1); Trich (+) = 8% STD rates equivalent in UCx positive and negative groups **Only predictor of STD was # sexual partners in past year Conclusion: Consider STD testing all women with dysuria seeking ED care, particularly those with >1 sexual partner in the past year.

25 Is Non-Invasive STD Testing Ready for Prime Time?

26 Non-invasive (urine) testing for GC and chlamydia Systematic review Cook et al. Ann Intern Med 2005;142: Pooled Pooled SensitivitySpecificity Polymerase chain reaction >97% -chlamydia women/men 83%/84% -GC women 56% Transcription-mediated amplification >97% -chlamydia women 93%/88% -GC women 91% Strand displacement amplication >97% -chlamydia women 90%/93% -GC women 85% Conclusion: non-invasive testing equivalent to cervical swab testing –Except for GC PCR –?confirmatory test when screening low (<5%) prevalence population If spec=98%, then about 1/3 positives are false-positives If spec>99%, probably not necessary…

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28 Vaginitis Symptoms 35 yo woman c/o 4-5 days of foul-smelling, cheesy vaginal discharge and severe itching. Calls by telephone. Question #1: What clinical features can be used to reliably diagnose vulvovaginal candidiasis? When should I perform microscopy?

29 Etiology of Vaginitis in PC 40% Bacterial Vaginosis 30% Unknown 20% Candida 10% Trichomonas Other Causes GC/chlamydia?… investigate when fever/lower abd pain HSV allergic reaction (chemical, latex, semen) atrophic vaginitis

30 Challenges in History Women buying OTC yeast preps –candida=33%; BV=19%; mixed=21%; normal exam=12%; trichomonas=2% Patients and physicians disagree on key findings patientphysician –clear d/c 21% 13% –yellow d/c 15% 6% –white/gray d/c 42% 71% Poor agreement between call center nurse diagnosis and physician

31 Vaginitis -Likelihood Ratios for Hx/PEx (Anderson et al) Likelihood Ratios positive negative YEAST Cheesy Discharge 2.4 ( )0.5 ( ) Watery Discharge 0.1 ( )1.5 ( ) Itching 1.7 ( )0.3 ( ) Chief Complaint 3.3 ( )0.8 ( ) Malodor0.5 ( ) 1.6 ( ) Curdy D/C or Vulvar Inflamm. 17 (8.8-32) 0.2 ( ) Curdy D/C + Itching 150 (20-100) 0.2 ( ) Fishy Odor (PEx) 0.03 (0-0.5) 2.9 ( ) BACTERIAL VAGINOSIS Malodor (Hx) 1.6 ( )0.07* ( ) High Cheese Odor (PEx) 3.2 ( ) 0.30 ( )

32 Candida Vaginitis Post-Test Probabilities Anderson et al. PreTest Prob

33 Vaginitis Case: Yeast Prob 2.4 chs *1.5 wtry- *3.3 itch *0.5 odor =5.9 Step 1: -20/80 = Step 2: x 5.9 = Step 3: / = 60%

34 Vaginitis symptoms cont. Question #2: Why perform microscopy? –Agreement between clinician-read microscopy & culture is poor. –Rapid commercial tests are here/around the corner You diagnose candidal vaginitis… you treat with fluconazole 150 mg x 1, but patient returns 1 week later with recurrence. What now?

35 Complicated Candidiasis CDC MMWR 2002;51:RR-6 Recurrent vulvovaginal candidiasis obtain vaginal culture to assess for non-albicans species treatment: topical therapy x 7-14 d; or fluconazole 150 mg, po, repeated in 3 d maintenance (x 6 mo): clotrimazole 500 mg vag supp q week; fluconazole mg q week; itraconazole 400 mg q month or 100 mg q d. Severe vulvovaginitis treatment: topical therapy x 7-14 d; or fluconazole 150 mg, po, repeated in 3 d Non-albicans vulvovaginitis treatment: 7-14 d non-fluconazole azole drug; if recurs, 600 mg boric acid in gelatin capsule qd x 2 wks

36 Bacterial Vaginosis CDC MMWR 2002;51:RR-6 Criteria 3 of 4 present: vaginal discharge clue cells vaginal pH > 4.5 whiff test (fishy odor after 10% KOH Management of Sex Partners response to Rx and relapse are not affected by Rx of sex partner Treatment Clinical Criteria Recommended Regimen* metronidazole 500 mg bid x 7 d, OR metronidazole gel 0.75%, one full applicator (5 g) iv, qd x 5 d, OR clindamycin cream 2%, one full applicator (5 g) iv qhs x 7d Alternative Regimens metronidazole 2 g po x 1, OR clindamycin 300 mg po bid x 7 d, OR clindamycin ovules 100 g iv qhs x 3 d

37 Trichomoniasis CDC MMWR 2002;51:RR-6 Counseling Management of Sex Partners treat sex partners Treatment Microscopy or Cx Recommended Regimen* metronidazole 2 g po x 1 Alternative Regimens metronidazole 500 mg bid x 7 d

38 SUMMARY UTI Typical Voiding Sx and no vaginitis... Empiric Rx Know local E.coli antibiotic-resistance rates Threshold 20-30% sulfa-resistance to switch to FQ first-line… Consider STD testing, particularly in young, sexually active women (prevalence >=10%)… particularly for Chlamydia Non-invasive testing is a reliable option Vaginitis Curdy discharge + vulvar inflamm/itching = Yeast Malodor = non-yeast Absence of malodor history may rule-out BV.


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