1. CATHERINE M. BETTCHER, M.D. CME DIRECTOR, ASSISTANT PROFESSOR DEPARTMENT OF FAMILY MEDICINE UNIVERSITY OF MICHIGAN UTIs in Women

2. Learning Objectives Apply evidence-based recommendations to the diagnosis of UTI in adult women Determine when telephone triage for diagnosis is appropriate Apply evidence-based recommendations for the treatment of UTI in adult women Implement strategies to prevent recurrence of UTI

3. Incidence Most common bacterial infection in women 27% of college-aged women had another UTI within 6 months Colgan R, Williams M. Am Fam Phys. 2011; Kodner CM, Thomas Gupton, EK. Am Fam Phys. 2010.

4. Etiology E. Coli86% Staph saprophyticus4% Klebsiella species3% Proteus species3% Enterobacter species1.4% Colgan R, Williams M. Am Fam Phys. 2011

5. Complicating Factors for Cystitis  Diabetes  Immunosuppression  Pregnant  Urologic abnormalities, including nephrolithiasis and catheter use  Recent hospitalization / nursing home  Symptoms for > 7 days  ? Postmenopausal Gradwohl SE et al. University of Michigan guideline. 2011.

6. Lower Urinary Tract Symptoms Dysuria, frequent voiding of small volumes, urinary urgency Less commonly hematuria and suprapubic discomfort Not vaginal discharge or irritation

7. Use of Urine Dipstick Leukocyte esterase indirectly indicates pyuria Nitrite only turns positive in presence of bacteria that make nitrate reductase Negative nitrites and leukocyte esterase decreases the odds of UTI by 40-60% Simati et al. Am Fam Phys. 2013.

8. Use of Urine Culture Suspicion of acute pyelonephritis Atypical symptoms Symptoms that do not resolve or that recur within 2- 4 weeks after treatment Colgan R, Williams M. Am Fam Phys. 2011; Gradwohl SE et al. University of Michigan guideline. 2011.

9. Asymptomatic Bacteriuria Gradwohl SE et al. University of Michigan guideline. 2011. Defined as >50,000 CFU/ml of bacteria in urine culture of asymptomatic patients Higher incidence in patients with chronic indwelling catheters No screening or treatment recommended except for:  Pregnancy  Before urologic procedures

10. What counts as positive urine culture? Sensitivity of 50% if threshold for positive > 100,000 CFU/ml Sensitivity > 90% if threshold for positive > 100 CFU/ml Gradwohl SE et al. University of Michigan guideline. 2011.

11. Complicated Cystitis Send culture with sensitivities Treat with trimethoprim/sulfa or a fluoroquinolone for 7-14 days Obtain follow up urinalysis Consider evaluation for structural abnormalities

12. Kodner CM, Thomas Gupton EK. Recurrent urinary tract infections in women: diagnosis and management. Am Fam Phys. 2010;82(6):638- 643.

13. Phone Triage by RN Avoid office visits  reduce cost, increase appropriate antibiotic use Use in women with previous UTI responsive to antibiotic

14. Phone Triage Gradwohl SE, Bettcher CM, Chenoweth CE, Harrison RV, Zoschnick LB. Urinary tract infection. Ann Arbor, MI: Office of Clinical Affairs, University of Michigan Health System, 2011.

15. Treatment of UTI 3-5 day course of antibiotic Longer courses for complicated UTI Increasing resistance to trimethoprim / sulfa, but antibiotic concentrates in the urine Gradwohl SE et al. University of Michigan guideline. 2011

16. Treatment Regimens 1 st Line:Trimethoprim / Sulfamethoxazole 160/800 mg (1 DS tab) bid x 3 days Nitrofurantoin100 mg bid x 5 days Fosfomycin3-g single dose 2 nd Line:Ciprofloxacin250 mg bid x 3 days Ciprofloxacin extended release500 mg daily x 3 days Levofloxacin250 mg daily x 3 days 3 rd Line:Amoxicillin / clavulanate500/125 mg bid x 7 days Cefdinir300 mg bid x 10 days Cefpodoxime100 mg bid x 7 days Colgan R, Williams M. Am Fam Phys. 2011. Avoid trimethoprim / sulfa if resistance exceeds >20% or if used for UTI in previous 3 months Avoid fluoroquinolones in pregnancy

17. Recurrent UTIs Defined as > 3 / year, or 2 within past 6 months Probably caused by reinfection Obtain urine culture No specific guidelines to recommend imaging  Consider US or CT with recurrent non-coital UTIs, persistent hematuria associated with UTIs, acute pyelonephritis, or renal insufficiency Treat the same as uncomplicated UTI Consider follow up urine culture to distinguish relapse from recurrence Kodner CM, Thomas Gupton, EK. Am Fam Phys. 2010; Gradwohl SE et al. University of Michigan guideline. 2011.

18. Risk Factors for Recurrent UTI Risk factorOdds ratio Sex > 9 times in past month10.3 Sex 4-8 times in past month5.8 Age at 1 st UTI ≤ 15 yrs3.9 Maternal history of UTIs2.3 New sex partner in past year1.9 Spermicide use in past year1.8 Kodner CM, Thomas Gupton, EK. Am Fam Phys. 2010 * Post-menopausal with post-void residual > 50 ml

19. Prevention of UTI Antibiotic prophylaxis Intravaginal estrogen in post-menopausal women Self-initiated therapy AntibioticContinuous prophy Postcoital prophy cephalexin125 to 250 mg250 mg ciprofloxacin125 mg nitrofurantoin50 to 100 mg norfloxacin200 mg trimethoprim100 mg trimethoprim/sulfamethoxazole40/200 mg40/200 to 80/400 mg Kodner CM, Thomas Gupton, EK. Am Fam Phys. 2010

20. Do cranberry products prevent UTIs? 2008 guideline: cranberry products decrease UTIs in sexually active women 2012 Cochrane review included 14 more studies, total of 4473 participants  cranberries do not reduce UTIs overall or for subgroups (women with recurrent UTIs, older people, pregnant women, children with recurrent UTI) Jepson RG, et al. Cochrane Database of Systematic Reviews 2012.

21. UTIs in Pregnancy Screen for asymptomatic bacteriuria between 12 and 16 wks Treat with 7 day course of Category B drug Send follow up urine culture Hospitalize for acute pyelonephritis

22. Conclusions Diagnose UTI based on history, possibly supplemented by UA Prescribe trimethoprim/sulfa or nitrofurantoin as 1 st line treatment Counsel patients about risk factors for recurrent UTI Prescribe antibiotic prophylaxis, or allow patients to self treat

23. References Arnold JJ, Hehn LA, Klein DA. Common questions about recurrent urinary tract infections in women. Am Fam Phys. 2016;93(7):560-569. Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Phys. 2011;84(7):771-776. Flower A, Wang LQ, Lewith G, Liu JP, Li Q. Chinese herbal medicine for treating recurrent urinary tract infections in women. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD010446. Gradwohl SE, Bettcher CM, Chenoweth CE, Harrison RV, Zoschnick LB. Urinary tract infection. Ann Arbor, MI: Office of Clinical Affairs, University of Michigan Health System, 2011. Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD001321. Kodner CM, Thomas Gupton EK. Recurrent urinary tract infections in women: diagnosis and management. Am Fam Phys. 2010;82(6):638-643. Simati B, Kriegsman W, Safranek S. Dipstick urinalysis for the diagnosis of acute UTI. Am Fam Phys. 2013;87(10).