Management

Management of UTI in Women

• Uncomplicated Cystitis
  • Urologic investigation in not routinely indicated
  • Diagnosis is often empiric, however, a urinalysis and/or culture can provide helpful documentation of the true diagnosis and causative organism
  • Caveats
    • Normal vaginal flora can appear to be gram-negative bacteria on urinalysis
    • Pyuria may be noted in a variety of inflammatory conditions of the urinary tract
    • If the patient is drinking increased fluids and voiding frequently, the urine will be dilute, and signs of infection on urinalysis may be missing
    • One-third of women with acute symptomatic cystitis caused by E. coli, S. saprophyticus, or Proteus have colony counts of midstream urine specimens ranging from 10² to 10⁴ cfu/mL. Thus, a pure culture in the presence of symptoms must be considered significant, regardless of colony count.
  • Treatment
    • Often empirical and not based on culture data
    • Drug choice criteria
      • The relative likelihood that it will be active against enteric bacteria that commonly produce UTIs
      • Its ability to achieve high concentrations in the urine
      • Its tendency not to alter the bowel or vaginal flora or to select for resistant bacteria
      • Limited toxicity
      • Availability at reasonable cost to the patient
    • 3 days of antibiotic will suffice to clear the vast majority of uncomplicated urinary tract infections. Single dose therapy is slightly less efficacious.
  
  
• Unresolved Bacteriuria
  • Persistent symptoms following treatment for UTI, necessitates repeat urine culture and sensitivity testing.
  • Choice of antibiotic will depend on the results obtained, and a 7- to 10-day course would be reasonable.
  • Repeat culture and bacterial identification (if positive) following treatment for unresolved bacteriuria is important in order to later differentiate the problem from recurrent infection from a site within the urinary tract.
  
  
• Recurrent Bacterial Cystitis
  • Culture history is critical in differentiating reinfection from a site outside the urinary tract as the cause of recurrent cystitis from reinfection from a site of bacterial persistence within the urinary tract
  • Recurrent infections that occur after successful antimicrobial eradication (negative culture) and that are subsequently caused by varying strains of Enterobacteriaceae are pathognomonic for reinfection
  • Evaluation
    • A renal and bladder ultrasound will demonstrate normal anatomy, absence of infection stones, and low bladder urinary residual urine volume
    • Flexible office cystoscopy will rule out any urethral stenosis (very rare), urethral diverticulum, or local bladder pathology
  • Treatment strategies
    • Long-term, low-dose antibiotic prophylaxis at six month intervals (rarely used today)
    • "Self-start" therapy relies on the patient to make the clinical diagnosis of UTI. Patients are given a prescription for an appropriate urinary antibiotic (nitrofurantoin, trimethoprim-sulfamethoxazole, cephalosporin), which they take for 3 days at the first sign of infection
      • Dip-slide culture before and after medication is optional
      • If the symptoms do not respond or reoccur within a few days, a visit to the physician for appropriate culture and sensitivity testing is required
      • Fever and flank pain, or the presence of gross hematuria should trigger a visit to the physician.
    • Single-dose therapy
      • Although this might clear the bacteria from the urinary tract, symptoms often persist for 48 hours, and the patient is left unsure as to whether more antibiotic or a different antibiotic is necessary.
    • Post-intercourse therapy
    • If infections seem to be exclusively related to intercourse, and frequency of intercourse is not too high, one can consider a prophylactic antibiotic just before sexual activity to prevent infection.
      • Those having sex on a nightly basis might do better to treat symptomatic infections with short-term courses of antibiotics, thus limiting overall use of antibiotic
  
  
• Choice of Antibiotic
  • Many excellent, inexpensive, first-line antimicrobials to consider for the treatment of uncomplicated lower urinary tract infections in women
    • Nitrofurantoin
    • Trimethoprim with or without sulfamethoxazole (TMPSMX)
    • Cephalosporins
  • Ampicillin and amoxacillin, traditionally regarded as inexpensive first-line therapy, have generally fallen out of favor due to their interference with the fecal flora and the resultant emergence of resistant strains such that these drugs are now ineffective against as many as 30 percent of common urinary isolates.
  • Fluoroquinolones
    • Expensive, powerful oral agents
    • Have a very broad spectrum of activity against most urinary pathogens including Pseudomonas aeruginosa
    • Routine use for treatment of uncomplicated UTI is controversial
    • Gram-positive activity is limited and efficacy against Enterococcus is poor
    • The fear that overuse may lead to the development of resistance and the fact that for most uncomplicated UTIs less expensive drugs are just as effective has tended to limit their use. They remain a valuable class of antibiotic, best restricted to complicated UTIs, pseudomonal infections, or treatment of resistant organisms.
  
  
• Asymptomatic Bacteriuria of Pregnancy
  • Studies suggest a 20 to 40 percent incidence of pyelonephritis if asymptomatic bacteriuria is untreated in this population
  • Bacterial pyelonephritis in pregnancy has been associated with infant prematurity and perinatal mortality
  • Screen for asymptomatic bacteriuria in pregnancy, treat it aggressively, and obtain follow-up cultures
  
  
• Asymptomatic Bacteriuria in the Elderly
  • Up to 20 percent of women and 10 percent of men older than 65 years have bacteriuria. The figures are even higher for nursing home residents
  • Studies suggest that noncatheterized male and female residents of nursing homes with bacteriuria have no higher frequency of courses of an timicrobial treatment, infections, or hospitalizations than those without persistent bacteriuria.
  • Symptomatic urinary tract infections in the elderly patient should be appropriately treated. In addition, it would seem prudent to treat any bacteriuria due to urea-splitting bacteria such as Proteus mirabilis to prevent stone formation
  • Routine treatment of other asymptomatic bacteriuria in the elderly patient appears unjustified

References

Management of Bacterial Cystitis in Men

• Bacterial Cystitis
  • Treatment should be based upon culture results, using the most specific and narrow spectrum antibiotic to which the organism is sensitive.
  • In men, a 7-10 day treatment course is usually prescribed.
  • Trimethoprim-sulfamethoxazole or nitrofurantoin are often good choices for therapy. fluorouinolones (Cipro, Levaquin) are best reserved for resistant organisms or nosocomial infections, as resistance to these very important broad-spectrum antibiotics seems to be growing secondary to widespread usage.
  
  
• Asymptomatic Bacteriuria in Elderly Men
  • Treat if urea-splitting organisms, immune deficiency disorders, or planned urinary tract instrumentation
  
  
• Candida Bladder Infection
  • Associated with systemic, broad-spectrum antibiotic usage, immunosuppression, diabetes mellitus.
  • Remove any indwelling catheter if possible
  • Consider stopping unnecessary steroids or antibiotics
  • Continuous bladder irrigation with amphotericin B (50mg/L sterile water every 24 hours)
  • Oral fluconazole (50-100mg per day for 7 days) for Candida albicans.

References