Overview of Urinary Tract Infections in Adults: Symptoms, Diagnosis, and Treatment Guidelines
This information discusses the symptoms and diagnostic approach for urinary tract infections in adults, along with the current management guidelines. It covers the prevalence of UTIs as a common healthcare concern, focusing on uncomplicated UTIs, acute uncomplicated cystitis, and pyelonephritis. The content addresses the etiology, preferred treatment regimens, and diagnostic criteria for identifying UTIs.
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URINARY TRACT URINARY TRACT INFECTIONS INFECTIONS Peter Julian A. Francisco, MD, DFM Clinical Associate Professor UPCM
OBJECTIVES OBJECTIVES 1. To discuss the symptoms and approach to diagnosis of urinary tract infection in adults. 2. To discuss the guidelines and current management in the treatment of urinary tract infection.
URINARY TRACT INFECTIONS (UTI) URINARY TRACT INFECTIONS (UTI) One of the leading indications for seeking healthcare and using antimicrobials in the community and hospital settings1. The most frequently acquired infections in the community, in the hospitals and other healthcare institutions2. 1.Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update. 2. Johansen, T.E.B.; Naber, K.G.. Urinary Tract Infections. Antibiotics 2014, 3, 375-377.
UNCOMPLICATED UTI UNCOMPLICATED UTI
ACUTE UNCOMPLICATED CYSTITIS (AUC) | ACUTE UNCOMPLICATED CYSTITIS (AUC) | DIAGNOSIS DIAGNOSIS Acute dysuria, frequency, urgency in a non-pregnant, otherwise healthy premenopausal female. Etiology: E. coli (75-90%), S. saprophyticus (5-15%) National Antibiotic Guidelines, DOH. 2017
ACUTE UNCOMPLICATED CYSTITIS (AUC) | ACUTE UNCOMPLICATED CYSTITIS (AUC) | TREATMENT TREATMENT PREFERRED REGIMEN 1STLINE 2NDLINE Nitrofurantoin macrocrystals 100mg QID x 5 days or Fosfomycin 3g x 1 dose sachet in 3-4 oz (90-120mL) water. Cefuroxime 250mg BID x 7 days or Cefixime 200mg BID x 7 days or Amoxicillin clavulanate 625mg BID x 7 days National Antibiotic Guidelines, DOH. 2017
ACUTE UNCOMPLICATED PYELONEPHRITIS | ACUTE UNCOMPLICATED PYELONEPHRITIS | DIAGNOSIS DIAGNOSIS Fever, flank pain, costovertebral angle tenderness, nausea / vomiting with or without signs or symptoms of cystitis in an otherwise health premenopausal female. Etiology: E. coli, as well as other Enterobacteriaceae Urine analysis, gram stain, culture and susceptibility tests should be done. Blood cultures are not routinely done unless septic. National Antibiotic Guidelines, DOH. 2017
ACUTE UNCOMPLICATED PYELONEPHRITIS | ACUTE UNCOMPLICATED PYELONEPHRITIS | TREATMENT TREATMENT PREFERRED REGIMEN (ORAL) 1ST LINE 2ND LINE Ciprofloxacin 500mg BID x 7-10 days or Levofloxacin 750mg everyday x 5 days Cefuroxime 500mg BID x 14 days or Cefixime 400mg everyday x 14 days or Amoxicillin Clavulanate 625mg TID x 14 days (when GS shows Gram + cocci) National Antibiotic Guidelines, DOH. 2017
ACUTE UNCOMPLICATED PYELONEPHRITIS | ACUTE UNCOMPLICATED PYELONEPHRITIS | TREATMENT TREATMENT PREFERRED REGIMEN (PARENTERAL) 1ST LINE 2ND LINE Ceftriaxone 1-2g every 24 hours or Ciprofloxacin 400mg every 12 hours or Levofloxacin 250-750mh every 24 hours or Amikacin 15mg/kg every 24 hrs or Gentamicin 3-5mg/kg every 24 hrs +/- Ampicillin Ampicillin Sulbactam 1.5g every 6 hours (when GS shows g+ cocci) Ertapanem 1g every 24 hours Piperacillin tazobactam 2.25-4.5g every 6-8 hours National Antibiotic Guidelines, DOH. 2017
ASYMPTOMATIC ASYMPTOMATIC BACTERIURIA BACTERIURIA
QUESTION QUESTION True/False Asymptomatic Bacteriuria is defined as patients who are asymptomatic with a >100,000 cfu/mL bacterial strain on urinalysis.
ASYMPTOMATIC BACTERIURIA IN ADULTS| ASYMPTOMATIC BACTERIURIA IN ADULTS| ETIOLOGY ETIOLOGY E. coli causes 75% to 95% of episodes of asymptomatic bacteriuria, cystitis and pyelonephritis. Other causes: Enterobacteriaceae, other Gram-negative rods, Enterococcus faecalis, Staphylococcus species and Group B streptococcus. Johansen, T.E.B.; Naber, K.G. Urinary Tract Infections. Antibiotics 2014, 3, 375-377
ASYMPTOMATIC BACTERIURIA IN ADULTS| ASYMPTOMATIC BACTERIURIA IN ADULTS| DIAGNOSIS DIAGNOSIS Diagnosis should be based on the results or urine culture specimens that are collected aseptically and with no evidence of contamination. WOMEN: 2 consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts > 100,000 cfu/mL. MEN: A single clean-catch voided urine specimen with once bacterial species isolated in a quantitative count > 100,000 cfu/mL. BOTH MEN and WOMEN: A single catheterized urine specimen with one bacterial species isolated in a quantitative count >100 cfu/mL. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update.
ASYMPTOMATIC BACTERIURIA | ASYMPTOMATIC BACTERIURIA | INDICATIONS FOR SCREENING INDICATIONS FOR SCREENING Screening and treatment is recommended to prevent bacteremia and sepsis to the following patients: Patients who will undergo genitourinary manipulation or instrumentation. All pregnant women. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update.
ASYMPTOMATIC BACTERIURIA | ASYMPTOMATIC BACTERIURIA | INDICATIONS FOR SCREENING INDICATIONS FOR SCREENING Periodic screening and treatment is recommended to the following patients: Patients with diabetes mellitus. Elderly patients Patients with indwelling catheters Solid organ transplant patients People living with HIV Spinal cord injury patients Patients with urologic abnormalities Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update.
ASYMPTOMATIC BACTERIURIA | ASYMPTOMATIC BACTERIURIA | SCREENING TEST SCREENING TEST RECOMMENDED: Urine Culture In the absence of urine culture, significant pyuria (>10 wbc/hpf) or a positive gram stain of unspun urine (>2 microogranisms/oif) in two consecutive midstream urine samples. Urine culture and sensitivity are not necessary when urinalysis is negative for pyuria or urine gram stain is negative for organisms. Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment among patients for whom screening, and treatment is not recommended. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update.
ASYMPTOMATIC BACTERIURIA | ASYMPTOMATIC BACTERIURIA | TREATMENT TREATMENT ANTIBIOTICS RECOMMENDED DOSE AND DURATION FDA RISK CATEGORY Cephalexin 500mg BID for 7 days B Cefuroxime Axetil 500mg BID for 7 days B Fosfomycin Trometamol 3g single dose B Amoxicillin - Clavulanate 625mg BID for 7 days B Nitrofurantoin microcrystal* 100mg QID for 7 days; 100mg BID for 7 days for monohydrate microcrystal formulation B Trimetophrim - sulfamethoxazole 160/80mg BID for 7 days C (avoid in 1st and 3rd trimester) *May cause hemolytic anemia, anophthalmia, hypoplastic left heart syndrome. ASD, cleft lip and palate. May be given on the second trimester of pregnancy until 32 weeks AOG. Use in the first trimester of pregnancy is appropriate when no other suitable alternative antibiotics are available. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update.
RECURRENT UTI RECURRENT UTI
RECURRENT UTI| RECURRENT UTI| DIAGNOSIS DIAGNOSIS Diagnosed when a healthy non-pregnant woman with no known urinary tract abnormalities has 3 or more episodes of acute uncomplicated cystitis documented by urine culture during a 12-month period or 2 or more episodes in a 6-month period.1,2,3 Can either be a relapse or reinfection.4 1. Gopal, M. et al. Clinical symptoms predictive of recurrent urinary tract infections. Am J Obstet Gynecol. 2007 Jul;197(1):74. e1-4. 2. Albert X, Huertas, et al. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev. 2004; (3): CD001209 3. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update. 4. Nicolle LE. Managing recurrent urinary tract infections in women. Womens Health
RECURRENT UTI| RECURRENT UTI| DIAGNOSIS DIAGNOSIS Routine screening for urologic abnormalities is not recommended for the general patient population (strong recommendation, low quality of evidence). Screening is recommended in the following situations: - No response to appropriate antimicrobial therapy or rapid relapse after such therapy. - Gross hematuria during a UTI episode or persistent microscopic hematuria. - Obstructive symptoms - Clinical impression of persistent infection - Infection with urea-splitting bacteria (Proteus, Morganella, Providencia) - History of pyelonephritis - History or symptoms suggestive of urolithiasis - History of childhood UTI - Elevated serum creatinine
RECURRENT UTI| RECURRENT UTI| DIAGNOSIS DIAGNOSIS WORK-UPS: - Radiologic or imaging studies and cystoscopy are not routinely indicated in patients with recurrent UTI. (Weak recommendation, low quality of evidence) - Renal ultrasound or CT scan may be done to screen for urologic abnormalities. (Strong recommendation, low quality of evidence). - Patient with anatomical abnormalities should be referred to a specialist for further evaluation. (Strong recommendation, low quality of evidence)
RECURRENT UTI| RECURRENT UTI| MANAGEMENT MANAGEMENT Prophylaxis is recommended in women whose frequency of recurrence is not acceptable to the patient in terms of level of discomfort or interference with activities of daily living. It may be withheld if the frequency of recurrence is tolerable to the patient. CONTINUOS PROPHYLAXIS - Daily low intake of antibiotics for 6-12 months (strong recommendation, moderate quality of evidence) POST COITAL PROPHYLAXIS - Single dose of antibiotics after intercourse (strong recommendation, moderate quality of evidence) INTERMITTENT PROPHYLAXIS - Self-treatment with a single antibiotic dose based on patient s perceived need. (weak recommendation, low quality of evidence)
Philippine Clinical Practice Guidelines on the Diagnosis and Management
RECURRENT UTI| RECURRENT UTI| MANAGEMENT MANAGEMENT TREATMENT OF INDIVIDUAL EPISODES OF UTI IN WOMEN WITH RECURRENT UTI - Any of the antibiotics for acute uncomplicated cystitis may used in the treatment of individual episodes of UTI in women with recurrent UTI. (Strong recommendation, moderate quality of evidence) - Consider intermittent self-administered therapy in highly educated, well-informed, motivated patients, wherein the patients are able to recognize the characteristic signs and symptoms of UTI, are compliant with medical instructions and have a good relationship with a medical provider. (Strong recommendation, moderate quality of evidence) Philippine Clinical Practice Guidelines on the Diagnosis and Management
Philippine Clinical Practice Guidelines on the Diagnosis and Management
COMPLICATED UTI COMPLICATED UTI
QUESTION QUESTION True / False Urine GC/CS must always be obtained before the initiation of treatment?
COMPLICATED UTI | COMPLICATED UTI | DIAGNOSIS DIAGNOSIS 1. Significant bacteriuria (100,000 CFU/mL) and clinical symptoms (in the setting of functional or clinical abnormalities in the urinary tract of kidneys). 2. Presence of an underlying disease that interferes with host defense mechanisms 3. Condition that increases the risk of acquiring infection and/or treatment failure. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update.
COMPLICATED UTI | COMPLICATED UTI | DIAGNOSIS DIAGNOSIS Urine sample for gram stain, and culture and sensitivity testing must always be obtained before the initiation of treatment. Imaging of the urinary tract is warranted whenever anatomic of structural abnormalities are suspected. CT Scan is preferred over KUB UTZ, however, the imaging modality to be used may depend on local availability. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update.
COMPLICATED UTI | COMPLICATED UTI | TREATMENT TREATMENT Mild to moderate illness - Oral fluoroquinolones or amoxicillin / clavulanic acid. Severely Ill Patients - Broad spectrum parenteral antibiotics - Fluoroquinolones are not recommended as empiric antibiotics due to the high rates of resistance locally. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update.
COMPLICATED UTI | COMPLICATED UTI | TREATMENT TREATMENT ORAL REGIMEN - Ciprofloxacin 500-750mh BID or 1000mg extended release tablet OD x 7-14 days* - Norfloxacin 400mg BID x 7-14 days* - Ofloxacin 200mg BID x 10 14 days* - Levofloxacin 500 750mg OD x 7-14 days* - Amoxicillin / clavulanate 500mg/125mg TID or 875mg/125mg BID x 7-14 days PARENTERAL REGIMEN - Amikacin 15mg/kg every 24 hours - Doripenem 500mg every 8 hours - Ertapanem 1gm every 24 hours - Gentamicin 3-5mg/kg/day every 24 hours - Imipenem cilastin 250-500mg every 6-8 hours - Meropenem 1g every 8 hours - Piperacillin Tazobactam 2.25-4.5gms every 6-8 hours * Determine if the patient has risk factors for drug-resistance prior to use. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update.
COMPLICATED UTI | COMPLICATED UTI | MONITORING MONITORING Urine culture should be repeated one to two weeks after completion of antibiotics. If significant bacteriuria persists post-treatment, consider referral to specialists. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update.
Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2015 Update.
IN SUMMARY IN SUMMARY 1. Discussed the symptoms and approach to diagnosis of urinary tract infection in adults. 2. Discussed the guidelines and current management in the treatment of urinary tract infection.
