Sogc Guideline: Recurrent Uti

Front 1

Explain the 5 levels of evidence according to the Canadian Task Force on Preventive Health Care

Back 1

I: from at least one RCT

II-1: from well-designed controlled trials without randomization

II-2: from well-designed cohort (prospective or retrospective) or case-control studies

II-3: from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (eg. Tx w/ penicillin in 1940s) can be included

III: expert opinion, clinical expereince, or descriptive studies

Front 2

Explain the 6 classes of recommendations according to the Canadian Task Force on Preventive Health Care

Back 2

A: good evidence to recommend the preventive action

B: fair evidence to recommend the preventive action

C: existing evidence is conflicting and does not allow making a recommendation for or against the preventive action; other factors may influence decision-making

D: fair evidence to recommend against the preventive action

E: good evidence to recommend against the preventive action

L: insufficient evidence (quality or quantity) to make a recommendation; other factors may influence decision-making

Front 3

What percentage of adult women experience a UTI during their lifetime?

Back 3

50-60%

Front 4

Does the incidence of acute cystitis increase or decrease with age?

Back 4

Decreases with age

- 0.5 episodes per person per year in young women

- 0.07 episodes per person per year in post-menopausal women

Front 5

What is the definition of recurrent UTI?

Back 5

2 uncomplicated UTIs in 6 months or 3 or more positive cultures in the preceding 12 months

Front 6

What is considered a relapse?

Back 6

Recurrent infection with the same organism despite adequate therapy

Front 7

What is considered a reinfection?

Back 7

- Recurrent UTI caused by a differential bacterial isolate

or

- by the previously isolated bacteria after a negative intervening culture or an adequate time period (2 or more weeks) between infections

Front 8

Differential diagnosis for UTI

Back 8

- vaginitis
- acute urethritis
- interstitial cystitis
- PID

- other mimicking organisms include:
- Chlamydia trachomatis
- Neisseria gonorrhea
- Candida
- BV
- HSV

Front 9

What is the positive culture rate for self-diagnosis for women with recurrent UTI?

Back 9

84%

Front 10

List positive predictive factors for recurrent UTI

Back 10

- symptoms after intercourse
- prior history of pyelonephritis
- absence of nocturia
- prompt resolution of symptoms after initiation of treatment (48 hours)

Front 11

List negative predictive factors for recurrent UTI

Back 11

- presence of nocturia
- persistence of symptoms between episodes of treated infection

Front 12

For what percentage of all UTI episodes is E. coli responsible?

Back 12

80%

Front 13

Name other organisms responsible for acute cystitis

Back 13

- Staphylococcus saprophyticus (4%)
- Klebsiella pneumoniae (4%)
- Proteus mirabilis (4%)

- Citrobacter and Enterococcus are less likely causes of UTI in women

Front 14

How does lactobacilli help protect against recurrent UTIs?

Back 14

prevention of initial colonization with uropathogens

- 90% of vaginal flora in pre-menopausal women

Front 15

List behavioural risk factors for recurrent UTIs in pre-menopausal women

Back 15

- increased frequency of intercourse
- use of a spermicide
- new sexual partners

- increased tone in external sphincter during micturition

Front 16

List non-behavioural risk factors for recurrent UTIs in pre-menopausal women

Back 16

- history of UTI before age 15
- maternal history of UTI

Front 17

What changes to vagina does menopause bring?

Back 17

- thinning of vaginal epithelium
- decreased amount of glycogen

- decreased lactobacilli
- increased in pH
- increased colonization with uropathogens

Front 18

List risk factors for recurrent UTIs in post-menopausal women

Back 18

- non-secretors of histocompatibility blood-group antigens
- incontinence
- significant pelvic floor prolapse
- elevated PVRs
- DM
- previous history of UTI

Front 19

Who requires a complete urologic workup?

Back 19

- infection with non-E. coli organisms
- persistent hematuria after resolution of infection

Front 20

What is the standard definition of UTI on culture?

Back 20

- > 100 000 CFUs per HPF (excellent specificity, only 50% sensitivity)

- > 1000 CFUs per HPF is sufficient to document infection in women with UTI symptoms (80% sensitivity, 90% specificity)

Front 21

What is suggestive of vaginal contamination on a midstream sample?

Back 21

> 20 epithelial cells per HPF

Front 22

What are the diagnostic characteristics of urinary nitrite on dipstick for UTI?

Back 22

- specificity 92%
- sensitivity 19-48%

- poor NPV

Front 23

What are the diagnostic characteristics of leukocyte esterase on dipstick for UTI?

Back 23

- specificity 41-86%
- sensitivity 72-97%

- not specific

Front 24

What are the diagnostic characteristics of blood on dipstick for UTI?

Back 24

- specificity 42-46%
- sensitivity 68-92%

Front 25

In treatment of acute UTIs, what antibiotics should be avoided due to high resistance?

Back 25

ampicillin and sulfonamides

- 15-20% resistance in E. coli strains in some areas

Front 26

What are some treatment regimens for acute UTIs?

Back 26

- 3-day regimen of TMP, TMP-SMX, or fluoroquinolone
- >5-day regimen of beta-lactams
- minimum 7-day regimen of nitrofurantoin

- single-dose fosfomycin

Front 27

When can fluoroquinolones be used as first-line for acute UTIs?

Back 27

- have or suspected of having antimicrobial resistance
- allergy or intolerance to conventional therapy
- areas where resistance to TMP-SMX >15-20%

Front 28

List ways of preventing recurrent UTIs

Back 28

- switching from spermicide-containing contraception
- prophylactic antibiotics (RR = 0.15, NNT = 2.2)
- acute self-treatment in 2 or less episodes
- 3 or more should use continuous or post-coital
- vaginal estrogen
- cranberry products (RR = 0.66)
- acupuncture
- probiotics and vaccine need more research

- bacterial interference and topical hyaluronic acid still under development

Front 29

What are the most frequently reported adverse events for antibiotic prophylaxis for recurrent UTIs?

Back 29

- nausea
- vaginal and oral candidiasis

Front 30

What are some severe complications with the use of nitrofurantoin in continuous antibiotic prophylaxis?

Back 30

- aplastic anemia
- polyneuritis
- acute cholestatic and hepatocellular reactions
- pulmonary toxicity (uncommon, may develop after one month to 6 years of use)

Front 31

What is the recommended duration of antibiotic prophylaxis?

Back 31

- 6-12 months
- rarely extended to 2-5 years

- most women revert to previous pattern of recurrent UTIs once prophylaxis is stopped

Front 32

How does vaginal estrogen prevent recurrent UTIs in post-menopausal women?

Back 32

- maturation and thickening o vaginal epithelium with increased cellular glycogen
- reappearance of vaginal lactobacilli
- prevention of overgrowth and colonization of uropathogens in the vagina

Front 33

Obstetrical risks in women with bacteriuria

Back 33

- preterm delivery
- low BW infant

Front 34

Indications for antibiotic prophylaxis against UTIs in pregnant women

Back 34

1. all women with a pre-pregnancy history of recurrent UTIs
2. persistent symptomatic or asymptomatic bacteriuria after 2 antibiotic treatments
3. after only one UTI for a women who has sickle cell trait or DM

- can use both continuous and post-coital regimens
- nitrofurantoin (50mg) or cephalexin (250mg) recommended, but not in last 4 weeks of pregnancy