0:08 how many people feel like the women who
0:10 come in Bernie T eyes are very
0:13 distressed and they leave with a very
0:18 satisfied visit right that's actually a
0:20 little bit beyond the scope of this
0:23 guidelines but it is important to have
0:25 this information for that sort of
0:29 patient centered discussion and I think
0:31 when you do that they will walk away
0:33 with a little bit more of that satisfaction
0:34 satisfaction
0:36 so it's education and it's that shared
0:38 decision-making coming together with a
0:41 plan you know directly directly
0:43 addressing their concerns and needs but
0:44 I think first and foremost we have to
0:46 arm ourselves with evidence so that you
0:49 know we can be the experts and lead and
0:55 guide them so here are my disclosures so
0:59 the learning objectives include
1:02 reviewing the recently released in May
1:05 of 2019 guidelines on recurrent UTIs
1:08 recurrent UTIs and women we're gonna
1:10 summarize the evidence underlying these
1:11 guidelines as well as some important
1:14 concepts and we're gonna discuss the
1:18 relevance to some clinical scenarios so
1:20 the a you a guideline was a
1:23 collaboration of a the AOA the Canadian
1:26 Association and sufu was led by Jennifer
1:30 anger and Toby chai were the chairs and
1:31 I was fortunate to be a part of this
1:34 group so as we know UTIs are prevalent
1:37 costly and burdensome the majority of
1:39 women will experience an acute UTI in
1:41 their lifetime many times they will have
1:43 a UTI and then subsequently have another
1:45 episode and some of these women will
1:46 then go on to have multiple recurrent
1:50 episodes the evaluation and treatment of
1:52 UTIs is costly up to two billion dollars
1:54 a year in the u.s. there's been a
1:56 significant growth of antibiotic
1:57 resistance in the last 20 years
2:00 interestingly the women who get
2:03 recurrent UTIs tend to have treatment
2:04 that doesn't adhere to the guidelines
2:07 whether they're pushing or people are
2:08 kind of going beyond the bounds so we
2:11 would encourage people to stay within
2:14 with guidelines for these patients the
2:15 need is to decrease the risk of
2:18 antibiotic resistance reduce the adverse
2:21 effects of antibiotics provide guidance
2:23 on antibiotic and non antibiotic
2:25 prevention strategies reduce the
2:28 recurrence of UTI events and improved
2:29 clinical outcomes and quality of life
2:32 for these women so as I said it was a
2:35 collaborative guideline committee and we
2:37 wanted to define the evidence-based
2:39 management in healthy female patients
2:41 with recurrent UTIs and established
2:43 guidelines for the estate bust
2:45 evaluation and management as well as
2:47 evaluate treatment and preventative
2:51 interventions so the study population in
2:53 this group was an index patient and
2:55 otherwise healthy female adult with
2:58 uncomplicated recurrent UTIs the
3:00 infection is culture proven and
3:02 associated with acute onset symptoms
3:05 this inclu excludes pregnant women
3:08 immunocompromised anyone with any
3:11 anatomical functional abnormalities cell
3:12 people who self Catharine of indwelling
3:15 catheters systemic bacteremia diabetes
3:18 spinal cord injury and peripheral
3:20 neuropathy so interestingly that's a lot
3:23 of our illogic practices but we had to
3:25 start with the healthy population first
3:28 we did not discuss the prevention of UTI
3:30 and the procedural or operative settings
3:33 so by definition we had to define what I
3:35 give our current UTI is and we used the
3:37 definition that was most commonly used
3:40 in literature two episodes in six months
3:43 or three episodes a year uncomplicated
3:45 again refers to no anatomic or
3:46 functional abnormalities no immune
3:49 compromised and no multi drug-resistant
3:52 bacteria so a systematic review is
3:56 performed a literature search there was
3:57 criteria for inclusion exclusion of
4:01 studies data was extract extracted the
4:03 risk of bias was assessed and the data
4:04 was synthesized and the body of evidence
4:08 was rated so this is the same evidence
4:09 strength diffused in all the AOA
4:11 guidelines on the left side is there
4:13 it's a strong recommendation a moderate
4:15 conditional clinical principle or expert
4:18 opinion and then across its the evidence
4:19 of either strong a
4:23 or see so I reordered the guidelines
4:28 from strongest to decreasing so our
4:29 strong recommendations were that number
4:32 one and clinicians should not treat
4:35 asymptomatic bacteria in patients this
4:38 was a great level evidence of B for
4:40 antibiotic treatment clinicians should
4:42 use first-line therapy this includes
4:45 nitro from toen bactrim and fosfomycin
4:47 dependent on your local antibiogram for
4:49 the treatment of symptomatic UTIs and
4:53 this was also Evelyn's evidence great be
4:56 moving on to moderate recommendations
4:59 clinicians to obtain urinalysis urine
5:01 culture and sensitivity for each
5:04 symptomatic acute cystitis episode prior
5:06 to initiating treatment to patients in
5:09 recurrent UTIs functions may offer
5:11 patient initiate treatment also called
5:13 self start treatment to select UTI P
5:15 recurrent UTI patients with acute
5:17 episodes while waiting cultures and
5:19 clinicians should omit surveillance
5:21 urine testing and asymptomatic patients
5:24 with Brut UTIs as far as antibiotic
5:25 treatment questions should treat
5:28 recurrent UTIs experiencing acute cystitis
5:28 cystitis
5:30 episodes with a shorter duration as
5:33 possible generally no longer than seven
5:37 days some more moderate recommendations
5:39 as far as antibiotic prophylaxis
5:41 following a discussion of the risks
5:43 benefits and alternatives clinicians may
5:45 prescribe antibiotic prophylaxis to
5:47 decrease the risk of future UTIs and
5:49 women of all ages Lee diagnosed with
5:52 UTIs and it as far as the topic of
5:54 estrogen in Perry and postmenopausal
5:57 women with recurrent UTIs clinicians
5:58 should recommend vaginal estrogen
6:00 therapy to reduce the risk of future
6:05 UTIs if there's no contraindication so
6:06 moving on to some conditional
6:09 recommendations clinicians may offer
6:12 cranberry prophylaxis for women with
6:15 recurrent UTIs this is evidence level
6:19 grade see as far as clinical principles
6:21 in the evaluations clinicians should
6:23 obtain a complete patient history and
6:26 perform an exam and women presenting
6:29 with recurrent UTIs to make a diagnosis
6:30 of her krazee-eyez
6:32 clinicians must document positive urine
6:34 cultures prior from their prior
6:36 symptomatic episodes and clinicians
6:37 should obtain repeat you're in studies
6:40 when initials urine specimen is suspect
6:45 for contamination moving on to expert
6:46 opinion and we are going to get to a
6:49 case that will discuss these warm
6:51 cystoscopy upper tract imaging should
6:53 not be routinely obtained in the index
6:55 patient presenting with recurrent UTIs
6:58 an antibiotic treatment in patients with
7:00 recurrent UTIs experience acute cystitis
7:03 episodes and associated with urine
7:05 cultures resistant to oral antibiotics
7:07 clinician may treat with a culturally
7:09 directed parental antibiotics for a
7:11 shortest duration as possible generally
7:14 no longer than 7 days for a faulty
7:16 evaluation clinicians should not perform
7:18 a post treatment test of cure in
7:21 asymptomatic patients and clinicians
7:22 should repeat urine cultures to guide
7:24 further management when UTI symptoms
7:29 persist following antibiotic therapy so
7:30 we're gonna start with a case but I do
7:32 want to mention the a you a guideline
7:34 document is online and freely available
7:36 I would encourage you to read it there's
7:38 just a wealth of information in there so
7:39 we're not gonna get to everything
7:41 everything in there but I think we're
7:43 gonna highlight some of the key points
7:47 so we have here a 35 year old woman with
7:47 recurrent UTIs
7:50 she has recurrent episodes of dysuria
7:51 that are associated with sexual activity
7:54 she typically goes to an urgent care she
7:56 gets a UA in culture and his treated
7:57 with antibiotic her cultures are
8:00 typically e.coli with a greater 100,000
8:02 colony-forming units her episodes
8:04 resolved your antibiotics and no
8:06 symptoms between infections so what
8:08 parts of her history are important and
8:11 what our next steps as far as her
8:15 symptoms dysuria is the mainstay of the
8:17 diagnosis of UTI an acute onset
8:19 generally less than one week of dysuria
8:22 or fever and associated with other UTI
8:24 specific symptoms these can include
8:27 hematuria new or worsening urgency
8:29 frequency incontinence and super pubic
8:32 pain I think part of our job is to
8:35 educate women on what a UTI specific
8:37 episode is or symptom specific episode
8:39 is because as you know some of them will
8:41 come in and say I have an odor or my turns
8:41 turns
8:43 cloudy I know a UTI well do you have any
8:46 symptoms oh no but I know I have a UTI
8:48 and so I think we can you know educate
8:49 women and certainly once you educate
8:51 them their reason you know they they
8:53 realize that they don't really want to
8:54 take antibiotics all the time so I think
8:57 really teasing out their symptoms or
8:59 educating your nurses and your staff to
9:01 do that I think it's very important so
9:03 there are obviously many nonspecific
9:06 symptoms you know a big patient
9:07 population that overlaps with this is
9:10 the OAB population they have urgency
9:11 frequency and incontinence all the time
9:12 and so how do you distinguish between
9:16 their UTI symptoms is it worse than your
9:18 baseline you know is it acutely different
9:19 different
9:21 oh no it's to say you know but I just
9:24 thought so there and then the tough one
9:26 is this general sense the lack of
9:28 well-being certainly women say that they
9:29 don't feel well they have fatigue
9:31 malaise weakness but if certainly if
9:33 that's the only symptom they should be
9:35 worked up more broadly but challenging
9:37 one is the eighty plus year old woman
9:39 and the family comes in and she's out of
9:41 it no she has a UTI or does she have a
9:44 UTI and certainly you know she doesn't
9:47 have any symptoms you know but what's
9:48 the benefit what's the harm and I think
9:51 that's a discussion certainly to have
9:58 so diagnosis for acute onset UTI
10:00 symptoms this should be in conjunction
10:02 with a laboratory detection of a Europe
10:05 pathogen in the urine so urine culture
10:06 traditional urine culture is the
10:08 mainstay of diagnosis during an acute
10:12 episode there are molecular diagnostics
10:15 that are on the market now and certainly
10:17 we know a lot more about the microbiome
10:20 of the lower urinary tract and this
10:23 bacteria this normal flora may be
10:26 protective a few future episodes and so
10:28 we don't really know what the role is of
10:30 these sort of high-throughput sequencing
10:32 these PCR based methods have you seen
10:35 these reports they're like pump
10:37 completely I mean very detailed every
10:39 pathogen you can know demand and they
10:41 have all of them they're nearly all
10:43 positive so you know certainly we want
10:46 to advance the technology of diagnosis
10:50 and evaluation of UTIs but the rule of
10:52 what this where this fits in is not
10:54 to determine as the studies have not
10:56 been done and so the guidelines could
10:58 not recommend this for general clinical
11:02 practice so you can use your best
11:05 judgment there there was a big
11:07 discussion about antimicrobial de
11:08 stewardship and the consideration of
11:10 collateral damage this is you know
11:12 certainly big in the entire medical
11:14 community so we've got to reduce
11:16 inappropriate treatment decrease pots
11:18 broad-spectrum antibiotic use
11:20 appropriate tailor necessary treatment
11:23 for the shortest duration in order to
11:26 prevent future resistance and collateral
11:29 damage that's a very important concept
11:32 because there are downstream effects of
11:34 people taking antibiotics they're
11:36 altering their gut flora they're
11:39 selecting drug resistances there's a lot
11:42 of fascinating biology and Studies on
11:45 this some interesting Studies on the
11:49 increase c-diff in the UTI patients
11:52 based on their antibiotic choices so
11:53 something something considered certainly
11:55 to follow and talk about with your
11:58 patients so we're going back to our case
12:01 the healthy 35 year old woman guidelines
12:03 statement one clinicians should obtain a
12:04 complete patient history and perform a
12:08 pelvic exam so she's had two children
12:10 she's otherwise healthy she's on a
12:12 little contraception she has normal
12:14 external genitalia and no parry throat
12:16 pathology does she need any imaging or
12:22 further diagnostic testing so the
12:24 guideline statement for cystoscopy upper
12:25 track imaging should not be routinely
12:28 obtained and an index patient presenting
12:31 with a UTI but then she's like oh I did
12:33 have that sling surgery two years ago
12:35 and my UTIs actually have increased
12:37 since then does that change your workup
12:39 so if there's a clinical suspicion of
12:40 something anatomic potentially
12:43 contributing certainly you this is the
12:45 AOA sort of algorithm and one of the
12:47 areas of it sort of the top and to the
12:49 right says you can consider additional
12:51 evaluation a protract imaging cystoscopy
12:53 or dynamics based on your clinical
12:56 suspicion so it's not required in all
12:58 people that the yield for that is
13:01 certainly very low as you know patients
13:03 do get some reassurance from that
13:06 but the data does not support that so in
13:08 her case you know you could discuss
13:10 whether or not she needs that and
13:13 certainly a cystoscopy could be
13:16 considered this is sort of what we
13:17 talked about the beginning of the talk
13:19 you go into our history and what she's
13:21 dealing with and she's less she talks
13:23 about all that sort of the psychosocial
13:25 impact of her et eyes she has a lot of
13:28 fear and the fear of what what is this
13:30 doing to her health women carry a lot of
13:32 guilt and shame and it just has it
13:34 there's a high amount of distress on to
13:38 their quality of life and so I think
13:41 this is an important place to certainly
13:42 reassure them that is not something
13:45 they're doing you know there's a lot of
13:46 talk about wiping and what you're doing
13:48 in pairs you know height hygiene and I
13:51 think that it translate to the women
13:52 sometimes they feel judged and they feel
13:54 like they're - you're telling them that
13:57 you're they're bad but really I think it
14:00 just is a supportive understanding
14:02 conversation you can certainly talk
14:03 about the risks of antibiotics and the
14:05 natural history of UTIs there's a very
14:06 low risk of progression to
14:08 pyelonephritis in an anatomically
14:11 healthy person also there are times when
14:12 you're you can counsel them but there
14:13 are times where you're going to have a
14:15 UTI like symptoms that are mild and they
14:18 will self resolved with supportive care
14:19 measures there's been studies on
14:22 ibuprofen certainly water use of
14:26 perineum so you can counsel them that
14:28 there are some self-care measures that
14:29 can be taken that are healthy and
14:32 supportive this is something that you
14:34 experience in your practice it's leveled
14:35 of distress people are nodding their
14:40 head yeah so again a different topic but
14:42 there are things that we can do to
14:43 better meet their needs and I think it
14:45 just has to go with what are their true
14:46 concerns you know are they concerned
14:47 they have cancer well then you can
14:48 reassure them about that are they
14:52 concerned that that there you know
14:53 there's long term consequences you can
14:57 reassure them about that so going back
15:01 to the guidelines she's like what can we
15:03 do now clinicians may offer cranberry
15:06 prophylaxis for worker UTIs so she's
15:07 like you know what after our talk about
15:09 the antibiotics I don't really want to
15:10 go there but you know what are the
15:12 things that we can do so you have a
15:13 discussion with her she opts for a hydrate
15:14 hydrate
15:16 in a daily cranberry tablet with 36
15:19 milligrams of PA C's she asks if she
15:22 should add add any other supplements so
15:24 to review the data on cranberry I think
15:25 this is a very popular important
15:27 question the mechanism action is that
15:29 the PA C's prevent the adhesion of the
15:32 bacteria to the yura thelia the thing is
15:33 that these PhDs are in various
15:35 concentrations based on the formulation
15:38 used supplements aren't regulated by the
15:39 FDA they're sort of over-the-counter
15:41 product so you don't really know what
15:42 you're getting and so you should try to
15:43 encourage them to get a high quality
15:45 product this is very low risk to
15:47 patients they like it they like doing
15:50 something natural however there is some
15:52 GI distress certainly and sugar
15:53 associated with the cranberry juice
15:55 there were eight randomized clinical
15:57 trials juice cocktail cocktails and
16:00 tablets if you look at the data if
16:02 you're comparing these eight randomized
16:05 clinical trials of cranberry to nothing
16:07 meaning placebo or nope you know no
16:09 cranberry you actually decrease the risk
16:12 okay if you look at cranberry compared
16:15 to antibiotics the difference is less
16:17 clear and it actually favors antibiotics
16:19 so kind of puts that into perspective
16:22 there's probably some validity to it but
16:23 just because of the heterogeneity of
16:25 this studies some studies are going to
16:26 say cranberries don't work so I'm going
16:29 to say they do so that that kind of puts
16:31 into perspective it patients like it
16:34 certainly it can be can be offered as
16:36 far as lactobacillus this has been
16:38 studied with great interest because of
16:40 antibiotic resistance there were five
16:42 trials there's not enough data to
16:44 recommend certainly there were many
16:45 trials with vaginal suppositories which
16:47 are not available in the US versus oral
16:49 and Chris POTUS is sort of one of the
16:52 things to watch as far as the element in
16:54 that I'm good I'm sort of running out of
16:56 time so I gotta move a little faster but
16:59 there was a really good study good as in
17:02 important and impactful for clinical
17:04 recommendations increased water intake
17:06 in healthy young women who have low
17:08 water intake to start so if they're
17:11 drink less than if they have low water
17:12 in tip to start that got randomized to
17:15 add 1.5 liters or continue what you're
17:17 doing for one year they were able to
17:21 reduce their UTIs significantly in one
17:22 year's time this is due to probably
17:24 dilution and flushing reducing nutrients
17:26 for growth this was funded by a water
17:30 company but I think it's certainly a
17:32 certainly a reasonable thing to add
17:34 you can counsel them do your normal
17:36 thing add a liter and a half of water a
17:38 day so you know 2 litres a day would
17:40 probably be reasonable so patients are
17:42 certainly open to this and it does help
17:44 there's lated limited data on these
17:46 other elements as far as the guidelines
17:48 panel they could not recommend but these
17:49 are things that patients come to you
17:51 with and it's certainly if they think
17:53 it's helping is not doing harm they can
17:55 continue some of it you know for example
17:57 within I mean there just haven't been
17:59 many studies so it but if it's certainly
18:00 useful and helpful in your practice
18:01 that's okay
18:03 there are probably you know some
18:05 promising therapies in here herbal
18:06 therapies was very limited limited
18:09 Studies on enter vesical hyaluronic acid
18:11 biofeedback interest lane just
18:13 biofeedback maybe people have less UTIs
18:15 and there's some immune therapies and
18:17 vaccines in the future but more studies
18:19 to come she does well for two months
18:21 then calls your office for acute onset
18:25 dysuria what now you should get a new
18:28 culture and treat her she asked for
18:30 treatment you're gonna do first-line
18:32 therapies including that referred to and
18:36 back to him and fosfomycin she's now
18:38 coming back and saying you know what I
18:39 wanted something else
18:41 let's look can what else can we do for
18:43 it to prevent UTIs so then we can talk
18:46 about antibiotic prevention of UTIs this
18:48 is well studied people can go on
18:51 continuous therapy low-dose trimethoprim
18:54 bactrim nitrogen cephalexin or foster
18:56 Meissen or they can go on intermittent
18:57 prophylaxis this is generally for
18:59 example for her her episodes are
19:01 associated with sexual intercourse so
19:03 she can do it around that time
19:05 what if she were perimenopause or
19:08 postmenopausal and you you know you do
19:10 exam she has vulva vaginal atrophy the
19:12 data on vaginal estrogen is very strong
19:14 there's been multiple randomised trials
19:15 that decrease the incidence and time to
19:18 recurrence at UTI systemic estrogen does
19:20 not help this phenomenon but if they're
19:22 on systemic estrogen you can add vaginal
19:23 estrogen and certainly if they have a
19:24 history of breast cancer you can
19:27 coordinate with their oncologist there's
19:30 various formulations there's no data to
19:32 favor one formulation the other they're
19:34 essentially equivalent has to do with
19:37 their insurance and cost and then there
19:39 is a another you know
19:41 important one is that you should not
19:43 treat an sivak bacteria and patients you
19:45 know a postmenopausal woman comes in she
19:47 gets up routine you a it's positive do
19:50 you treat do you not it's actually
19:51 there's data to show that they have
19:53 poorer outcomes when asymptomatic
19:56 bacteria is treated so take-home
19:58 messages cultures are necessary we
19:59 should do a sort as coarse as possible
20:02 in order to limit collateral damage we
20:03 should do shared decision-making with
20:04 our patients and the management is
20:06 focused on leaving symptoms preventing
20:08 recurrence and reducing adverse events
20:09 I'd like to knowledge the entire
20:11 guidelines panel panel and everyone
20:12 involved thank you [Applause]
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