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