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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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