New guidance issued for UTI management
Review your patient charts for the past month. If national statistics are any indication, chances are many of those cases include a diagnosis of urinary tract infection (UTI).
About 11% of U.S. women report at least one provider-diagnosed UTI each year.1 To aid clinicians in the diagnosis, treatment, and prevention of UTIs in nonpregnant women, the American College of Obstetricians and Gynecologists (ACOG) has just issued a practice bulletin to address management of the condition.2
Despite the frequency of UTIs, confusion remains about diagnostic and treatment strategies, says Jeanne Sheffield, MD, associate professor of maternal/fetal medicine at the University of Texas Southwestern Medical Center in Dallas, a bulletin co-author. One of the biggest problems lies in use of pure clinical history to diagnosis possible infection, since many diseases present with similar complaints to a urinary tract infection, notes Sheffield.
"Using just pure clinical history is a problem if the symptoms persist," she states. "You do need to come in for urine culture."
According to the ACOG practice bulletin, UTI covers such infections as:
- asymptomatic bacteriuria – when there are considerable bacteriuria in a woman with no symptoms;
- cystitis – when infection is limited to the lower urinary tract and occurs with symptoms of dysuria and frequent and urgent urination and occasionally suprapubic tenderness;
- acute pyelonephritis – when there is infection of the renal parenchyma and pelvicalyceal system, accompanied by significant bacteriuria, and usually occurs with fever and flank pain.2
The presence of bacteriuria is diagnosed using a clean-voided midstream urine sample. "Traditionally, 100,000 single isolate bacteria per milliliter has been used to define significant bacteriuria, with excellent specificity, but a sensitivity of 50%," states the practice bulletin. "To diagnose bacteriuria, decreasing the colony count to 1,000-10,000 bacteria per milliliter in symptomatic patients will improve the sensitivity without significantly compromising specificity."
How about use of urine dipstick testing? Such testing for leukocyte esterase or nitrite represents a quick, inexpensive method with a sensitivity of 75% and specificity of 82%.1 While dipstick testing can serve as a good screening test, women with negative test results and symptoms still should have a urine culture or urinalysis, or both performed, because false-negative results are common, the bulletin advises.2
"In a patient with a brand-new urinary tract infection, history and these diagnostic strips might be useful if they do get better; however, with a patient with comorbidities or in patients with persistent symptoms or recurrent urinary tract infections, urine culture is definitely the way to go," says Sheffield.
Recent research looked at using urine dipsticks to predict UTI in a urogynecology practice. It was determined that no combination of dipstick and/or symptoms adequately predicted an infection to the point that a recommendation to dispense with the need for culture.3
Study co-author Deborah Kuklinski, MS, RNC, WHNP, a women's health nurse practitioner at the Urogynecology Center in the Medical College of Wisconsin in Milwaukee, says, "We found that the urine analysis doesn't give us a good sense of UTIs. I think it's important for clinicians to consider urine cultures when they have a patient that might fall into the urogynecology population."
In the past, providers have treated uncomplicated acute cystitis with seven to 10 days of antimicrobial therapy; however, recent data have shown that three days of therapy is equal in efficacy to a longer duration of care.4 For uncomplicated acute bacterial cystitis, review the following recommended treatment regimens:
- trimethoprim–sulfamethoxazole: one tablet (160 mg trimethoprim, 800 mg sulfamethoxazole) twice daily for three days;
- trimethoprim: 100 mg twice daily for three days;
- ciprofloxacin: 250 mg twice daily for three days;
- levofloxacin: 250 mg once daily for three days;
- norfloxacin: 400 mg twice daily for three days;
- gatifloxacin: 200 mg once daily for three days;
- nitrofurantoin macrocrystals: 50-100 mg four times daily for seven days, or nitrofurantoin monohydrate 100 mg twice daily for seven days;
- fosfomycin tromethamine: 3 g dose (powder), single dose.
For uncomplicated acute bacterial cystitis in women, use of trimethoprim-sulfamethoxazole for three days is the preferred therapy, with a 94% bacterial eradication rate. In areas where resistance to this antimicrobial agent is more than 15-20%, another of the listed regimens should be chosen, the bulletin advises.2
References
- Fihn SD. Clinical practice. Acute uncomplicated urinary tract infection in women. N Engl J Med 2003; 349:259-266.
- ACOG Practice Bulletin No. 91: Treatment of Urinary Tract Infections in Nonpregnant Women. Obstet Gynecol 2008; 111:785-794.
- Kuklinski D, Koduri S. Predicting urinary tract infections in a urogynecology population. Urol Nurs 2008; 28:56-60, 67.
- Milo G, Katchman EA, Paul M, et al. Duration of antibacterial treatment for uncomplicated urinary tract infection in women. Cochrane Database Syst Rev 2005; 2:CD004682.
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