RECURRENT UTI - RECENT UPDATE BY DR SHASHWAT JANI

RECURRENT UTI - RECENT UPDATE BY DR SHASHWAT JANI

1. Recurrent U.T.I. Recent Updates Dr. Shashwat K. Jani. M. S. ( Obs – Gyn ) Diploma in Advance Laparoscopy . Consultant Assistant Professor , Smt. N.H.L. Municipal Medical College. Sheth V. S. General Hospital , Ahmedabad . Mobile : [phone]. E-mail : [email protected]

2. Urinary tract infection (UTI) is one of the commonest bacterial infections globally encountered by women. The risk of women acquiring a UTI in their lifetime has been estimated to be over 50 %, with about 25 % having a recurrence . 28-Mar-17 Dr Shashwat Jani. 99099 44160. 2

3. R.U.T.I. Symptomatic infections that follow complete resolution of a previous UTI. In a primary care setting , 53 % of women above the age of 55 years & 36% of younger women report a recurrence within 1 year. Hence, its management and prevention is of utmost significance for all clinicians including non-specialists and those in the primary care setting. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 3

4. Imp. Definitions UTI can manifest as either cystitis (lower UTI) OR pyelonephritis (upper UTI ). C omplicated UTI : associated with a structural or functional urinary tract abnormality or an underlying pathology , both of which can subsequently increase risks of acquiring an infection or failure of therapy. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 4

5. Uncomplicated UTI : Sporadic , community acquired episodes of cystitis and pyelonephritis in otherwise healthy individuals, but could lead to more serious outcomes and thus require additional attention. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 5

6. Recurrent UTI D efined as … > 2 episodes of uncomplicated UTI in the last 6 months OR > 3 episodes in the last 12 months , documented by culture. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 6

7. Relapse Vs. R einfection Relapse : Caused by the same bacterial strain implicated in a previous UTI within 2 weeks of the completion of treatment for the original infection. Reinfection : A recurrent UTI arising for > 2 weeks after treatment or after sterile intervening culture is considered to be a reinfection, even if the infecting pathogen is the same as the original. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 7

8. Factors predisposing to treatment failure: Recent antibiotic treatment Hospital acquired infection Renal or bladder calculi Obstructive uropathy Renal cysts Renal diseases such as reflux nephropathy, chronic interstitial nephropathy, analgesic nephropathy, diabetic nephropathy, sickle cell nephropathy, immunosuppression. 28-Mar-17 8

9. Pathogenesis Bacterial strains are uniquely equipped with specialised virulence factors , e.g . different types of pili , which facilitate the ascent of bacteria from the faecal flora , vaginal introitus or periurethral area up the urethra into the bladder, or less frequently, allow the organisms to reach the kidneys . 28-Mar-17 Dr Shashwat Jani. 99099 44160. 9

10. In P remenopausal W omen : Vaginal colonisation by lactobacilli , promoted by estrogens. This results in the production of lactic acid , maintaining a low pH that inhibits growth of many pathogenic bacteria . I n Postmenopausal W omen : lactobacilli are not present and the vagina becomes primarily colonised with enterobacteria , in particular E . coli . This is a major factor leading to increased susceptibility to clinically significant UTI. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 10

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12. Commonest Organisms Escherichia coli is the predominant uropathogen responsible for both sporadic and recurrent UTI, seen in 70–85%of cases. Other causative organisms include Staphylococcus saprophyticus (10–15 % of cases ), Klebsiella pneumoniae and Proteus mirabilis. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 12

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14. Fungi (Candida and Cryptococcus spp.) and Parasites ( Trichomonas and Schistosoma ) Klebsiella and group B streptococcus infections are relatively more common in patients with diabetes. Pseudomonas infections are relatively more common in patients with chronic catheterization. Proteus mirabilis is a common uropathogen in patients with indwelling catheters , spinal cord injuries, or structural abnormalities of the urinary tract. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 14

15. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 15 The diagnosis of clinically significant UTI requires both clinical assessment of symptoms and bacteriological evaluation.

16. Clinical Presentation ANY 3 OUT OF 5 : Frequency , P olyuria , D ysuria , S uprapubic tenderness Haematuria Unpleasant odour C loudy . 28-Mar-17 Dr Shashwat Jani. 99099 44160. 16

17. Clinical manifestations depending on site of infection Urethritis: Discomfort in voiding Dysuria Urgency frequency 28-Mar-17 Dr Shashwat Jani. 99099 44160. 17

18. Cystitis: dysuria, urgency and frequent urination Pelvic discomfort Abdominal pain Pyuria Hemorrhagic cystitis: Visible blood in urine. Irritating voiding symptoms 28-Mar-17 Dr Shashwat Jani. 99099 44160. 18

19. Pyelonephritis: Invasive nature Suprapubic tenderness Fever and chills White blood cell casts in urine Back pain Nausea and vomiting Complications include sepsis, septic shock and death. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 19

20. Stepwise Mx Of RUTI History - appropriate for recurrent UTI. Confirm bacteriological evidence of infection. Exclude underlying anatomical or functional abnormality using appropriate imaging and endoscopic evaluation. Advise on prophylactic lifestyle changes . Consider a prophylactic antibiotic regimen. Consider alternative strategies . 28-Mar-17 Dr Shashwat Jani. 99099 44160. 20

21. Imp. History Points Age of first UTI No. of previous UTI episodes Ix & Rx taken Lower or Upper UTI symptoms Sexual & contraceptive history Past Med. History : DM , neurological dis., any previous urolithiasis , previous Sx , Instrumentation in urinary tract. Any medications 28-Mar-17 Dr Shashwat Jani. 99099 44160. 21

22. Differentiation by History Lower UTI- frequency, urgency, dysuria , haematuria . Upper UTI - fever , rigor and lion pain and symptoms of lower UTI . 28-Mar-17 Dr Shashwat Jani. 99099 44160. 22

23. Assessment General & Neurological examination Renal size & tenderness Is the bladder palpable? Vaginal examination : local cause or prolapse 28-Mar-17 Dr Shashwat Jani. 99099 44160. 23

24. Investigations Routine : Urine Dip stick Test Urine for microscopic examination Urine for culture & sensitivity If systemic involvement is suspected : USG IVP CT / MRI 28-Mar-17 Dr Shashwat Jani. 99099 44160. 24

25. 1. Urine Dip stick 28-Mar-17 Dr Shashwat Jani. 99099 44160. 25

26. Urine Dip stick A leucocyte and nitrite positive urine dipstick has been considered a highly sensitive test in predicting a UTI. However, since some bacteria , such as S. saprophyticus , lack the enzymes to reduce nitrates into nitrites, false-positive results are fairly common. So, not much reliable test to rule out UTI. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 26

27. 2. Urine Microscopy Rapid & reliable test Presence of pus, white blood cells, red blood cells Bacterial count > 10 5 /ml – significant bacteriuria Presence of Cast , Epithelial cells 28-Mar-17 Dr Shashwat Jani. 99099 44160. 27

28. 3. Urine Culture 28-Mar-17 Dr Shashwat Jani. 99099 44160. 28

29. Ideally obtained before and without delaying antibiotics is recommended in patients with Recurrent UTI. R ecommended in… P regnant women, P atients with immunosuppression Urinary tract malformations, U rinary tract stones, R ecent urologic instrumentation, I ndwelling catheters, N eurogenic bladder, K idney transplant 28-Mar-17 Dr Shashwat Jani. 99099 44160. 29

30. Also helpful , while starting empiric therapy, in patients with … Previous history of known resistant infections , Failure of empiric antibiotics , Multiple recurrent UTIs. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 30

31. Specimen Collection The urine collected in a wide mouthed container from patients A mid stream specimen is the most ideal for processing P atients passes urine with a labia separated and mid stream sample is collected 28-Mar-17 Dr Shashwat Jani. 99099 44160. 31

32. Transport of Urine for Culturing Urine All collected specimens of urine to be transported to laboratory with out delay Delay of 1 – 2 hour deter the quality of diagnostic evaluations. If the delay is anticipated the specimens are at preserved at 4 c In field conditions Boric acid can be added at a concentration of 1.8 % 28-Mar-17 Dr Shashwat Jani. 99099 44160. 32

33. Following bacterial counts are clinically relevant: > 10 3 cfu /mL of uropathogens in a mid-stream sample of urine (MSU) in acute uncomplicated cystitis in women. > 10 4 cfu/mL of uropathogens in an MSU in acute uncomplicated pyelonephritis in women. > 10 5 cfu /mL of uropathogens in an MSU in women, or in straight catheter urine in women, in a complicated UTI. In a suprapubic bladder puncture specimen, any count of bacteria is relevant Culture in UTI 28-Mar-17 Dr Shashwat Jani. 99099 44160. 33

34. Imaging studies Indicated in : Pts. With Urinary outflow obstruction Systemic involvement with fever Fail to respond to antimicrobial therapy of 72 hours. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 34

35. X - RAY KUB USG KUB Unenhanced helical CT MRI Dimercaptosuccinic acid (DMSA) scanning Excretory urography / IVP Voiding cystourethrography Cystoscopy 28-Mar-17 Dr Shashwat Jani. 99099 44160. 35

36. Intravenous pyelography / excretory urography 28-Mar-17 Dr Shashwat Jani. 99099 44160. 36

37. Voiding cystourethrography Cystoscopy 28-Mar-17 Dr Shashwat Jani. 99099 44160. 37

38. TREATMENT Continuous antibiotic prophylaxis Postcoital antibiotic prophylaxis Self-start antibiotic therapy 28-Mar-17 Dr Shashwat Jani. 99099 44160. 38 Antibiotic Prophylaxis

39. Ideal antibiotic for UTI : Adequate coverage over E.coli Concentration in urine Duration of therapy Low resistance Cost Low adverse effect profile 28-Mar-17 Dr Shashwat Jani. 99099 44160. 39

40. Continuous antibiotic prophylaxis TMP/SMX (40 mg/200 mg daily or thrice weekly ) Trimethoprim (100 mg daily) Ciprofloxacin (125 mg daily) Cephalexin (125 mg to 250 mg daily) Nitrofurantoin (50 mg to 100 mg daily) Norfloxacin (200 mg daily) Fosfomycin (3 gm every 10 days) 28-Mar-17 Dr Shashwat Jani. 99099 44160. 40

41. Post Coital Prophylaxis ( Within 2 hours of Coitus ) TMP/SMX (40 mg/200 mg to 80 mg/400 mg ) Ciprofloxacin (125 mg ) Cephalexin (250 mg ) Nitrofurantoin (50 mg–100 mg daily) Norfloxacin (200 mg) Ofloxacin (100 mg ) 28-Mar-17 Dr Shashwat Jani. 99099 44160. 41

42. Self-start antibiotic therapy Ideal for women who are not suitable candidates for long-term prophylaxis. Additional option for women with the and start antibiotics. Pt. is given Prescription for 3 day course of Antibiotics. Patients are advised to contact doctor, if symptoms do not resolve within 48 hours , for treatment based on culture and sensitivity . 28-Mar-17 Dr Shashwat Jani. 99099 44160. 42

43. The Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases recommends… N itrofurantoin = 100 mg, twice daily for 5 days, TMP-SMX = 160/800 mg twice daily for 3 days, Fosfomycin = 3 gm , single dose. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 43

44. For Severe Cases of RUTI Pathogen Treatment options Escherichia coli Ceftriaxone 50mg/kg i.v /I.M Qday Pseudomonas aeroginosa Gentamycin 6-7.5mg /kg i.v Q8hr / Qday Klebsiella sps Enterobacter sps Proteus sps Ceftadizine 100-150mg/kg/day i.v Q8hr Enterococcus sps Ampicillin 100-200mg/kg/day Q6hr 28-Mar-17 Dr Shashwat Jani. 99099 44160. 44

45. Non-antibiotic prevention strategies 28-Mar-17 Dr Shashwat Jani. 99099 44160. 45

46. Oestrogen therapy 28-Mar-17 Dr Shashwat Jani. 99099 44160. 46

47. Oestrogen therapy A 2008 Cochrane review demonstrated vaginal oestrogen to be an effective prophylaxis in the prevention of recurrent UTIs. Oestriol cream : 0.5 mg Vaginally every night for 2 weeks, and then twice a week for 8 months. Oral Oestrogen tabs are ineffective and also causes breast tenderness & Vaginal bleeding. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 47

48. Cranberry 28-Mar-17 Dr Shashwat Jani. 99099 44160. 48

49. Cranberry - Controversial A Cochrane review of 24 studies , with a total of 4,473 subjects , revealed that cranberry products were of no benefit compared to placebo in most populations. A recent retrospective review concluded that clinical studies on cranberry products strongly support their prophylactic use in young and middle-aged women but that evidence among other patients remains controversial. 28-Mar-17 Micali S, Isgro G, Bianchi G,Miceli N, Calapai G, NavarraM(2014) Cranberry and recurrent cystitis:more thanmarketing ? Crit Rev Food Sci Nutr 54(8):1063–1075

50. Ascorbic Acid ( Vit – C ) O ften recommended as a supplement that can prevent recurrent UTIs by acidification of the urine. Weak association. 100 mg / day. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 50

51. Methenamine salts Hydrolyzed to ammonia and formaldehyde when in acidic urine , which act as a bactericide to some strains of bacteria. Less side effects A Cochrane review on the use of methenamine hippurate concluded that short-term use is effective in preventing RUTI. 28-Mar-17 Lee BB, Simpson JM, Craig JC, Bhuta T (2007) Methenamine hippurate for preventing urinary tract infections. Cochrane Database Syst Rev 4:CD003265 Dr Shashwat Jani. 99099 44160. 51

52. Emerging Therapies 28-Mar-17 Dr Shashwat Jani. 99099 44160. 52

53. D - Mannose Inhibits bacterial adherence to urothelial cells. Weak recommendations . Need further clinical trials to prove its efficacy. Recommended for prevention prophylaxis only. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 53

54. Lactobacillus (probiotics) A recent phase 2 trial has found that treatment with probiotics following UTI is associated with a decrease in recurrent UTIs. Still strong validation is required. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 54 Restore the vaginal lactobacilli Compete with urogenital pathogens Prevent bacterial vaginosis , a condition that increases the risk of UTI

55. Vaccination 28-Mar-17 Dr Shashwat Jani. 99099 44160. 55

56. Uro-Vaxom is an oral capsular vaccine comprising 18 heat killed E. coli strains. It has been found to be an effective prophylaxis for prevention of UTI . A meta-analysis of four studies comprising 891 patients demonstrated that Uro - Vaxom significantly reduced the risk for development of UTI . 28-Mar-17 Dr Shashwat Jani. 99099 44160. 56

57. Uro Vaxom Preventive treatment and/or consolidation therapy: 1 capsule daily on an empty stomach, for 3 consecutive months . Treatment during acute episodes : 1 capsule daily on an empty stomach as comedication to conventional antimicrobial therapy, until disappearance of the symptoms but for at least 10 consecutive days. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 57

58. Urovac : Vaginal suppository vaccine comprises 10 uropathogenic strains of bacteria ( six E. coli strains and one strain each of Proteus, Mirabilis , Morganella morganii, K.pneumoniae and Enterococcus faecalis ). Currently this vaccine has successfully completed a phase 2 trial. Intranasal vaccines : Currently under research. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 58

59. RUTI in P regnancy Nitrofurantoin 100 mg q12 h, 3-5 days (Avoid in G6PD deficiency) Amoxicillin 500 mg q8 h, 3-5 days Co-amoxicillin/ clavulanate 500 mg q12 h, 3-5 days Cephalexin 500 mg q8 h, 3-5 days Trimethoprim q12 h, 3-5 days. Avoid trimethoprim in first trimester/term 28-Mar-17 Dr Shashwat Jani. 99099 44160. 59

60. Pregnancy & RUTI. With symptomatic or asymptomatic bacteriuria , the risk of a preterm delivery and low birth weight infant is significantly increased . A follow-up culture for test of cure a week after completion of Rx and monthly follow-up until the completion of the pregnancy. 28-Mar-17 Dr Shashwat Jani. 99099 44160. 60

61. Prophylactic Measures to prevent RUTI Avoid long intervals between urination. Have at least eight to ten drinks (mug-size) daily . These could be water or sugar free cranberry juice, squash or other fluids. Caffeinated drinks are best avoided. Shower instead of taking a bath . Avoid using bubble bath or other cosmetic bath products . 28-Mar-17 Dr Shashwat Jani. 99099 44160. 61

62. Avoid using any feminine hygiene sprays and scented douches. Avoid using a vaginal diaphragm for birth control. Empty the bladder after sexual intercourse, as sexual relations can often trigger UTIs . After urination, wipe from front to back . 28-Mar-17 Dr Shashwat Jani. 99099 44160. 62

63. 28-Mar-17 63 Dr Shashwat Jani. [phone]