Update in diagnosis and management of UTIs
2/7/2018
Update in diagnosis and management of
UTIs
Brian S. Schwartz, MD UCSF, Division of Infectious Diseases
? I have no disclosures
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Lecture outline
? Challenges in cystitis ? Complicated UTI/pyelonephritis ? Asymptomatic bacteriuria ? Recurrent UTIs ? Pre-op urine screening
2/7/2018
Case
? 27 y/o female presents to your clinic with 4 days of dysuria and frequency. Denies vaginal discharge or pelvic pain. Urinalysis reveals:
? 3+ Leukocyte esterase ? 1+ Heme ? 2+ Nitrite
? What do you do next?
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2/7/2018
Do you obtain a urine culture?
A.Yes B.No
Do you give empiric antibiotics?
A. No B. Nitrofurantoin x 5 days C. TMP-SMX x 5 days D. Ciprofloxacin x 3 days E. Cefazolin x 7 days
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2/7/2018
When should you get a urine culture for uncomplicated cystitis?
? Uncomplicated UTI: culture not needed
? Will likely be susceptible E coli
? Culture if...
? Complicated UTIs (pyelo) ? Recurrent UTIs ? High local rates of resistance
Hooton TM. NEJM. 2012
IDSA updated guidelines for uncomplicated UTI
Goal: Low resistance, low"collateral damage"
?Nitrofurantoin 100 mg PO BID x 5 days
?TMP-SMX DS PO BID x 3 days
? avoid if resistance >20%, recent usage
?Fosfomycin 3 gm PO x 1
Gupta K. CID 2011
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2/7/2018
Nitrofurantoin in elderly?
? Study of older women (mean age 79)
? Mean GFR was 38 mL/min
? Evaluated for Rx failure on different abx
? Other vs. nitrofurantoin ? 130/1989 (6.5%) vs. 516/3739 (13.8%), CI 0.36-0.53
? However, higher Rx failure in high GFR group too ? Cipro more effective than nitrofurantoin in all ? Failure rate same for nitrofurantoin vs. TMP-SMX
Singh N. CMAJ. 2015
Safety of nitrofurantoin in elderly?
? Age > 65 years with Dx cystitis ? N=13,421 (2007-12) ? Evaluated for nitrofurantoin use lung injury ? Nitrofurantoin exposure lung injury ? Chronic use lung injury (aRR 1.53 [1.04-2.24])
Santos JM. JAGS. 2016
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