Urinary Tract Infection: Guidelines for Clinical Care
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Guidelines for Clinical Care Quality Department Ambulatory Urinary Tract Infection Urinary Tract Infection Guideline Team Team Leader Patient population: Adult women with uncomplicated UTI Steven E Gradwohl, MD General Medicine Objective: Implement a cost-effective strategy for uncomplicated UTI in women Team Members Key Points Catherine M Bettcher, MD Family Medicine ■ Diagnosis Carol E Chenoweth, MD • History. Diagnosis is made primarily by history. In women with dysuria and frequency, in the Infectious Diseases absence of vaginitis, the diagnosis is UTI 80% of the time [IC*]. R Van Harrison, PhD • Phone triage. In women with prior history of uncomplicated UTI's, consider phone triage [IIC*]. Medical Education • Urinalysis. Urinalysis for detection of pyuria by dipstick or microscope has a sensitivity of 80- Lauren B Zoschnick, MD Obstetrics & Gynecology 90% and a specificity of 50% for predicting UTI [IB*]. • No urine culture. Urine culture is NOT indicated in the vast majority of UTI’s [IIIC*]. UC has a sensitivity of 50% (if threshold for positive is >105 organisms), sensitivity can be increased to Initial Release 2 June, 1999 >90% if threshold is >10 organisms. Consider urine culture only in recurrent UTI or in the Most Recent Major Update presence of complicating factors. May, 2011 ■ Treatment Interim/Minor Revision September, 2016 • First line - Five days of nitrofurantoin [IA*]. • Second line -Three days of trimethoprim / sulfa [IA*]. Seven days of 1° cephalosporin or amoxicillin-clavulanic acid [IA*]. Ambulatory Clinical Guidelines Oversight ■ Follow-up Grant M Greenberg, MD, • No tests if asymptomatic. No laboratory follow-up is necessary if asymptomatic [IIIB*]. MA, MHSA • For recurrent UTI’s. In patients with recurrent UTI's (>3 / year) R Van Harrison, PhD – consider antibiotic prophylaxis / self-initiated therapy [IIA*] – urologic structural evaluation rarely indicated [IIID*] Literature search service * Strength of recommendation: Taubman Health Sciences I = generally should be performed; II = may be reasonable to perform; III = generally should not be performed. Library Level of evidence supporting a diagnostic method or an intervention: A=randomized controlled trials; B=controlled trials, no randomization; C=observational trials; D=opinion of expert panel. Clinical Background For more information Clinical Problem Antibiotic treatment should be prescribed only 734-936-9771 for as long as necessary to be effective. and Management Issues Recurrent UTI’s may be managed better by self- Incidence initiated therapy or prophylaxis than by © Regents of the continuing to treat each case emergently. This University of Michigan Urinary tract infections (UTI) are estimated to guideline provides an approach to uncomplicated account for over 7 million office visits per year, UTI that results in good clinical outcomes and These guidelines should not at a cost of over $1 billion. Up to 40% of utilizes clinical care resources appropriately. be construed as including all women will develop UTI at least once during proper methods of care or excluding other acceptable their lives, and a significant number of these methods of care reasonably women will have recurrent urinary tract Rationale for Recommendations directed to obtaining the infections. same results. The ultimate judgment regarding any The rationale for recommendations addresses: specific clinical procedure Cost-Effective Strategy or treatment must be made • Risk factors by the physician in light of • Complicating factors the circumstances presented Establishing a cost-effective strategy for the by the patient. diagnosis and treatment of UTI is important • Uncomplicated UTI because of its high incidence. Laboratory tests • Recurrent UTI’s should be ordered only when the results are • Asymptomatic bacteriuria likely to alter the process or outcome of care. • Acute uncomplicated pyelonephritis • UTI in pregnancy (Continued on page 3) 1 Figure 1. Diagnosis and Management of UTI in Adult Non-Pregnant Women Adult non-pregnant woman with UTI symptoms telephones office Eligible for prescription by phone? (See nursing Protocol) Previous history of • Similar symptoms to prior UTI’s Empiric treatment Yes uncomplicated UTI’s? • Lack of vaginitis symptoms (See Table 3) • No complicating factors/pyelo No symptoms (see Table 2) No Asymptomatic after 3 Schedule office visit No days? Yes Vaginitis symptoms? Evaluate for gynecologic Yes Follow-up PRN e.g., itching or discharge pathology No Consider: Urinalysis microscopic Negative • Pelvic exam dipstick results • Urine culture Positive Complicating conditions: • Complicating factors? (Table 2) See complicating factors section UTI uncomplicated? No • Recurrent UTI’s? (>3/year) See recurrent UTI section • Pyelo symptoms? See pyelonephritis section • Pregnancy? See pregnancy section Yes Table 1. Laboratory Charges (M-Labs) Five days of nitrofurantoin Urinalysis - dipstick $27 (No urine culture necessary.) Urinalysis - microscopic (complete) $27 Urine culture $35 • Re-visit Table 2. Complicating Factors • Consider: Symptoms persist? Yes -- Pelvic exam Diabetes Mellitus -- Urine culture with Immunosuppression sensitivities Urologic Structural / Functional Abnormality Nephrolithiasis present Recent Hospitalization / Nursing home Follow-up PRN Catheter (No follow-up UA or UC Symptoms for > 7 days necessary) Table 3. Treatment Regimens and Cost1 Table 4. Management of Recurrent UTI 1. Treat acute UTI (see Table 3). First Line: Brand Generic 2. Check follow-up urine culture if necessary to distinguish Nitrofurantoin2 100 mg BID x 5 days $32 $17 relapse from recurrence, otherwise generally not necessary. 3. Educate. Counsel about risk factors: Second Line: • consider alternative to use of spermicide Trimethoprim/Sulfa DS BID x 3days $17 $5 • consider vaginal estrogen in postmenopausal women Cephalexin 500 mg BID x 7 days $130 $28 4. Prophylaxis. Consider: Amoxicillin-clavulanic acid 875-125 $7 $5 • continuous or postcoital antibiotic (trimethoprim / sulfa SS mg x 7 days 80/400 daily or nitrofurantoin 50-100 mg at bedtime) Fosfomycin 3 gm x 1 dose $70 n/a • self initiated therapy (Table 3) 5. Structural evaluation is generally not indicated. 1 Cost = Average wholesale price based -10% for brand products and Maximum Allowable Cost (MAC) + $3 for generics, from Red Book Online, 9/2016, and Michigan Department of Community Health M.A.C. Manager, 9/2016. 2 Nitrofurantoin should not be used with creatinine clearance less than 50 ml/min 2 UMHS Urinary Tract Infection Guideline, September 2016 Rationale for Recommendations (continued) apparent that low colony counts (102 to 104) may simply represent early UTI; moreover, it appears that symptoms associated with low colony counts respond to antibiotic Risk Factors treatment, as well as symptoms with high counts. The majority of UTI's occur in sexually active women. Laboratory diagnosis. Common tests used are: urinalysis Risk increases by 3-5 times when diaphragms are used for by dipstick and urine microscopy under 40x power, both contraception. Risk also increases slightly with not voiding generally readily available in the clinic setting. Urine after sexual intercourse and use of spermicide. Increased culture is more expensive and requires 24 to 48 hours for risk has not been demonstrated with oral contraceptives, not results. None of these tests have been shown to be ideal voiding before intercourse, non-cotton underwear, and use screening tools. of condoms. Dipstick analysis for leukocyte esterase, an indirect test for Microbial Etiology the presence of pyuria, is the least expensive and time intensive test. It is estimated to have a sensitivity of 75- Escherichia coli is the predominant pathogen in 96% and specificity of 94-98%. Depending on the cut-off uncomplicated UTI in women, associated with more than used for "abnormal" pyuria as detected by urine 80% of cases. Staphylococcus saprophyticus is found in microscopy, the positive predictive value for pyuria is only 15% of cases. Other members of the Enterobacteriaceae 50%. No studies were found directly comparing dipstick family, such as Klebsiella sp., Proteus sp., or Enterobacter for leukocyte esterase with urine culture. When compared sp. are associated with uncomplicated UTI. Group B to culture, dipstick is less sensitive for lower thresholds for streptococci are an uncommon pathogen in UTI in young UTI (i.e., 102-104 cfu/mL) and specificity is healthy women, but requires treatment in pregnant women. correspondingly higher for the same thresholds. Nitrite testing by dipstick is considerably less useful, probably in Complicating Factors and Medical Conditions large part because it is only positive in the presence of bacteria that produce nitrate reductase, and can be Patients with complicating factors and medical conditions confounded by consumption of ascorbic acid. are at increased risk of development of pyelonephritis or infection with resistant organisms. Complicating factors Microscopic examination of unstained, centrifuged urine by are listed in Table 2 and include underlying urologic a trained observer under 40x power has a sensitivity from structural abnormalities, diabetes, immunosuppression, 82-97% and a specificity of 84-95%, again varying pregnancy, recent hospitalization, or urologic tract depending on defined thresholds for UTI. Microscopic manipulation. It is necessary to differentiate these women urinalysis showing pyuria has a widely variable predictive from those with uncomplicated UTI in terms of both work- value for urinary