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The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in AdultsUpdate 2004Merrill Van YuCase #1Kim, 33 years old, female, married, sexually active, with an unremarkable health history, asks for a house call for recent onset of pain in urination, urinary frequency and urgency. She has no costovertebral tenderness on examination.Acute Uncomplicated Cystitis in WomenDefinitionNon-pregnant women, 18-64 years old, presenting with dysuria, frequency, or gross hematuria, with or without back painNo risk factors for complicated UTIHospital acquired infectionIndwelling urinary catheterRecent urinary tract infectionRecent urinary tract instrumentation (in the past 2 weeks)Functional or anatomic abnormality of the urinary tractRecent antimicrobial use (in the past 2 weeks)Symptoms for > 7 days at presentationDiabetes mellitusImmunosuppressionWomen who present with the above symptoms plus vaginal irritation or vaginal discharge must undergo further diagnostic tests to confirm the presence of acute uncomplicated cystitis or other concomitant conditions

4Case #1 contdKim brings you aside. Do I really have to pee in a cup? That makes me uncomfortable. Im not a big fan of needles too.Diagnostic TestsPre-treatment urine culture and sensitivity is not recommended Standard urine microscopy and dipstick leukocyte esterase (LE) and nitrite tests are not prerequisites for treatment In women who present with additional symptoms such as vaginal discharge or vaginal irritation, either a standard urine microscopy or dipstick for LE and nitrites can be done to confirm the diagnosis

6TreatmentAntibioticsDose and FrequencyDurationTMP-SMX800/160 mg BID3 daysCiprofloxacin250 mg BID3 daysOfloxacin200 mg BID3 daysNorfloxacin400 mg BID3 daysLevofloxacin250 mg BID3 daysGatifloxacin400 mgSingle doseNitrofurantoin100 mg QID7 daysCefixime400 mg OD3 daysCefuroxime125-250 mg BID3-7 daysCo-amoxiclav625 mg BID7 daysNOT ampicillin nor amoxicillinTMP-SMX down to Nitrofurantoin are Grade A recommendations while Cefixime to Co-amoxiclav are grade B recommendations.

Three-day therapy is the recommended duration of treatment (Grade A) except fornitrofurantoin, which must be given for 7 days.

In otherwise healthy elderly women presenting with signs and symptoms of acute cystitis, athree-day course of any of the antibiotics listed in table 4 is also recommended.7Response to TherapyPatients whose symptoms worsen or do not improve after 3 days should have a urine culture and the antibiotic should be empirically changed, pending result of sensitivity testingPatients whose symptoms fail to resolve after the 7-day treatment should be managed as a complicated urinary tract infectionCase #1 contdKim was given Ciprofloxacin 250 mg BID for 3 days with relief noted. She brings up her anxiety about peeing in a cup again. Post-Treatment Urine CultureRoutine post-treatment urine culture and urinalysis in patients whose symptoms have completely resolved are not recommendedCase #2Just as you were about to leave Kims home, her sister Kylie asks to talk to you outside the gate. She explains that she has been having fever and chills for the past 3 days, accompanied by nausea and vomiting. She wonders if shes having a urinary tract infection too.Acute Uncomplicated Pyelonephritis in WomenDefinitionClassical SyndromeFever (T > 38C)ChillsFlank painCostovertebral angle tendernessNausea and vomitingWith or without signs or symptoms of lower urinary tract infectionLaboratory FindingsPyuria (> 5 WBC/hpf of centrifuged urine) on urinalysisBacteriuria (> 100,000 CFU of a uropathogen/mL on urine cultureDiagnostic TestsUrinalysis and Gram stain are recommendedUrine culture and sensitivity should also be performed routinely to facilitate cost-effective use of antibioticsBlood cultures are not routinely recommendedBlood cultures done twice are recommended for patients who present with signs of sepsissigns of sepsis:presence of any two of the following: temperature >38 C or < 36 C, leukopenia (WBC< 4,000) or leukocytosis (WBC > 12,000), tachycardia (HR>90 beats/min), tachypnea (RR> 20/min or PaCO2 40mmHg drop from baseline)14Case #2 contdUnlike her sister Kim, Kylie has no problems peeing in a cup. Urinalysis and urine C/S revealed WBC > 10/hpf and Gram negative coccobacilli, respectively. She asks if she could just take the medications at home since she has to take care of her children.TreatmentTreated as OutpatientsNon-pregnantNo signs and symptoms of sepsisLikely to adhere to treatment and return for follow-up

*An initial parenteral dose of ceftriaxone may be given followed by an oral antibioticIndications for AdmissionInability to maintain oral hydration or take medicationsConcern about compliancePresence of possible complicating conditionsSevere illness with high feverSevere painMarked debility and signs of sepsis

Empiric TreatmentORALAntibiotic and DoseFrequency and DurationOfloxacin 400 mgBID; 14 daysCiprofloxacin 500 mgBID; 7-10 daysGatifloxacin 400 mgOD; 7-10 daysLevofloxacin 250 mgOD; 7-10 daysCefixime 400 mgOD; 14 daysCefuroxime 500 mgBID; 14 daysAmoxicillin-Clavulanate 625 mg (Gram positive organisms)TID; 14 daysEmpiric TreatmentPARENTERALAntibiotic and DoseFrequency and DurationCeftriaxone 1-2 gmQ 24Ciprofloxacin 200-400 mgQ 12Levofloxacin 250-500 mgQ 24Gatifloxacin 400 mgQ 24Gentamicin 3-5 mg/kg BW (+/- Ampicillin)Q 24Ampi-Sulbactam 1.5 gm (Gram positive)Q 6Piperacillin-Tazobactam 2.25-4.5 gmQ 6-8*Given until patient is afebrileEmpiric Treatment NOT recommendedAminopenicillins (ampicillin or amoxicillin)1st generation cephalosporinsTMP-SMX (but can be used when organism is susceptible on urine C/S)Ampicillin + Aminoglycoside (except when enterococcal infection is suspected)Case #2 contdYou gave Kylie Ciprofloxacin 500 mg BID for 7 days with relief of symptoms. Shes very happy and sends you a box of chocolates to show her appreciation.Workup for Urologic AbnormalitiesRoutine urologic evaluation and routine use of imaging procedures are NOT recommendedConsider urologic evaluation:Patient remains febrile within 72 hours of treatmentRecurrence of symptoms to rule out:NephrolithiasisUrinary tract obstructionRenal or perinephric abscessesOther complications of pyelonephritisFollow-up Urine CultureNOT necessary in patients clinically responding to therapy (usually apparent in < 72 hours after initiation of treatment)NOT recommended post-treatment in those clinically improved SHOULD BE PERFORMED in women whose symptoms do not improve during therapy and those whose symptoms recur after treatmentManagement of RecurrenceAntibiotic treatment based on urine culture and sensitivity test results, in addition to assessing for underlying genitourologic abnormalityDuration of re-treatment in the absence of a urologic abnormality is 2 weeksFor patients whose symptoms recur and whose culture shows the same organism as the initial infecting organism, a 4-6 week regimen is recommendedCase #3You received a call from another sister, Khloe, who had abnormal urinalysis and urine culture results recently as she was applying for a movie role. However, she does not have any complaints nor problems with urination. Shes anxious that these may affect her career. Asymptomatic Bacteriuria in AdultsDefinition and DiagnosisPresence of > 100,000 CFU/mL of one or more uropathogens in:2 consecutive midstream urine specimens OR 1 catheterized urine specimen in the absence of symptoms attributable to urinary tract infectionScreeningUrine culture recommendedIn the absence of facilities for urine culture, significant pyuria (>10 WBC/hpf) or a positive Gram stain of unspun urine (>2 microorganisms/OIF) in 2 consecutive midstream urine samples can be used to screen for ASBTarget for ScreeningPatients who will undergo genitourinary manipulation or instrumentation Post-renal transplant patients up to the first 6 monthsPatients with diabetes mellitus with poor glycemic control, autonomic neuropathy or azotemiaAll pregnant women

Should NOT be Screened for ASBHealthy adultsPatients with diabetes mellitus with adequate glycemic control, no autonomic neuropathy or azotemiaElderly patientsPatients with indwelling cathetersImmunocompromised patientsOther solid organ transplant patientsHIV patientsSpinal cord injury patientsPatients with urological abnormalitiesTreatment*A 7- to 14-day course is recommendedAntibioticsDose and FrequencyDurationTMP-SMX800/160 mg BID3 daysCiprofloxacin250 mg BID3 daysOfloxacin200 mg BID3 daysNorfloxacin400 mg BID3 daysLevofloxacin250 mg BID3 daysGatifloxacin400 mgSingle doseNitrofurantoin100 mg QID7 daysCefixime400 mg OD3 daysCefuroxime125-250 mg BID3-7 daysCo-amoxiclav625 mg BID7 daysCase #4Another sister, Kourtney, 35 years old, married, G2P1(1001), pregnant at 5 weeks AOG, visited you for dysuria. No fever nor costovertebral angle tenderness noted.Urinary Tract Infection in PregnancyA. Asymptomatic Bacteriuria in PregnancyDiagnosisPresence of > 100,000 CFU/ml of one or more uropathogens in two consecutive midstream urine specimens or one catheterized urine specimen, in the absence of symptoms attributable to a urinary tract infectionIn settings where obtaining 2 consecutive urine cultures are not feasible or difficult, 1 urine culture is an acceptable alternative for the diagnosis of ASB in pregnancyScreeningALL pregnant women must be screened for ASB on their first prenatal visit between the 9th to 17th weeks, preferably on the 16th week age of gestationScreening TestTEST OF CHOICE: Urine culture of clean-catch midstream In areas where urine culture is not available, the following can be used for screening: An initial gram stain of centrifuged urine (cut-off: same morphology of bacteria seen in >6 of 12 hpfs in centrifuged urine sample). If positive, this must be followed by a urinalysis to determine pyuria. A cut-off level of >5 wbc/hpf suggests ASBTo minimize multiple visits to the lab and/or clinic, both tests can be requested simultaneously, but with the urinalysis being performed after a positive gram stain result. (Please see Algorithm section)Urine dipsticks for leukocyte esterase and/or nitrite tests are not recommended for screening for ASB in pregnancy. Urinalysis alone is not recommended for screeningTreatmentAmong the drugs that can be used are nitrofurantoin (not for those near-term), co-amoxiclav, cephalexin, and cotrimoxazole (not in the 1st and 3rd trimesters) depending on the sensitivity results of the urine isolate A 7-day course is recommendedA follow-up culture should be done one week after completing the course of treatmentTreatmentCategory B, L1, L2Category C, L3Category D, L3NitrofurantoinAmoxicillin-ClavulanateCephalosporinsTMP-SMXAvoid in 1st and 3rd trimester)AminoglycosidesUrinary Tract Infection in PregnancyB. Acute Cystitis in PregnancyWhen to SuspectUrinary frequency, urgency, dysuria and bacteriuria without fever and costovertebral angle tenderness Gross hematuria may also be presentDiagnostic TestsUrine culture and sensitivity test of a midstream clean catch urine specimenIn the absence of a urine culture, the laboratory diagnosis of acute cystitis can be determined by the presence of significant pyuria defined as > 8 pus cells/mm3 of uncentrifuged urine OR > 5 pus cells/hpf of centrifuged urine, and a positive leukocyte esterase and nitrite testTreatmentAntibiotics against E. coliTMP-SMX and fluoroquinolones are relatively contraindicated during pregnancy because of their potential teratogenicity and the third trimester risk of kernicterus with TMP-SMX. A 7- day course is recommendedPost-Treatment Urine CultureShould be obtained to confirm eradication of bacteriuria and resolution of infectionPregnant patients with pyelonephritis, recurrent UTIs, concurrent gestational DM, concurrent nephrolithiasis or urolithiasis, and pre-eclampsia, should be monitored at monthly intervals until delivery to ensure that urine remains sterile during pregnancy

42Urinary Tract Infection in PregnancyC. Acute Pyelonephritis in PregnancyWhen SuspectedShaking chills, fever (T>38 C), flank pain, nausea and vomiting, with or without signs and symptoms of lower urinary tract infections and physical finding of costovertebral angle tendernessUrinalysis shows pyuria of > 5 WBC/hpf of centrifuged urine and bacteriuria of > 10,000 CFU of a uropathogen/mL of urine Diagnostic TestsGram stain of uncentrifuged urine is recommended to differentiate gram positive from gram-negative bacteriuriaUrine culture and sensitivity test should also be performed routinely Blood cultures are not routinely recommended for all pregnant patients with acute pyelonephritisTreatmentShould be hospitalized and immediately treatedPatients without sepsis and able to take oral medications can be treated as outpatientsTreatment duration is 10-14 daysNOT fluoroquinolones and aminoglycosides Post-Treatment Urine CultureShould be obtained to confirm resolution of the infectionShould be monitored at intervals until delivery to confirm continued urine sterility during pregnancyCase #5Another sister, Kendall, messages you on Facebook. She says that she has been having recurrent urinary tract infections in that past year. She is concerned because this might affect her modeling career. Recurrent Urinary Tract Infection in WomenDiagnosisRecurrent UTI is diagnosed when a non-pregnant woman with no known urinary tract abnormalities has episodes of acute uncomplicated cystitis documented by urine culture occurring more than twice a yearIndications for ProphylaxisFrequency of recurrence is not acceptable to the patient in terms of level of discomfort or interference with activities of daily livingMay be withheld if the frequency of recurrence is tolerable to the patient

ProphylaxisAntibiotic regimenContinuous prophylaxisPostcoital prophylaxisHormonal treatments in postmenopausal women

Case #6Their mother, Kris, calls you up suddenly in the middle of the night. She says that she is also having problems with urination. She admits to be taking steroids for an undisclosed condition.Complicated Urinary Tract InfectionDefinitionSignificant bacteriuria (> 100,000 CFU/mL), which occurs in the setting of functional or anatomic abnormalities of the urinary tract or kidneysConditions that Define Complicated UTIPresence of an indwelling catheter or intermittent catheterizationIncomplete emptying of the bladder with >100 mL retained urine post-voidingObstructive uropathy due to bladder outlet obstruction, calculus and other causesVesicoureteral reflux and other urologic abnormalities including surgically created abnormalities

Conditions that Define Complicated UTIAzotemia due to intrinsic renal diseaseRenal transplantationDiabetes mellitusImmunosuppressive conditionsUTI caused by unusual pathogens or drug-resistant pathogensUTI in males except in young males presenting with exclusively lower UTI symptomsDiagnostic TestsUrine sample for Gram stain, culture and sensitivity testingNeed for hospitalizationMarked debilitySigns of sepsisUncertainty in diagnosisUnable to maintain oral hydration or take oral medicationsTreatmentMild to moderate illness: Oral fluoroquinolonesSeverely ill patients: Broad-spectrum parenteral antibioticsTreatment RegimensOral RegimenCiprofloxacin 250-500 mg BID x 14 daysNorfloxacin 400 mg BID x 14 daysOfloxacin 200 mg BID x 14 daysLevofloxacin 250-500 mg OD x 10-14 daysParenteral RegimenAmpicillin 1 gm q 6 hrs + gentamicin 3 mg/kg/day q 24 hrsAmpicillin-sulbactam 1.5 gm to 3 gm q 6 hrsCeftazidime 1-2 gm q 8 hrsCeftriaxone 1-2 gm q 24 hrsImipenem-cilastatin 250-500 mg q 6-8 hrsPiperacillin-Tazobactam 2.25 gm q 6 hrsCiprofloxacin 200-400 mg q 12 hrsOfloxacin 200-400 mg q 12 hrs IVLevofloxacin 500 mg q 24 hrs IVFollow-up TestsUrine culture 1 to 2 weeks after completion of medicationsFurther workup to identify and correct the anatomical, functional or metabolic abnormalitySpecific Issues of Concern in Complicated UTICatheter-Associated UTIUTI in Diabetic PatientsUTI in Renal Transplant PatientsUTI in Patients with HIV/AIDSUrinary CandidiasisCase #7Their brother, Rob, 24 years old, male, with a very healthy monogamous sexual relationship with his girlfriend of 5 years, sought consult at the OPD for dysuria and frequency in urination.Definition and DiagnosticsUrinalysis> 5 WBC/hpf in a clean catch midstream specimenUrine cultureGrowth of > 1000 CFU/mLUrinary Tract Infection in MenA. Uncomplicated Cystitis in Young MenCase #7 contdHe was treated with TMP-SMX for 7 days with resolution of the conditionCase #86 months later, their father Bruce arrived in your house after experiencing chills, low back pain and perineal pain. He also noted dysuria, frequency, urgency, and nocturia. Upon rectal examination reveals a markedly tender, swollen prostate.

Prostatitis SyndromesCategoryCharacteristic Clinical FeaturesIAcute bacterial prostatitisAcute infection of the prostate gland characterized by fever,chills, low back pain and perineal pain. Irritative voidingsymptoms (dysuria, frequency, urgency, nocturia) arecharacteristic. Rectal examination reveals a markedly tender,swollen prostate.IIChronic bacterial prostatitisRecurrent infection of the prostate caused by persistence of the same organism despite treatment. Symptoms are irritativevoiding & pain of varying degrees. Rectal examination reveals no characteristic finding.IIIChronic prostatitis / Chronic pelvic pain syndrome (CP/CPPS)No demonstrable infection; primarily pain complaints, plusvoiding complaints and sexual dysfunction affecting men of allages. Usually cause is unknown.Prostatitis SyndromesCategoryCharacteristic Clinical FeaturesIII-AInflammatory subtypeSymptomatic patients without bacteriuria but with inflammation (white cells) in semen, expressed prostatic secretions (EPS) or post-prostatic massage urineIII-BNon-inflammatory subtypeNo white cells in semen, EPS or post-prostatic massage urineIVAsymptomatic inflammatory prostatitisNo subjective symptoms, inflammation detected either byprostate biopsy or the presence of white cells in expressedprostatic secretions or semen during evaluation of othergenitourinary complaintsDiagnostic TestsAcute Bacterial ProstatitisMid-stream urine sample for dipstick testing, culture for bacteria, and antibiotic sensitivityProstatic massage should not be performedChronic Bacterial Prostatitis Lower urinary tract localization procedure - standardRecurrent UTI caused by the same pathogen are the hallmark of chronic bacterial prostatitisChronic Prostatitis / Chronic Pelvic Pain SyndromeNo gold standardSEMINAL FLUID ANALYSIS IS RECOMMENDED FOR ALL TYPES OF PROSTATITISTreatmentAcute Bacterial ProstatitisStart empiric treatment immediatelyAdequate hydration, rest, and analgesics such as NSAIDsEmpiric therapy with TMP/SMX or oral fluoroquinolone 30-day treatmentChronic Bacterial ProstatitisFirst-line treatment: Ciprofloxacin 500 mg BID for 28 days OR Ofloxacin 200 mg BID for 28 days OR Norfloxacin 400 mg BID for 28 daysFor those allergic to quinolones: Doxycycline 100 mg BID for 28 days Minocycline 100 mg BID for 28 days OR Trimethoprim 200 mg BID daily for 28 days OR TMP-SMX 160/800 mg BID for 28 daysTreatmentRecalcitrant Chronic Bacterial ProstatitisRadical transurethral resection of the prostate or total prostatectomyFor symptomatic relief: Sitz baths, anti-inflammatory agents, prostatic massage, etcLong-term, low-dose suppressive therapy for nonresponders to full treatmentTMP-SMX 80/400 mg once daily for 4 to 6 weeksChronic Prostatitis / Chronic Pelvic Pain Syndrome Antibiotics or alpha-adrenergic blockers are not recommendedHeat treatment may be usefulNonbacterial ProstatitisAllopurinol not recommendedCase #8 contdBruce was inserted an antimicrobial-impregnated catheter attached to a urine bag on May 2, 2015 for difficulty urinating. Daily meatal care was done and the catheter was changed every 5 days. He was also given levofloxacin 250 mg BID Prevention of Catheter-Associated Urinary Tract InfectionCase #9Kim calls you up again and asks how her family can prevent having urinary tract infections. Shes trying out alternative medicine/holistic approach to health and does not want to take medications but instead wishes to use locally grown organic fruits.Nonpharmacologic Interventions for UTITRUE OR FALSECranberry juice and cranberry products ARE NOT RECOMMENDED for the prevention of urinary tract infections in populations at riskCranberry juice and cranberry products ARE RECOMMENDED for the treatment of urinary tract infectionLactobacilli both in oral form and vaginal suppositories ARE RECOMMENDED in the prevention of UTICranberry juice and cranberry products are not recommended for the prevention of urinary tract infections in populations at riskCranberry juice and cranberry products are not recommended for the treatment of urinary tract infectionLactobacilli both in oral form and vaginal suppositories are not recommended in the prevention of UTI

79TRUE OR FALSECoconut juice IS NOT RECOMMENDED in the prevention or treatment of urinary tract infectionOral water hydration IS RECOMMENDED in the prevention or treatment of UTIDrinking more water and voiding soon after intercourse IS RECOMMENDED to prevent urinary tract infectionThere is insufficient evidence to recommend coconut juice in the prevention or treatment of urinary tract infectionThere is insufficient evidence to recommend oral water hydration in the prevention or treatment of UTIThere is insufficient evidence to recommend drinking more water and voiding soon after intercourse to prevent urinary tract infection

80Thank you!