How To Treat A Urinary Tract Infection In Women

Transcription

1 Outpatient Management of Urinary Tract Infections in Women Same Day Care Curriculum Development Project Paul R. Chelminski, MD, MPH, FACP Associate Residency Program Director

2 Work In Progress

3 Uncomplicated vs. Complicated UTI in Women Uncomplicated UTI: Healthy young non- pregnant woman Complicated UTI: All others 50% of all women experience uncomplicated UTI (0.5 to 0.7%/yr) 1/200 [ 1/2000 men per year]

4 Case 1 63 year old female with dysuria, hematuria, fever, low back pain x 3d 2UTI s in past year PMHx: DM, urinary incontinence, HTN, depression Social: On disability d/t depr n; lives in assisted living ROS: Chills, nausea

5 Case 1 PE: T P 110 BP 111/63 (supine), 105/62 (standing) Tired appearing but not distressed Pain to percussion over low back. U/A: S.G , 3+ blood, +LE, +Nitrite WBC 13, BUN 28 (baseline 19), Cr 1.4 (baseline 1.0)

6 Case 1 What are the additional elements of the evaluation? What are the likely causative pathogens? How is UTI defined Asymptomatic bacteriuria 10 5 CFU/ml Cystitis: 10 2 CFU/ml (95% sens, 85% spec) Can this patient be treated as an outpatient? What are your antibiotic choices? Broad spectrum (cipro, levo, NOT moxifloxacin) Consider double coverage

7 UTI Microbiology Uncomplicated E. coli: 80 to 85% Staph. Saprophyticus: 4.4% K. pneumoniae: 4.3% Proteus: 3.7% Others: Citrobacter Enterococcus Complicated Add pseudomonas, serratia,,p providencia, staph aureus Enterococcus more common Staph sapro uncommon

8 Case 2 27 yo female calls office dysuria & frequency for 3 days Chronic asthma & seasonal allergies Meds: OCP s, Advair, albuterol, fluticasone Social: Lawyer, monogamous relationship with partner. Requesting to be treated w/o visit because has to leave in Am for work to NYC

9 Questions: Is it reasonable to treat without a visit? What characteristics would mandate a visit? What is appropriate treatment & duration? Does the patient need a U/A & Cx? Case 2

10 UTI Risk Factors

11 Dysuria

12 Predictive Value of the Clinical Increase Prob UTI Dysuria: LR+ 1.5 Frequency: LR+ 1.8; Hematuria: LR+ 2.0 Back Pain: LR+ 1.6 CV tenderness: LR+ 1.7 Evaluation Decrease Prob UTI No dysuria: LR- 0.5 No back pain: LR- 0.8 H/O vag d/c: LR- 0.3 H/O vag irriatation: LR Pretest probability UTI=prevalence of asymptomatic bacteriuria 5% Pretest probability UTI=prevalence of asymptomatic bacteriuria 5% 1 Symptom UTI probability 50% (Pretest clinical probability) Dysuria + frequency + hematuria 81% probability Dysuria + frequency without vaginal d/c or irritation yield LR 25 or 96% prob Vaginal d/c or irritation without yields LR 0.3 and 0.2 respectively Self-Diagnosis UTI: LR+ 4.0

13 Predictive Value of Clinical Assessment* PE: marginal importance (CV tenderness) Can Urinalysis Reliably Exclude UTI Sens: 75% (75 to 96%)Spec: 82% (94 to 98%) LR+ 4.2, LR- 0.3 Scenario: Frequency w/o dysuria, back pain, & negative dipstick yields post-test test prob 18% >5% prevalence & may mandate urine culture Bent S et al Does this woman have an acute uncomplicated urinary tract infection? Bent, S. et al. Does this woman have an acute uncomplicated urinary tract infection? JAMA May May 29; 287(20)

14 To Test/Treat or Not Test/Treat

15 Guideline-Based Phone Care* *Saint, S.et al. Am J Med Jun; 106(6)

16 Guideline-Based Phone Care Intervention 1883 women with?cystitis managed according to guideline at 22 clinics 745 (40%) managed by triage nurse over phone Control 245 received usual care at control clinics 1498 historical controls

17 Guideline-Based Phone Care Cost savings >$300,000; patients very satisfied.

18 Accuracy of Self-Diagnosis Self diagnosis with autonomous initiation of abx 84% and 86% accurate in two studies 92% cure rate in both studies

19 Cost Benefit Analysis Benefits Rapid relief of distress Less disruption of daily routine/work Decreased medical costs (accrues to society and patient) MD s can see more complicated patients Costs Monetary?? Medication side effects for unnecessary Rx Antibiotic resistance (societal not patient cost) No current mechanisms to reimburse systems (professional cost)

20 Back To Our Patient Uncomplicated UTI: Treatment Three day course appropriate(tmp-smx SMX, or ciprofloxacin) Alternatives Cefpodoxime (100 bid x3d)=tmp-smx x 3d Nitrofurantoin t i (100 bid x 5d=TMP-SMX x 3d Amox-clav not as effective as cipro B-Lactams not as effective for 3 days as 5 days

21 Local Susceptibilities: UNC 2007