UTI treatment: In general, shorter duration is better for uncomplicated infections
Presenter: Laila Woc-Colburn, MD, Emory University School of Medicine, Atlanta
Urine Trouble: What’s New in Treating Urinary tract Infections? Presented April 29, 2023.
Differentiating urinary tract infection (UTI) from asymptomatic bacteriuria helps health care providers avoid harming patients with inappropriate antibiotic therapy. In instances in which patients are clinically stable and have nonspecific symptoms of infections, active monitoring and oral hydration may obviate the need for antibiotics for UTI. Otherwise, empiric antibiotics can be given until urine culture results are known, said Laila Woc-Colburn, MD, Emory University School of Medicine, Atlanta.
Bacterial contamination of the urethra in a person without symptoms is common, and when combined with a normal urinalysis (an abundance of epithelial cells), is indicative of asymptomatic bacteriuria. A diagnosis of UTI requires bacterial colonization of the urethra that migrates to the bladder and causes an inflammatory response. In a patient in whom UTI is suspected, Dr. Woc-Colburn suggests taking a midstream urine sample in the early morning, “because the bacteria have been there for about 3 to 4 hours—enough time to change the nitrites to nitrates.” A positive urinalysis will show leukocyte esterase and nitrates with gram-negative pathogens. “If the culture has epithelial cells or less than 10,000 colony-forming units [per high-power field], that is not a UTI,” she said. Some bacteria responsible for UTIs (eg, Enterococcus spp, Staphylococcus suppurativa) do not produce nitrates.
In the workup for UTI, if the patient has localizing urinary symptoms such as dysuria, urgency, and suprapubic pain, or nonlocalizing symptoms that do not suggest infection at another site (eg, pneumonia, cellulitis), suspect a UTI and send a urinalysis with reflex to culture if pyuria is present. Without localizing symptoms or pyuria, investigate for other potential causes of the patient’s symptoms. If pyuria and localizing urinary symptoms are present or if the patient is clinically unstable, start empiric antibiotics and then adjust the regimen based on the results of the urine culture.
If the patient has no localizing symptoms and is clinically stable, institute active monitoring without antibiotics, prescribe oral hydration, and follow the results of urine cultures and the patient’s clinical course over the next 48 hours. With clinical deterioration or if the clinical condition is unchanged with no alternate diagnosis, start empiric antibiotics and adjust based on urine cultures.
With negative urine cultures, stop antibiotics and investigate for other possible causes of symptoms.
Treatment of asymptomatic bacteriuria is indicated in pregnant women, patients undergoing a urologic procedure, and within 30 days after kidney transplantation.
Shorter is better
First-line agents in the United States for treating UTIs are nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin. In general, shorter treatment is better, said Dr. Woc-Colburn. “Long treatments of 14 or 21 days or even prophylaxis are not being seen to help the patient,” she said. “The reason is collateral damage.” Collateral damage can take the form of Clostridium difficile infection, a change in the patient’s microbiome, and increased bacterial resistance.
Seven days of antibiotics are sufficient for patients with bacteremia with complicated UTI when IV beta-lactams are used for the entire treatment course or when antibiotics are transitioned to highly bioavailable agents.
In a cohort study of adults with Escherichia coli, Klebsiella spp, or Proteus spp bacteremia from a suspected urinary source, beta-lactam antibiotics were not statistically significantly associated with a higher relative risk of recurrent bacteremia compared with fluoroquinolones or trimethoprim-sulfamethoxazole, and there was no difference in mortality.
Uncomplicated UTI
Among women with uncomplicated UTI, 5 days of nitrofurantoin resulted in a significantly greater likelihood of clinical and microbiologic resolution at 28 days compared with single-dose fosfomycin. Nitrofurantoin is considered first-line treatment in the United States and Europe, with trimethoprim-sulfamethoxazole and fosfomycin as second-line antibiotics.
A strategy of delayed prescription of antibiotics, referred to as “pill in the pocket,” may be attempted in certain patients with uncomplicated UTI. This strategy involves giving the patient an antibiotic prescription and asking them to wait 2 to 3 days before starting, with use of ibuprofen to treat the symptoms. In one study, 67% of women with uncomplicated UTI who received ibuprofen recovered fully without antibiotics, and pyelonephritis occurred in only 2%. This approach should not be tried for everyone, she said; for example, it should be avoided in patients with a history of pyelonephritis, immunosuppressed patients (including those with poorly controlled diabetes), patients with symptoms for more than 5 days, and elderly women.
Multidrug-resistant UTI
If multidrug-resistant complicated UTI, with or without bacteremia, is suspected, Dr. Woc-Colburn recommends placing a call to your infectious disease consultant. Delaying treatment in such cases has been found to be associated with increased risk of death. If the patient is infected with an organism that produces extended-spectrum beta-lactamase and that has resistance to trimethoprim-sulfamethoxazole and quinolones, “you are not going to be able to treat this as an outpatient,” she said. “You will need IV antibiotics.” Knowledge of the antibiogram and a multidisciplinary approach to management are imperative.
Prevention of recurrent UTI
For premenopausal women with recurrent uncomplicated UTIs, increasing daily water intake at first symptoms may help “clear” infections, she said. Non-antimicrobial prophylaxis with hormonal replacement using topical estrogen has been shown to be effective at preventing recurrent UTI, as has oral immunotherapy with OM-89.
References
Cortes-Penfield NW, Trautner BW, Jump LP. Urinary tract infection and asymptomatic bacteriuria in older adults. Infect Dis Clin North Am 2017; 31(4):673–688. doi: 10.1016/j.idc.2017.07.002
McAteer J, Lee JH, Cosgrove SE, et al. Defining the optimal duration of therapy for hospitalized patients with complicated urinary tract infections and associated bacteremia. Clin Infect Dis 2023 Jan 12:ciad009. doi: 10.1093/cid/ciad009
Sutton JD, Stevens VW, Chang NN, Khader K, Timbrook TT, Spivak ES. Oral β-lactam antibiotics vs fluoroquinolones or trimethoprim-sulfamethoxazole for definitive treatment of Enterobacterales bacteremia from a urine source. JAMA Netw Open 2020; 3:e2020166. doi: 10.1001/jamanetworkopen.2020.20166
Hooton TM, Vecchio M, Iroz A, et al. Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections: a randomized clinical trial. JAMA Intern Med 2018; 178(11):1509–1515. doi: 10.1001/jamainternmed.2018.4204
Kwok M, McGeorge S, Mayer-Coverdale J, et al. Guideline of guidelines: management of recurrent urinary tract infections in women. BJU Int 2022; 130 Suppl 3(Suppl 3):11–22. doi: 10.1111/bju.15756
Disclosures
Laila Woc-Colburn, MD, has no relationships with entities whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.