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Don’t Just Give ‘em Antibiotics! A Simple Way to Diagnose and
Treat UTI'sBellamy Hawkins, PA-C
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What is a UTI?
2www.urologycentersalabama.com Bellamy Hawkins, PA-C
Pathophysiology• 3 routes
• Ascending due to inoculation of urethra with bowel flora
• Hematogenous spread from kidney
• Lymphatic spread• Uncommon pathogens more
likely in special populations• Diabetes, structural
abnormalities, indwelling catheter
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Epidemiology
3www.urologycentersalabama.com Bellamy Hawkins, PA-C
• Most common organism:• E. coli (75-95% of cases)• Klebsiella and proteus
• Incidence:• 7 million physician visits annually
• Prevalence:• F>M
• Attributed to shorter distance from urethra to anus• Females: 53 per 100 lifetime prevalence• Males: 14 per 100 lifetime prevalence
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Risk Factors
4www.urologycentersalabama.com Bellamy Hawkins, PA-C
• Female• Sexual intercourse• History of UTI• Use of spermatocides, diaphragms, and spermicides
• Comorbidities• Diabetes• Structural abnormalities
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Diagnosis of UTI
5www.urologycentersalabama.com Bellamy Hawkins, PA-C
• History• Dysuria, frequency, hematuria
(gross/microscopic), AMS in elderly• Physical
• +/- flank pain, suprapubic pain• UA findings suggestive of UTI
• (+) Leukocyte esterase• (+) nitrites• (+) bacteria
• Definitive diagnosis requires urine culture• > 100K colonies/mL on urine culture is
considered diagnostic for UTI
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Female UTI Algorithm
6www.urologycentersalabama.com Bellamy Hawkins, PA-C
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Complicated vs. Uncomplicated
7www.urologycentersalabama.com Bellamy Hawkins, PA-C
• Uncomplicated UTI• Females
• Complicated UTI• Immunosuppressed• Pregnant• SCI• Male• Pediatric• Chronic foley catheter, ureteral
stent• Urinary tract structural
abnormalities• Stones• Renal insufficiency
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Dysuria: How to know it’s a true infection
8www.urologycentersalabama.com Bellamy Hawkins, PA-C
Bacterial Cystitis• Symptoms:
• Fever• Chills• Flank pain
• Positive UA and positive UCX
Non-bacterial/Interstitial cystitis (IC)• Symptoms:
• Pelvic pain• Dysuria• Frequency, urgency
• Associated with stress or dietary changes
• Negative UA and negative UCX
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Male UTI
9www.urologycentersalabama.com Bellamy Hawkins, PA-C
• Always requires a workup• Risk factors:
• BPH• Prostatitis• Neurogenic bladder• Kidney/bladder stones
• Uncircumcised could lead to false positive UA dipstick • Always get clean catch AND culture if high level of suspicion for UTI
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Recurrent UTI
10www.urologycentersalabama.com Bellamy Hawkins, PA-C
• ≥ 2 infections in 6 months OR ≥ 3 in 1 year• Workup
• CT A/P to rule out anatomic abnormalities or stones• Pelvic exam for females• Cystoscopy• Urine culture
• Treatments• Post-coital antibiotics• Low dose daily suppression• Vaginal estrogen creams (postmenopausal women)• Hydration• Frequent voiding
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When to prescribe antibiotics
11www.urologycentersalabama.com Bellamy Hawkins, PA-C
• Patient with signs and symptoms of UTI• Positive UA dipstick and/or urine culture• Patients with other comorbidities
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Antibiotic Stewardship
12www.urologycentersalabama.com Bellamy Hawkins, PA-C
• Antibiotic resistance is widely increasing across the board
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Multidrug Resistant UTI
13www.urologycentersalabama.com Bellamy Hawkins, PA-C
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Empiric Therapy
14www.urologycentersalabama.com Bellamy Hawkins, PA-C
• Empiric therapy in patients not at risk for MDR organisms
• Nitrofurantoin (Macrobid)• TMP-SMZ (Bactrim)• Fosfomycin
• Empiric therapy in patients at risk for MDR organisms
• Fluroquinolones (ie. Cipro, Levaquin)
• Broad spectrum beta-lactams (ie. Third or later cephalosporins)
• Culture directed therapy
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Prevention is Key
15www.urologycentersalabama.com Bellamy Hawkins, PA-C
Conclusive• Hygiene• Hydration• Sterile technique during
catheterization• Avoiding overtreatment of
asymptomatic pyuria or bacteruria
• Void after intercourse
Nonconclusive• Avoid douching, tampons, IUDs• Cranberry supplements
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What Constitutes Referral?
16www.urologycentersalabama.com Bellamy Hawkins, PA-C
• Complicated UTI• Obstructing kidney stones• Recurrent Complicated UTI• Relapsing infection• Gross hematuria• Interstitial (non-bacterial) cystitis
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THANK YOU
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Resources
18www.urologycentersalabama.com Bellamy Hawkins, PA-C
• The 5-minute urology consult (Gomella et.al)• Pocket guide to urology (Wieder)• CDC• Uptodate (https://www.uptodate.com/contents/acute-simple-
cystitis-in-women)• https://www.auanet.org/education/auauniversity/for-medical-
students/medical-student-curriculum/adult-uti