Urinary tract infection-recurrent and complicated

Recurrent urinary tract infections are categorized as reinfection or relapse type.

Recurrent UTI is commonly defined as culture proven UTIs that have occurred at least twice within six months or three times within 12 months.

Complicated UTIs, including acute pyelonephritis, affects nearly 3,000,000 individuals annually in the United States.

C What omplicated UTI is responsible for at least 600,000 annual hospital admissions in the United States.

Patients with complicated UTI or acute pyelonephritis are hospitalized and receive  therapy for antibiotic resistant uropathogens for which there are  limited or no available oral treatment options.

Widespread and emerging resistance to beta lactam antibiotics complicates management of complicated UTIs.

Complicated UTIs typically affect patientswho have structural functional abnormalities of the urinary tract.
Patients with complicated UTIs often have prior urologic procedures, recent antibiotic exposure, recent or long-term catheterization, or recent or current hospitalizations.
Patients at high risk for complicated urinary tract infections include pregnant women, patients with diabetes, patients with other immunocompromised states.
Patients with complicated UTIs typically have symptoms of pyelonephritis, including fever, chills, and flank pain, with or without nausea.

Urine cultures in patients with complicated UTIs may reveal diverse microbiota and above average patterns of antimicrobial resistance.

Antimicrobial resistance is escalating worldwide, particularly among common gram-negative pathogens that cause urinary tract infection and acute pyelonephritis.

Reinfection occurs after successful treatment of a UTI caused by bacterial infection originating outside of the urinary tract and characterized by a delayed recurrence with a different strain of infection.

Relapse of an infection refers to bacterial infection which persists within the urinary tract despite therapy and is characterized with a rapid recurrence of infection with the same strain of organism.

With reinfection minimal urological evaluation is needed, while with recurrent infections extensive urological work up is necessary to correct underlying abnormalities.

Common life events associated with increased UTI frequency include: sexual debut, new sexual partner, new form of contraception, urinary catheter use, pelvic surgery, menopausal estrogen loss, fecal incontinence or diarrhea, or onset of significant health condition such as immunosuppression, diabetes, neurological disease affecting the bladder or associated treatment.

UTIs disproportionately affect women, and postmenopausal women are especially vulnerable to recurrent UTI.

About 25% of healthy women suffer from reinfection that cause acute uncomplicated cystitis.

Approximately 20-30% of women who have had an infection will experience a recurrence with concurrent morbidity.

Increased risk with pregnancy, elderly, and patients with neuropathic bladder.

Reinfection risk factors for women include sexual intercourse, low vaginal estrogen levels, and use of spermicidal agents.

Healthy young men suffering from reinfection of the urinary tract usually are uncircumcised or have had sexual relations with a female with a UTI that causes acute uncomplicated cystitis.

Most healthy women and some of the healthy men who have reinfection of the urinary tract have uncomplicated infections, meaning normal urinary tracts and are cured and prevented by antibiotic therapy.

Antibiotic prophylaxis for women with recurrent uncomplicated UTIs, greater than 2-3/year, include low dose daily for 6 months: trimethoprin-sulfamethoxazole, trimethoprim, norfloxacin, ciprofloxacin, nitrofurantoin and cephalexin.

Complicated UTI refers to a symptomatic UTI in patients with the functional or structural abnormality, having had urinary instrumentation, having systemic diseases such as renal insufficiency, diabetes, or immune impairment.

Complicated UTIs sometimes are seen in young women, elderly women and men and reflect the presence of functionally and structurally abnormal urinary tracts.

Tx uti in women

Urinary Tract Infection in Women Clinical Practice Guidelines (2019)

Women presenting with recurrent lower urinary tract infections should undergo a complete patient history and pelvic examination.

A diagnosis of recurrent UTI must be based on documented positive urine culture results in association with prior symptomatic episodes.

Patients presenting with recurrent UTI should not routinely undergo upper tract imaging and cystoscopy.

In patients with recurrent UTI , urinalysis, urine culture, and sensitivity should be performed for each symptomatic acute cystitis episode.

Surveillance urine testing, including urine culture, should not be performed in asymptomatic patients with recurrent UTI.

Asymptomatic bacteriuria should not be treated.

Symptomatic UTIs in women should be treated with first-line therapy (ie, nitrofurantoin, TMP-SMX,) and should depend on local antibiogram.

The duration of antibiotic therapy for recurrent UTI in patients should be short as is reasonable, and typically no longer than 7 days.

Recurrent UTI in patients with acute cystitis that has shown resistance to oral antibiotics on urine culture may be treated with culture-directed parenteral antibiotics for as short a course as is reasonable , typically no longer than 7 days.

Posttreatment urinalysis or urine culture to test for cure should not be performed in asymptomatic patients.

UTI symptoms that persist after antimicrobial therapy should prompt repeat urine culture to guide further treatment.

Vaginal estrogen therapy with no contraindications should be recommended to perimenopausal and postmenopausal women with rUTIs to reduce the risk of future UTI.

Complicated infections indicate that the host is compromised and that the bacteria have antibiotic resistance or increased virulence.

Spectrum of complicated infections include cystitis, kidney infection, prostate infection and life threatening urosepsis.

Complicated urinary infections are caused by gram-negative E. coli, Proteus, Klebsiella, and pseudomonas species, and gram-positive bacteria enterococci, and staphylococci.

Many organisms in complicated urinary tract infections originate from patients exposed to antibiotics and or from a healthcare environment that are associated with virulent and resistant strains.

Complicated urinary tract infections urinalysis demonstrates white blood cells, bacteria as with uncomplicated UTIs.

Urine cultures should be obtained prior to initiating antibiotics, during therapy and after treatment to identify relapse.

In a randomized study of children under the age of 18 years with one or more UTIs received low dose trimethoprim -sulfamethoxazole or placebo for 12 months: 13% of children in the antibiotic group developed UTI, while 19% of children in the placebo group developed a UTI-a modest reduction in infections (Prevention of Recurrent Urinary Tract Infection in Children with Vesicoureteric Reflux and Normal Renal Tracts [PRIVENTtrial]) .

In the PRIVENT trial an absolute reduction of 6% indicated that 14 children would need to be treated to prevent one infection.

The benefit of antibiotic prophylaxis was most evident during the first 6 months of treatment, as prolonged treatment resulted in the development of resistant microbacterial UTIs (PRIVENT).

The combination of a beta lactam and a beta lactamase inhibitor are commonly used to treat complicated urinary tract infections-such agents include pipericillin and cefepime.

Taniborbactam a beta-lactamase inhibitor, when added to cefepime increases efficacy in complicated UTI.

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