Q&A: Ensuring proper diagnosis, being ‘good antibiotic stewards’ key to UTI treatment
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Key takeaways:
- The WikiGuidelines provide helpful data on diagnosis, antibiotics and antibiotic stewardship for physicians.
- Diagnosing UTIs in women require culture data and should be done to prevent untreated conditions.
Antibiotics remain the most common way to treat urinary tract infections, yet many women remain untreated because the condition is often overlooked or they do not receive appropriate testing and care.
“Take urinary tract infections (UTIs) seriously and be mindful of them,” Cynthia Fok, MD, associate professor in the department of urology at the University of Minnesota Medical School, told Healio. “Because I do think that it gets overlooked and there are some very treatable and preventable things we can do for women if we just acknowledge that they are happening and make sure women receive appropriate care.”
In November, the WikiGuidelines collaborative published its third clinical practice guidance — this one on the prevention, diagnosis and management of UTIs. As Healio previously reported, the guidance, developed by researchers from 12 countries and the first on UTIs in 14 years, touched on issues as varied as the role of cranberry juice and supplements to prevent UTIs, the role of topical estrogen and methenamine hippurate, reasonable empirical treatment regimens, optimal oral agents and an appropriate duration of treatment for gram-negative bacteremia from a urinary source.
Healio spoke with Fok about the prevalence of UTIs in U.S. women and the current treatments available, as well as the recent guidance published by the WikiGuidelines group.
Healio: How common are UTIs in women in the U.S.?
Fok: We know that at least 50% to 60% of women will experience at least one UTI in their lifetime. It is common and one of the most common things that people might go to urgent care for. It costs our health care system a couple billion dollars a year, so it is a very big deal.
I would not say there is a most common cause. Sometimes it’s congenital, just anatomy. The other common cause is postmenopause. Lack of estrogen can predispose people. Pregnancy is something that puts someone at risk for UTIs. Some of it can be related to intercourse, constipation or hygiene. Anybody that comes in, like what we see in urogynecology with recurrent UTIs, we try to go through that list to try to figure out what it is that contributed to their infections.
Healio: How can UTIs impact pregnant vs. nonpregnant women?
Fok: The reason UTIs are a concern for pregnant women is because it can predispose them to preterm labor. So, it is important for women who are pregnant to be closely monitored by obstetricians for infections. And, if they have symptoms, they need to make sure they can get evaluated. It is twofold. One is the risk for preterm labor. Second, I always tell people they have to be careful about what antibiotics are used during pregnancy. It is always a good idea to make sure women talk to their obstetricians if they are having any issues or symptoms.
Healio: Could you summarize the recent UTI guidance published by the WikiGuidelines group and what has changed compared with previous guidelines?
Fok: The new WikiGuidelines are great because they really do go through the wealth of literature on a lot of different things on UTIs. Researchers looked at the data for supplements, antibiotic use, antibiotic stewardship, as well as talking about some of the more complicated or unique situations of UTIs, like transplant patients, catheters, altered anatomy, those types of things.
This guideline does emphasize that we have to ensure these are UTIs with data, be good antibiotic stewards and use antibiotics in appropriate situations, and not use them for as long as we’ve been traditionally taught. The infectious disease guidelines included a new antibiotic antibiogram a couple years ago. The American Urologic Society and American Urogynecologic Society all have been developing their own UTI guidelines over the years. And this is a nice summary of a lot of the information that is already out there.
Healio: What are the current treatments available for UTIs?
Fok: Antibiotics that are most commonly used to treat UTIs here in the United States would be sulfamethoxazole, fluoroquinolones, fosfomycin and nitrofurantoin. There are some newer antibiotics designed for some of these more resistant UTIs, but a lot of those are not widely available here in the United States. When you look at the difference between treating men and women, in general, for men there is this idea of “complicated UTI,” needing, perhaps, a little bit longer course of treatment than for women, where a physician might say they have an “uncomplicated UTI.” There is some discussion in the WikiGuidelines about how to go about defining that, but the data out there is insufficient.
Healio: How can UTIs impact a woman’s daily life?
Fok: A UTI is uncomfortable and it hurts. You are in the bathroom a lot. You feel like you have to urinate a lot. It is that constant discomfort and pressure. That is a miserable feeling for anybody. It impacts how you can go about your daily activities and at work. For women that have recurrent UTIs, you get the twinge of symptoms and you are wondering, “Am I having an infection? Am I not? Do I need to go in? Do I not? Do I want to go spend the money to go to urgent care?” It causes a lot of stress and emotional burden when you’re having frequent infections. Sometimes you hear the stories like, “I go in, I have symptoms. They tell me I don’t have an infection. So, the next time, I ignored it, but then I ended up with a worse infection. Then they asked me, why did I ignore it?” The anxiety of whether to go to a clinic and spend money to get tested can add for a lot of stress to somebody’s life.
Healio: What do most physicians not realize about UTIs and their treatment?
Fok: Physicians are taught to ask things like, “Do you wipe front to back?” but most people are like, “What are you talking about?” This is what we are taught in medical school and most women look at you like you’re funny. There is no data for this, but anecdotally, a lot of people seem to end up with infections after using baby wipes or wet wipes. Some of those can get colonized with bacteria. I advise women not to use those. These can contribute to infections and we don’t always think about some of those hygiene practices.
Healio: Is there anything else you’d like to add?
Fok: We have to be mindful of telemedicine and UTIs. To be good antibiotic stewards, we should really have the cultures, and that is the part that gets hard. In a lot of minute clinics or virtual visits, we do not have the culture data. Especially in women, things like bladder cancer get diagnosed later because we may say, “Oh, she’s just having another UTI.” We have to be mindful of that and not miss things.
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For more information:
Cynthia Fok, MD, can be reached at csfok@umn.edu.