#39: How UTIs Have Evolved with Antibiotic Stewardship

 Dr. Boghuma Titanji, a third-year Internal Disease fellow at Emory University in Atlanta, defines Urinary Tract Infections as significant bacteriuria plus specific signs and symptoms that localize to the urinary tract.  To take it a step further she proceeds to break it down to complicated and uncomplicated UTIs.  Uncomplicated UTIs are those with the localization of signs and symptoms being limited to the bladder and below, with the patient having no other systemic symptoms.  Conversely complicated UTIs would have signs and symptoms localizing above the bladder which could lead to more serious deep seeded infections.  This difference is important when deciding upon the antibiotic to be used to treat the UTI.  Many times providers will choose not to do any labs on a “simple uncomplicated UTI”.  It may interest you to know that 60% of women who present with a UTI will have a recurrence within 6 months.  That is a high number.  Depending upon how quickly the UTI returns the quandary becomes, “Is this a recurrence or is this a relapse?” 

I pose the question, “Does it really matter?”  Standard of care dictates that if the patient returns with a UTI after three months of complete resolution of the first one, the course of treatment is the same as the first time.  If they return a third time after complete resolution it is then one should consider getting a lab test to determine what they are growing so you can be more targeted and careful with your antibiotic selection.   Why not send for a PCR test the first time to use the correct antibiotic from the beginning?  Perhaps you would be able to eliminate the recurrent episodes. 

Now that I have stirred up all kinds of sentiments, I emphasize my goal with these blogs is to make one think critically about how they treat their patients.  Additionally, I am all about antibiotic stewardship as I have mentioned before.  If there is a way to decrease the amount of antibiotics patients are given and still treat them appropriately I want to know.  One of my professors in school used the following quote frequently when we crawled into our comfortable little boxes and he wished us to think outside them, “Doctors are products of their training!”  We are taught if A then B, and many of us are guilty of hanging on to that logic throughout our careers.  The only constant thing in life is change and medicine is a reflection of that.  In the last thirty years, the treatments and tests for UTIs have evolved.  With all of the weapons (antibiotics), we have at our disposal to treat them we must have the knowledge to choose the most efficacious one.  With the use of PCR, the pathogen is defined quickly and antibiotic resistance is reported so the weapon you choose is correct the first time.  As always, ILDP appreciates your business and I personally wish you and your loved ones health and happiness. 

Thank you.

 

Lance Benedict

President/CEO Industry Lab Diagnostic Partners 

 

 

 

#38: How ILDP Assists Regarding UTI - Diagnosis and Treatment

 Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients.  Providers who are top antibiotic stewards have a multi-faceted approach.  They work continuously to stay informed of the etiology of diseases and they continuously review the literature regarding use of antibiotics for specific pathogens.  Additionally, and one of the most important in my opinion, they educate their patients on appropriate use of the prescribed antibiotic and then they, or their staff, follow up with the patient during the course of treatment and after.  They also make use of the most accurate and fastest type of diagnostic testing such as PCR testing.

When to order a PCR test is also part of good stewardship to prevent unnecessary antibiotic use.  Focusing on urinary tract infections in this article, patients MUST have signs/symptoms of a UTI to order PCR testing.  Specifically fever, frequency of urination, urgency, dysuria, costovertebral or suprapubic pain, etc.  A urinalysis is not made to be a screen for a UTI infection alone.  Everything on the urinalysis is non-specific.  Okay, I already hear the gnashing of teeth and the “Yeah, but nitrites were present on the UA”.  Nitrites in the urine do suggest the presence of bacteria that have reduced nitrates to nitrites, however urethral, rectal and vaginal contaminants can cause bacteria to be present and thus produce nitrites on a UA.  Furthermore, hematuria, proteinuria, and bacteriuria found on a UA without symptoms, are not sensitive or specific enough to diagnosis a UTI. 

Recent studies show E. Coli is still responsible for the majority of UTIs, with Klebsiella pneumonia, Pseudomonas aeruginosa and Proteus mirabilis following closely behind.  Interestingly Proteus and Providencia caused more UTIs in elderly men than E. Coli.  With the discovery of a new drug resistant gene NDM-1 in E. Coli and Klebsiella, the practice of antibiotic stewardship becomes more critical.  Irrational use of antibiotics is still conducted in many parts of the world and perhaps in certain regions our own country, enabling the continued growth of more drug resistant pathogens.  In one study, E. Coli was resistant against ampicillin (92%), cotrimoxazole (80%), ciprofloxacin (62%), nitrofurantoin (47%) and amikacin (4%).  Patients who have drug resistant pathogens don’t require a history of overuse of antibiotics as the reason for acquiring them.  Environments such as nursing homes are known for the spread of these type of pathogens. 

The cat is out of the bag so to speak in regard to rampant antibiotic usage.  It is our job as a lab to assist the provider to make the appropriate decision regarding the medications they prescribe their patients.  Our  testing for drug resistance markers enables us to do this and allows us to contribute to our community antibiotic stewardship.  Please hug on your elderly family members.  As always we thank you for your business.

Lance Benedict

President/CEO Industry Lab Diagnostic Partners