On collaborative management of recurrent UTI

In a population of about 160000 people in N Devon, about 400 people with 3 or more MSUs sent in on year. About 200 people on repeat trimethoprim or nitrofurantoin.

Since 2016 we have been running a joint microbiology / urology clinic for recurrent UTI. This is a summary of what we do, and the what it's done for first 36 patients. Main conclusions are :

• This is a group of patients who have been poorly served with high morbidity
• Bearing witness to the impact on their lives is the first step in developing a therapeutic alliance
• Attention to basics is important. This includes drinking plenty. It does not include advice on how to wipe.
• Self start strategies with patient defined course length works well for most people
• There are a few really complex patients who need ongoing support and this includes a different approach by the laboratory to do this - eg. next day sensitivities; interpreting mixtures in a way that is helpful; working up low numbers of "non pathogenic" organisms; looking for "atypical" organisms

This is what has happened :

• 24 patients with self start
• 18 better (less than 3 MSUs in year after clinic)
• 13 with follow up data from primary care
• 11 patients with prolonged high dose abx
• 4 better
• 9 with follow up data from primary care
• 1 patient continued prophylaxis
• 1 better
• 1 with follow up data from primary care

11 admissions in year before clinic appt; 1 admission in year after clinic

In patients with primary care data :

• 1978 DDDs of abx in year before clinic appt; 586 DDs in year after
• 324 consultations in year before; 169 in year after
• 187 UTI consultations in year before; 51 in year after

E coli most predominant pathogen

Some probable genuine mixtures

Some poorly defined

Some with no positive specimens

Although most patients have pyuria in specimens in the year before clinic, this is not universal, and may not be consistent over time

Complex anatomy main reason for failure. eg. cystoplasty; vaginal tapes; trauma

Some patients appear to have problems with prostate but not clearly defined - no abscesses

Underlying conditions may be an issue - particularly if immunosuppressed / steroids

Patient engagement with early self start may be an issue

About 50% of patients who fail lost to follow up

Significant number with complex micro work closely with lab results to define each infection and optimise Rx using early self start

One patient with RA appears to have had no problems since RA under control

Prescribing data on 3 of 5 complex patients working with lab on early self start shows reduction in abx usage from 287 DDDs to 67 DDDs.

What we do

Effect on life

• How often between episodes?
• Is start of episode clear? What are main symptoms?
• Completely  well or not between episodes?
• Nocturia often useful as a gauge of impact
• Flow symptoms
• In men – prostatitis and orchitis symptoms

Microbiology

• Proven with positive MSUs?
• Same organism?
• If same organism then more likely to consider prolonged high dose combination eradication
• E coli?
• D mannose may be effective
• Proteus?
• May be particularly important to maintain acidic pH and look for stones

If MSUs are negative :

• is there pyuria?
• Have fastidious organisms or non-typical organisms been looked for?
• Is this non-infective? Eg. interstitial cystitis.

Note that not all patients have pyuria, although an absence of pyuria makes diagnosis of infection more questionable.

If repeated mixed cultures, or other diagnostic uncertainty, then get higher quality specimen

• Peezy
• In out catheter

 Other laboratory tests

Inflammatory markers are not generally helpful and we don’t measure

Creatinine

• Evidence of pyelonephritis (Flank pain / rigors)
• may push away from nitrofurantoin
• may push towards more interventional approach

Anatomical problems

All patients need USS to assess for clear structural abnormalities and residual volume

If significant residual volume then this needs managing.

Most patients probably need cystoscopy at some point, although low pick up, and may be able to avoid if normal USS and no visible or non-visible haematuria between episodes.

Stents and stones are hard to manage – will be colonised.

Pneumaturia requires urgent investigation

Catheters

Is patient catheterised or intermittent catheterisation?

Why?

Things to try :

     Review technique especially if ISC.

Consider prophylactic abx at change and change frequency      

Washouts

     Intravesicular gentamicin

     Maintenance of mildly acidic pH

     Coated catheters

Precipitating factors

Sex

• Post coital voiding
• Post coital prophylaxis (guided by previous cultures; nitrofurantoin as default)

Periods

• Consider prophylaxis at this time
• Possibly explore options for suppressing menstrual cycle

Anything else (eg. dehydration, especially if fear of drinking before going out or at night)

Encourage to drink at least 2 litres of water per day – Fill 2 jugs with water in morning)

Aggravating factors that may need addressing

Constipation

Diabetes

Iron overload states

Steroids

General approaches to management

Tell patients to drink plenty. At least 2 litres per day. Fill jugs in morning and make sure finished by evening.

In post menopausal women, topical oestrogens should be tried for at least 6/12

Double voiding

Post-coital voiding

Explore alternative antibiotic management options, with a view to stopping prophylaxis, and/or reducing regular visits. Options include :

• Prescribe standby antibiotics and provide patients with redtop tube to submit MSU if symptomatic; and then immediately start a course of antibiotics (based on previous sensitivities – discuss with micro if complex) and continue until the day after symptoms have resolved.
• If related to sexual activity, consider post-coital prophylaxis.
• Prescribe a prolonged treatment course (at least 3/12) of two antibiotics based on previous results. This option may be good if consistently same organism / antibiogram. Probably less good if not consistent. Options include

• Cefalexin 500mg QDS
• Nitrofurantoin 100mg MR BD
• Trimethoprim 200mg BD
• Azithromycin 500mg OD

If breakthrough infections then continue baseline antibiotics and add new agents based on MSU results

Consider hipuric acid for 6/12. Prolonged courses probably should be avoided due to theoretical risk of bladder cancer.

If recurrent E coli consider D mannose (not if diabetic)

Consider intravesicular gentamicin if limited oral options and self-catheterises

Consider urinary pH monitoring both as a means of diagnosis and an aid to antibiotic optimisation (note particularly gentamicin favours high pH; nitrofurantoin lower pH).

Consider dietary modification. Generally promote vegetarian diet. Consider things like high dose vitamin C.

Ensure aggravating conditions managed appropriately, especially diabetes

Consider bladder washouts with eg. SubyG if ISC.

Consider cystistat (although rarely do this now)