Question of the Week # 220

220 )  A 32 year old woman presents to the office for evaluation of dysuria, frequency and urgency. She has had two episodes of urinary tract infection in the last 4 months. Her previous episodes were managed with 3 day course of trimethoprim-sulfamethoxazole.  She has been using cranberry juice but has not experienced any improvement in recurrences. At this time, she denies any flank pain or fever.  She is sexually active with one partner and uses diaphragms with spermicide for contraception. Physical examination is normal except for mild supra-pubic tenderness. There is no costo-vertebral angle tenderness. Urinalysis  reveals pyuria and 3+ leukoesterase. There are no WBC casts. Which of the following is the most appropriate recommendation to avoid recurrent urinary tract infections in this patient?

A) Post-coital voiding

B) Post-Coital Trimethoprim-sulfamethoxazole

C) Avoid vaginal spermicides

D) CT scan abdomen

E) Daily Trimethoprim-Sulfamethoxazole

4 Responses

  1. B…..

    how do you define recurrent urinary tract infection? Most define recurrent UTI when a woman has 2 or more symptomatic urinary tract infections in 6 months or 3 or more symptomatic UTIs over 12 months. What makes this definition less precise is the fact that the degree of discomfort in the woman usually is the determining factor that leads her to present to her primary care provider. Frustration usually motivates the woman to act.

    Once your primary provider has determined you have recurring UTI’s, the following recommendations may be made for young, healthy, non-pregnant women.

    For sexually active women:
    •If spermicides or diphragms are used, an alternative form of contraception may be recommended.
    •Drinking fluid and urinating after sexual intercourse: studies have not proven the effectiveness of this strategy. Although some providers opine that this “doesn’t hurt,” my opinion is that if it doesn’t help, why do it?
    •Antibiotics are highly effective. There are many ways to effectively use antibiotics to prevent recurrent urinary tract infections.
    •Cranberry juice and concentrated cranberry extract tablets have not been proven to be effective. In my opinion, the cost, the calories, and the unpalatable taste make other alternatives desirable.

    Antibiotic regimens:
    •Low dose antibiotics daily
    •Low dose antibiotics three times a week
    •Antibiotics after sexual intercourse
    •Alternatively, at the first sign of a urinary tract infection, when you first notice symptoms, an antibiotic is taken.

    Studies have suggested these methods are efficacious for 6 months up to several years of therapy.

    Does the type of antibiotic prescribed make a difference? It turns out that all antibiotics are equally effective. Some antibiotics have to be dosed for kidney disease. Antibiotics can have side effects including diarrhea and yeast infections. That’s why your primary provider is there to give you advice.

    Do I have to worry about drug resistance? Yes, however it turns out that drug resistance is rare in this setting. Sometimes a urine culture is needed to see if the antibiotics are treating the organism causing the infection.

  2. How about
    C) Avoid vaginal spermicides
    First try with avoiding vaginal spermicides and diaphragm.
    If it fails, then low dose antibiotic prophylaxis or post-coital TMP/SMX

  3. B) Conservative measures including limiting spermicide use and postcoital voiding lack evidence for their efficacy but are unlikely to be harmful (Level 4 evidence, Grade C recommendation).
    Cranberry products have conflicting evidence for their efficacy (Level 1 evidence, Grade D recommendation).
    Continuous antibiotic prophylaxis (Table 3) is effective at preventing UTI. (Level 1 evidence, Grade A recommendation).
    Postcoital antibiotic prophylaxis (Table 3) within 2 hours of coitus is also effective at preventing UTI (Level 1 evidence, Grade A recommendation).
    Self-start antibiotic therapy with a 3-day treatment dose antibiotic at the onset of symptoms is another safe option for the treatment of recurrent uncomplicated UTI (Level 1 evidence, Grade A recommendation).
    Vaginal estrogen creams or rings may also reduce the risk of clinical UTI relative to placebo or no treatment in postmenopausal women (Level 1 evidence, Grade A recommendation).
    Due to a lack of comparative evidence, the decision to begin therapy, choice of therapy and duration should be based on patient preference, allergies, local resistance patterns, prior susceptibility, cost and side effects (Level 4 evidence, Grade C recommendation).

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