International Symposium on UTI Management

Advances in Urinary Tract Infection Management

MEETING REVIEW International Symposium on UTI Management Highlights of an international symposium on Advances in Urinary Tract Infection Management March 9-12, 2000, Orlando, Fla. [Rev Urol. 2001;3(1):18-19] Key words: Cystitis • Prostatitis • Pyelonephritis • Urinary tract infection (UTI) T he Spring meeting of clinical investigators and urologic specialists from around the world covered a broad range of topics in urinary tract infection (UTI) management. Highlighted here will be their discussions of cystitis, pyelonephritis, and prostatitis. Cystitis John Warren, MD, of the University of Maryland School of Medicine, updated the international participants on the Infectious Disease Society of America (IDSA) UTI guidelines. The IDSA developed recommendations for the treatment of patients with uncomplicated UTIs based on a literature review that evaluated treatment regimens using 3 end points: eradication of initial bacteria, recurrence of bacteriuria, and adverse effects. The current standard therapy for uncomplicated acute UTIs in women is trimethoprim-sulfamethoxazole (TMPSMX), which has a bacterial eradication rate of approximately 94%. TMP alone and the fluoroquinolones are probably of similar efficacy. -Lactams had significantly lower rates of eradication as well as higher rates of recurrence and adverse events. A 3-day course of nitrofurantoin was less effective than TMP-SMX, but a 7-day course appeared to be equivalent. Nitrofurantoin and a new antibiReviewed by J. Curtis Nickel, MD, FRCSC, Queen’s University, Kingston, Ontario, Canada. 18 REVIEWS IN UROLOGY WINTER 2001 otic, fosfomycin, may assume greater importance as resistance to TMP and to TMP-SMX becomes more widespread. The IDSA recommendations support the use of fluoroquinolones as initial empiric therapy only if local resistance rates to TMP-SMX are high (ie, greater than 10% to 20%). This is to avoid the development of resistance in this class of antibiotics. A singledose treatment with a fluoroquinolone is less effective than are longer treatment courses, but there appears to be no additional advantage in treating beyond 3 days. As resistance patterns evolve over time, the guidelines will evolve with them. Kalpana Gupta, MD, of the University of Washington, noted that while most UTIs in women are isolated, recurrent UTIs develop in about 20% of women. These recurrences average 6 symptomatic days each, resulting in considerable loss of work and repeated exposure to antibiotics for these patients. In a recent case control study, Dr Gupta explored risk factors for recurrent UTIs and found they were similar to those for isolated UTIs. These risk factors included frequent sexual intercourse during the past year (4 to 8 times per month), first UTI before age 15, maternal history of UTI, and spermicide use during the past year. This study noted that postcoital voiding, douching, caffeine intake, history of chronic or sexually transmitted disease, body mass index, and underwear fabric were not associated with a change in relative risk of recurrent UTI. Vaginal colonization with Escherichia coli was found significantly more often in patients with UTI than in control patients (35% versus 11%), and this finding correlated with lower levels of hydrogen peroxide– producing lactobacilli. Raul Raz, MD, of Ha’Emek Medical Center in Afula, Israel, reminded attendees that the prevalence of bacteriuria in women increases steadily with age, annually affecting 5% to 10% of premenopausal women and up to 30% of women over age 50. Risk factors predisposing postmenopausal women to UTIs have been little explored. Urologic factors, such as reduced urinary flow, previous urologic surgery, urinary incontinence, cystocele, and estrogen deficiency, are all thought to play roles. Dr Raz examined the effects of intravaginal estriol applied twice weekly for 6 weeks on the incidence of UTI. In this placebo-controlled trial, the treatment group showed a dramatic increase in levels of lactobacilli and a decrease in Enterobacteriaceae, compared with baseline. Treated women remained free of UTIs for significantly longer than did women who received placebo. Gregor Reid, MD, of the University of Western Ontario, presented evidence to support the use of “nutraceuticals” or dietary supplements, probiotics, and functional foods to reduce the risk of UTIs and avoid the potential for antibiotic resistance. Evidence is mounting for the role of cranberry UTI Management Main Points • The NIH Chronic Prostatitis Symptom Index can be a valuable tool in clinical practice. • Foods such as cranberry juice may play a role in reducing adhesion of Escherichia coli in the urinary tract. • Recurrent urinary tract infections (UTIs) develop in 20% of women with UTIs and may be associated with vaginal colonization of E coli. • For patients with UTIs, fluoroquinolones may be used as empiric therapy when local resistance rates to trimethoprim-sulfamethoxazole are high. juice in inhibiting E coli adhesion in the urinary tract, thus potentially preventing UTIs and possibly lactobacilli by acting as a barrier to vaginal colonization by urogenital pathogens. Pyelonephritis David A. Talan, MD, of the Olive View–UCLA Medical Center, discussed new directions in emergency department management of acute pyelonephritis. The current standard of care of uncomplicated acute pyelonephritis is outpatient intravenous hydration, administration of antiemetics, and a 14-day course of antibiotic treatment (TMP-SMX, a quinolone, or a cephalosporin) with initial and follow-up cultures. Studies have shown that 2 weeks of treatment with TMP-SMX or ampicillin is equal to 6 weeks and superior to 1 week of treatment. Dr Talan described his recent multicenter, randomized, double-blind trial comparing the efficacies of ciprofloxacin (7 days) versus TMP-SMX (14 days) for uncomplicated acute pyelonephritis in premenopausal women. The 7-day ciprofloxacin regimen was superior in terms of bacterial eradication. It was also associated with fewer adverse events, less resistance, and lower total cost of treatment. Dr Talan concluded that the 7-day course of ciprofloxacin is highly effective, well tolerated, and acceptable to patients. Prostatitis J. Curtis Nickel, MD, of Queen’s University in Kingston, Ontario, said that prostatitis is the most common urologic diagnosis in men under age 50 and accounts for as many visits to urologists’ offices as does prostate cancer or benign prostatic hyperplasia. He described the new NIH classification system for prostatitis. In this classification, category I is similar to acute bacterial prostatitis, and category II is similar to chronic bacterial prostatitis. Category III, which encompasses chronic pelvic pain syndrome (more than 90% of patients), is further divided into the inflammatory (category IIIA) or the noninflammatory (category IIIB) type. Category IV includes patients with asymptomatic prostatic inflammation. Dr Nickel also discussed the recently validated and published NIH Chronic Prostatitis Symptom Index, which comprises 9 items exploring the domains of pain/discomfort, urinary symptoms, and quality of life/impact of symptoms. This comprehensive, brief, and easily understood index will be an important outcomes measure in research studies, but it has also proved very valuable in clinical practice. Various treatments for patients with prostatitis are presently being evaluated in large, multicenter studies. These treatments include antimicrobials, blockers, finasteride, immune modulators, cyclooxygenase-2 inhibitors, pentosan polysulfate, and microwave heat therapy. It was recommended that physicians and urologists treating patients with chronic prostatitis symptoms attempt to practice evidencebased medicine as the results of these trials become available. ■ Acknowledgement: This unique symposium, made possible through an educational grant from the Bayer Corporation, opened the door to international dialogue and consensus among investigators and clinicians interested in infectious diseases of the urinary tract. WINTER 2001 REVIEWS IN UROLOGY 19