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The article below is extracted from Medical Tribune dated 1 - 15 Oct 2006. You can download the issue from Medical Tribune website at http://www.medicaltribune.com/
Managing community-acquired UTI
Presented by Dr. Loh Chit Sin, consultant urologist, at a CME event jointly organized by the Malaysian Urological Association, Private Medical Practitioners’ Association of Selangor and Kuala Lumpur, and Emerging Pharma Sdn. Bhd.Approximately 5% of women will present with at least one episode of urinary tract infection (UTI) by 20 years of age. A local survey revealed that the average GP sees four to eight UTI cases a month, of which about 80% are women. Most patients are treated empirically based on urine dipstick findings... Although empirical treatment without urine culture is wide-spread and acceptable in general practice, the treatment is not without its drawbacks.
If empirical treatment fails, often subsequent urine cultures yield negative results and further antibiotic treatment cannot be based strictly on sensitivity profile. To compound the problem, due to the open access system of primary care, many patients quickly switch doctors when they fail to respond. GPs do not get a chance of following up on the results of the treatment they prescribed.
Guidelines for UTI treatment
The current guidelines by the Infectious Disease Society of America recommend a short 3-day course of cotrimoxazole and trimethoprim for healthy women with uncomplicated disease. If patients are allergic to both drugs, they can be given nitrofurantoin or ciprofloxacin.
The Academy of Medicine of Malaysia 1996 guidelines recommend cotrimoxazole, ampicillin or nitrofurantoin as the first-choice treatment, while the second choice is first- or second-generation cephalosporins.
However, quinolones are currently the most prescribed drugs for UTIs, indicating that the guidelines have little influence on community practice. The 10-year-old guidelines should be updated.
Treatment choice
Over the last decade, generic antibiotics have become available in UTI treatment. Co-amoxiclav can be used in place of ampicillin, while generic quinolones are cheaper. Cotrimoxazole is cheap but resistance is increasingly common. Patients die each year from Steven-Johnson syndrome caused by the sulphonamide component in cotrimoxazole.
Nitrofurantoin is not a popular choice because it requires 4 times daily dosing and causes side effects eg, nausea.
Cotrimoxazole, nitrofurantoin and quinolones can interact and cause hemolysis in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency, which is prevalent in Malaysia.
Cost of drugs as well as investigations are patient-driven factors in managing UTI. Patients expect rapid symptom improvement and short treatment with few side effects.
Compliance is rarely a problem in primary care treatment failures. Treatment failure is usually due to ineffective empirical antibiotics, especially cotrimoxazole.
The practice of not taking initial cultures from patients makes it difficult to prescribe further antibiotics, so broad spectrum antibiotics are usually prescribed to ensure successful treatment.
A useful step to consider is to collect patients’ urine before starting a course of antibiotics. A portion of the urine sample can be stored in the refrigerator for up to 48 hours so that if patients return with persisting symptoms, the sample can be sent to the laboratory for a culture test.
Occasionally, the underlying pathology of the urinary tract should be considered. Differential diagnosis may range from stone in the upper urinary tract and congenital problems in younger patients to bladder tumor in the elderly.
Lack of education is also a predisposing factor for recurrent UTI. Many patients present up to four times a year to different clinics and are prescribed different antibiotics. Most do not know that they can prevent recurrent UTI by taking certain steps eg, sufficient fluid consumption and proper sexual hygiene.
