Listen in as our expert panel unpacks updated definitions of complicated vs. uncomplicated urinary tract infections, navigates antibiotic selection and duration, and shares the latest evidence-based strategies to stop recurrent UTIs in their tracks.
Special guests:
- Dana Bowers, PharmD, BCPS, BCIDP
- Associate Professor
- Washington State University
- Akshith Dass, PharmD, MPH, BCPS, BCIDP
- Assistant Professor of Pharmacy Practice
- Northeast Ohio Medical University
- Pharmacy Clinical Specialist
- Cleveland Clinic Mercy Hospital
You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:
- Craig D. Williams, PharmD, FNLA, BCPS
- Clinical Professor of Pharmacy Practice
- Oregon Health and Science University
None of the speakers have anything to disclose.
This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in April 2026.
🏷️Use code mt1026b at checkout for 10% off a new or upgraded subscription.
TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.
The clinical resources related to this podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights:
- Article: Keep Boosting Antibiotic Stewardship for Complicated UTIs
- Article: Antimicrobial Stewardship: Separate Facts From Fiction
- Chart: Urinary Tract Infections
- Chart: Antibiotics in Pregnancy and Lactation
- FAQ: Antibiotic Therapy: When Are Shorter Courses Better?
- Toolbox: Antimicrobial Stewardship
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Transcript:
This transcript is automatically generated.
00:00:07 Akshith Dass
So asymptomatic bacteriuria means that the bacteria are present in the urine, but the person does not have any symptoms of a urinary tract infection. Importantly, this can also be true if the patient’s urine analysis shows pyuria or white blood cells in the urine, because pyuria alone does not equal infection.
00:00:31 Craig D. Williams
So the guidelines are progressively shrinking the durations recommended for some time and we’re beginning to change and increasingly not even adding on any transition antibiotics when patients leave the hospital. Potentially as soon as just three days into effective treatment regimens or certainly by 5 days. You know what’s common we would give that extra 3, 4, 5 days of outpatient antibiotics to complete their 7, 10, 14 day course and we’re just not doing that anymore.
00:01:00 Narrator
Welcome to Medication Talk, an official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, and the most trusted clinical resources. On this episode, join our expert panel as they unpack updated definitions of complicated versus uncomplicated urinary tract infections, navigate antibiotic selection and duration, and share the latest evidence-based strategies to stop recurrent UTIs in their tracks. Our guests today are Dr. Dana Bowers,
00:01:30 Narrator
an associate professor for the College of Pharmacy and Pharmaceutical Sciences at Washington State University, and Dr. Akshith Dass, an assistant professor of pharmacy practice at Northeast Ohio Medical University and a pharmacy clinical specialist at the Cleveland Clinic Mercy Hospital. You’ll also hear practical advice from TRC’s editorial advisory board member, Dr. Craig Williams from the Oregon Health and Science University.
00:01:57 Narrator
This podcast is an excerpt from one of TRC’s monthly live CE webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.
00:02:13 CE Narrator
And now, the CE information.
00:02:16 Narrator
This podcast offers continuing education credit for pharmacists, pharmacy technicians, physicians, and nurses.
00:02:23 Narrator
Please log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses. None of the speakers have anything to disclose. Now let’s join TRC editors and clinical pharmacists, Dr. Stephen Small and Sara Klockars, and start our discussion.
00:02:48 Steve Small
To start us off, Dana, how do we differentiate complicated versus uncomplicated UTIs and how have the definitions changed over time?
00:02:59 Dana Bowers
The definition of UTI has recently been updated with the most recent complicated UTI guidelines from IDSA.
00:03:07 Dana Bowers
Previous definitions for complicated versus uncomplicated relied more heavily on biological sex, female versus male, and then the presence of certain conditions like diabetes. A person had to be non-pregnant, premenopausal female without diabetes, and no urological abnormalities to be considered uncomplicated UTI. Then there was this sort of designation of acute pyelonephritis, which was sort of its own definition that included complicated
00:03:37 Dana Bowers
UTI characteristics, but infection within the kidney. And then everything else that didn’t fit into those two boxes then fell under this term, this nebulous term of sort of complicated UTI. And now what we see with the more recent updated guidelines from the IDSA is a more focused approach that looks
00:03:58 Dana Bowers
at the site of infection. And infections that are confined to the bladder in an afebrile patient, either male or female, is now defined as uncomplicated UTI.
00:04:09 Dana Bowers
To meet the definition of complicated UTI for the IDSA, this can include pyelonephritis, which is that infection in the kidney, and then patients who have systemic symptoms. So these will present outside of the bladder. So this is what we’re thinking, such as patients who are febrile or if they have bacteremia with UTI, catheter-associated UTI is also included in that, and prostatitis. All of those together
00:04:39 Dana Bowers
are now under this definition of complicated UTI. And one of the reasons that the definition was updated was to simplify it and make it easier and more straightforward for practicing clinicians. And another way was to help guide treatment options through clinical decision pathways. And so not sort of focusing on the diagnosis part of it, but really using complicated and uncomplicated to help guide treatment decisions.
00:05:12 Steve Small
Great contrast there between the two definitions. And as we talk about UTI symptoms, I’m sure some of our audience is also wondering what is asymptomatic bacteria or ASB?
00:05:25 Akshith Dass
So asymptomatic bacteriuria means that the bacteria are present in the urine, but the person does not have any symptoms of a urinary tract infection.
00:05:35 Akshith Dass
Importantly, this can also be true if the patient’s urine analysis shows pyuria or white blood cells in the urine, because pyuria alone does not equal infection. So when we think about it, we already reviewed the symptoms of a urinary tract infection, and based on that, we can differentiate between complicated and uncomplicated. But if those symptoms are absent and the bacteria is just present in the urine,
00:06:03 Akshith Dass
it could more often represent colonization rather than a true infection. So asymptomatic bacteriuria is quite common and the prevalence increases with age, and it is generally more common in women than in men. Some risk factors for asymptomatic bacteriuria are generally the same thing that make urinary colonization more likely. Some big ones include being female, increasing in age, pregnancy,
00:06:33 Akshith Dass
chronic catheter use, any impaired bladder emptying, whether that’s from a neurogenic bladder or a spinal cord injury, having comorbidities such as diabetes, or living in a long-term care facility. In terms of how common it is, asymptomatic bacteriuria can be seen in about 1 to 5% of healthy premenopausal women. The risk then doubles during pregnancy.
00:07:02 Akshith Dass
When we talk about long-term care residents, here’s where the numbers rise sharply. Around 25% to 50% of women and 15% to 50% of men can experience asymptomatic bacteriuria. And to think about the flora, the flora in those patients with asymptomatic bacteriuria isn’t really different from those with symptomatic urinary tract infections.
00:07:27 Akshith Dass
So when we’re seeing asymptomatic bacteriuria, it’s still the same flora such as E. coli, Klebsiella pneumoniae, Proteus mirabilis, Enterococcus, and even sometimes Group B strep. So it becomes a really important clinical distinction focusing on the patient’s symptoms when you find bacteria in the urine.
00:07:52 Steve Small
Great points there. And now we can dig deeper into how we can treat UTIs appropriately with antibiotics. For example, Dana, are there cases where you should use antibiotics for asymptomatic bacteria?
00:08:07 Dana Bowers
Yes. So there are specific cases where you would use antibiotics for asymptomatic bacteriuria. And pregnancy is really the main one that we think about because ASB is very common during pregnancy, as Akshith already mentioned. And this is going to increase the risk of symptomatic UTI and particularly pyelonephritis. And pyelonephritis is dangerous not only for the person who is pregnant, but also for the fetus. And so this can
00:08:36 Dana Bowers
cause preterm birth, it can cause anemia and sepsis. And so these are the reasons why pregnant people are recommended to be screened using a urine culture at least once during their pregnancy. And if it’s positive, then you would want to treat the asymptomatic bacteriuria in that case. And when these cultures are positive, even though the risk of pyelonephritis, those are things that we need to be concerned about, this isn’t something that requires
00:09:04 Dana Bowers
immediate attention at that moment. We can wait until we get a culture and we get the culture results to really determine our therapy based on culture results. The other group that we would want to screen and treat are patients that are undergoing urological interventions where we are expecting there to be a high degree of mucosal
00:09:27 Dana Bowers
bleeding. So an example of this would be a TURP, so transurethral resection of the prostate. And then also if patients are getting renal stones removed or kidney stones removed, there’s bacteria that can be involved in that. And so we would want to make sure that we screen these patients and then treat them for prior to the surgery. And then this is an addition to the perioperative antibiotic prophylaxis that they’ll get prior to whatever procedure they’re undergoing.
00:09:55 Steve Small
Which empiric antibiotics are preferred then for complicated versus uncomplicated UTIs? Are there differences we need to think about? And perhaps what antibiotics are typically avoided in certain cases?
00:10:09 Akshith Dass
Yeah, so in this situation, the IDSA has laid out, at least in your guidelines, have helped determine this. First we can start with the uncomplicated cystitis. So the traditional agents that we think of for uncomplicated cystitis
00:10:24 Akshith Dass
are typically nitrofurantoin for five days, trimethoprim-sulfamethoxazole for three days, or a single dose of fosfomycin. And these are longstanding IDSA guidelines for uncomplicated cystitis in women, where again, the usual target organism is E. coli. A few stewardship caveats for these typically first-line agents would be that for trimethoprim-sulfamethoxazole or trim sulfa,
00:10:52 Akshith Dass
the guidelines have mentioned it should generally be avoided for empiric use if the patient has had it recently for a UTI or if the local E. coli resistance exceeds 20%. So just an example of that, at my institution, again, we don’t produce a urine isolate only antibiogram, but for what we are working with so far, around 79% of all E. coli isolates in 2024 were susceptible to trim sulfa.
00:11:20 Akshith Dass
So again, 21% resistance at my institution. So we’re at the cusp which patients visiting our maybe for a simple cystitis may not qualify for empiric trim sulfa use. You see that fluoroquinolones are also listed. Again, these are very effective, especially oral options that can be used both in the inpatient as well as the outpatient setting. But the fluoroquinolone stewardship that’s being harped upon
00:11:50 Akshith Dass
and really paying attention to it, they’re considered as alternative or reserve agents for uncomplicated cystitis, mainly because of the collateral damage and resistance concerns and safety warnings, those that have been put out by both the FDA in 2016 and recently across the pond. The United Kingdom also released a very similar message in 2024 advising that fluoroquinolone should be reserved for situations
00:12:17 Akshith Dass
where other recommended antibiotics are not appropriate because of the irreversible side effects of the fluoroquinolone antimicrobials. And then oral beta-lactams can be preferred when your typical first-line agents are not appropriate, but overall they’re generally considered less effective than your preferred first-line agents. And then moving on to the complicated urinary tract infection picture.
00:12:43 Akshith Dass
Here we have to determine what the extent of infection is. The patient has sepsis with or without any shock. Then your preferred empiric antimicrobials from a list that you could choose from includes third or fourth generation cephalosporins. So in the hospital setting, this is mainly going to be ceftriaxone or cefepime, or you can choose a carbapenem, piptazo,
00:13:10 Akshith Dass
or your fluoroquinolones, levofloxacin, or ciprofloxacin. And the agent that we pick from this list then depends on additional factors, such as the patient’s list of microbiological history, the local antibiogram, maybe their allergy list. And then these agents are preferred over your relatively newer or novel beta-lactam, beta-lactamase agents, such as, for example, ceftazidime-avibactam, ceftolozane-tazobactam,
00:13:40 Akshith Dass
or cefiderocol, or your aminoglycosides, including plazomicin, for example, gentamicin, amikacin, et cetera. On the other hand, if the patient does not experience sepsis and they cannot take oral meds, again, this is where your IV antimicrobials are going to come into play. So your list includes agents like third or fourth generation cephalosporins, piptazo, or your fluoroquinolones. And then if the patient can’t take oral medications,
00:14:10 Akshith Dass
again, fluoroquinolones and trim sulfa become really good options in this scenario, mainly because they’re thought to have really good bioavailability and good systemic exposure in the kidney as well as the bladder. Agents to avoid in this scenario, especially when we’re talking about complicated urinary tract infections, would be nitrofurantoin as well as oral fosfomycin. These agents are useful
00:14:39 Akshith Dass
mainly for uncomplicated cystitis because they don’t have good kidney tissue penetration or bloodstream concentrations. So those are the agents that we would want to avoid for complicated UTIs.
00:14:54 Steve Small
Great review. Dana, anything to add from your perspective given the options that we have?
00:15:00 Dana Bowers
so where I live in the West, we don’t have as much resistance as sort of other places, maybe more so towards the East Coast. I think I’ve been fortunate in that way. So I really like nitrofurantoin and trimethoprim-sulfamethoxazole for uncomplicated UTI and then for, even for complicated when they don’t have sepsis. I also personally like the beta-lactams. They have sort of this complicated history where, you know, people have traditionally thought of them
00:15:30 Dana Bowers
as having inferior efficacy for UTI, but I think that we use them a lot clinically and especially the oral cephalosporins. And there’s more literature coming out and we could go on and on about the literature and sort of the problems with the studies that have been coming out and how to compare different, let’s say, cephalosporins, for example. But I think that these do get used clinically and we’ll be having more and more data to come and support that we
00:16:00 Dana Bowers
perhaps can use the oral cephalosporins more than perhaps we have in the past.
00:16:07 Steve Small
I think it’s great to hear these different experiences and it shows how UTI management depends on so many factors. And with that, I’ll hand over the mic to Sara.
00:16:18 Sara Klockars
Thank you. And we’re going to shift gears. We’ve talked a lot about the different antibiotics, the different types of infections. Sometimes we have cultures, sometimes we don’t.
00:16:27 Sara Klockars
So, Craig, what are some common issues or errors you see with UTI prescriptions?
00:16:35 Craig D. Williams
I mean, a lot of it does get to what we talked about in the first part, just kind of making sure you’re considering the patient when making your initial selection. So, and the big decision point being complicated or uncomplicated, you know, are there any systemic symptoms? Akshith just said looking at recent history can be useful if you have that on the patient.
00:16:53 Craig D. Williams
But then really once you’ve chosen an agent, we’ve talked a little bit about dose. For some agents, that’s easy. For some agents, that’s less easy. And then duration is kind of big. So for those of us on the hospital side where we’re helping transition patients, we’re having a lot more conversations about how long do patients really need therapy for. So the guidelines are progressively shrinking the durations recommended for some time and we’re beginning to change.
00:17:20 Craig D. Williams
Some of the advice that we give patients, and increasingly not even adding on any transition antibiotics when patients leave the hospital, potentially as soon as just three days into effective treatment regimens or certainly by 5 days, you know, it’s common we would give that extra 3, 4, 5 days of outpatient antibiotics to complete their 7, 10, 14 day course. And we’re just not doing that anymore. So that’s become a big area of focus for antimicrobial stewardship. But if that person’s looking a whole lot better,
00:17:49 Craig D. Williams
in two days, they do not need 14 or 10 or even seven days now commonly of antibiotics depending on what you use. So duration has become a big focus as you highlight on the slide.
00:18:04 Dana Bowers
I also agree that
00:18:05 Dana Bowers
Duration of therapy, this is a main one that I see especially for transitions of care. And so this is where antimicrobial stewardship is really stepped in and then pharmacists who specialize in transitions of care to making sure that as patients are discharged, that they are not getting an additional 5 days of therapy, that they looked at what they got in the hospital and then seeing, do we still need more antibiotics after that?
00:18:30 Dana Bowers
Another common thing that I see with UTI prescription is sort of automatically reaching for the fluoroquinolones. I think as stewardship pharmacists, we’ve done a lot of education on this and this has gotten better. But I think, you know, there may be some practitioners out there who are just really familiar with the fluoroquinolones and just
00:18:48 Dana Bowers
they know that they work in this disease state, and so they’ll automatically reach for those instead of thinking about from a stewardship perspective, what is going to be a good sort of overall agent that we can use that will decrease resistance development over time.
00:19:03 Craig D. Williams
We all still teach, certainly, nitrofurantoin, fosfomycin, generally not for pyelonephritis. Interestingly, they will work a fair amount of time for uncomplicated pyelonephritis, otherwise healthy person, but they fail
00:19:15 Craig D. Williams
enough that that’s still certainly a valid point. And that’s one of the things I can always rely on the medical students and residents to reliably get in medical school is don’t use nitrofurantoin and fosfomycin for pyelonephritis. That’s still a good rule of thumb. Do not use those agents for what we’re now calling complicated or pyelonephritis infections.
00:19:35 Sara Klockars
Excellent. Thank you.
00:19:37 Steve Small
And then Akshith, what criteria do you use to switch from IV to oral antibiotics in complicated UTIs? Is there any sort of maybe check boxes that you check off in your mind when determining whether to make that transition?
00:19:54 Akshith Dass
So to switch from IV to oral, what I usually look for are three main conditions. So one, is the patient clinically improving? That I think has to be the top priority.
00:20:05 Akshith Dass
The second one would be, can the patient take and absorb any oral medications by mouth?
00:20:11 Akshith Dass
So that could be like scanning the medication list, asking the nurse, seeing what the patient’s taking.
00:20:16 Akshith Dass
Are they consuming any diet by mouth?
00:20:19 Akshith Dass
And then thirdly, is there an effective oral antibiotic that is available?
00:20:24 Akshith Dass
So typically what a patient scenario could be, they maybe come to the hospital for a complicated urinary tract infection.
00:20:32 Akshith Dass
They get started on everyone’s favorite
00:20:35 Akshith Dass
antibiotic of choice, ceftriaxone, IV medication.
00:20:39 Akshith Dass
And it’s now day two, day three of your therapy.
00:20:43 Akshith Dass
The patient again should be getting better with the effective empiric antimicrobial choice.
00:20:48 Akshith Dass
By day three, typically is when your microbiology lab can chime in and help you out with some urine culture and susceptibility reports.
00:20:57 Akshith Dass
So at that point then now you can look at the susceptibility report, see if the patient is able to
00:21:04 Akshith Dass
take any medications by mouth if they’re clinically improving, such as no fevers, stable blood pressure, good heart rate, maybe their mental status is now improving if that was an issue in the past.
00:21:18 Akshith Dass
And overall symptom reduction, so no more dysuria, no more flank pain, or overall systemic illnesses.
00:21:25 Akshith Dass
And they’re willing to take medications by mouth.
00:21:28 Akshith Dass
Then when you scan
00:21:29 Akshith Dass
your susceptibility report and you can see there are effective oral agents available, then you want to make sure that you can look at more patient-specific factors like allergy lists, intolerances, any renal dose adjustments, and then pick an agent from that list which is optimally dosed for the given scenario.
00:21:49 Akshith Dass
So for example, if you know your patient’s experiencing a complicated urinary tract infection,
00:21:55 Akshith Dass
but the only oral agent available, for example, is nitrofurantoin,
00:22:00 Akshith Dass
you’re not going to go for that option, even though it is an oral option that’s available.
00:22:05 Akshith Dass
It’s not going to be an effective oral option for this complicated urinary tract infection picture.
00:22:13 Craig D. Williams
Yeah, those are great points.
00:22:14 Craig D. Williams
Another thing I’ll add briefly, this mostly is referring to beta-lactams, as Akshith said.
00:22:18 Craig D. Williams
On the inpatient side, that’s often what’s being started intravenously.
00:22:22 Craig D. Williams
Also for quinolones, they’re the same oral as they are IV.
00:22:27 Craig D. Williams
The other thing is, it’s not that uncommon for your blood cultures to turn positive.
00:22:31 Craig D. Williams
Bacteremia happens in probably at least 10% of hospitalized patients with complicated urinary tract infections.
00:22:39 Craig D. Williams
And the fact that your blood culture might have been positive, assuming it’s the same organism in the urine and it’s almost always gram-negative, does not need to change when you switch.
00:22:47 Craig D. Williams
If the patient’s clinically improving and stable and your culture says you have something, you have a good oral option you feel comfortable with based on your culture, you can still make that transition.
00:22:58 Steve Small
Great points there.
00:22:59 Steve Small
And what are important counseling points when we’re talking with patients about their UTI antibiotic therapy?
00:23:05 Steve Small
Are there any maybe side effects or interactions that you commonly watch for that maybe you keep top of mind with some of these classes or specific meds?
00:23:14 Steve Small
Akshith, what’s your take on that?
00:23:18 Akshith Dass
Yeah, so overall, the antimicrobials for urinary tract infections are typically well tolerated.
00:23:26 Akshith Dass
Some counseling points
00:23:28 Akshith Dass
for fluoroquinolones or things to watch out for, at least for the short term, would be any drug interactions.
00:23:34 Akshith Dass
So if your patient’s taking fluoroquinolones with any metallic compounds, any like multivitamins that may contain iron, calcium, magnesium of those sorts, watching out for those drug interactions and not, you know, separating the fluoroquinolones from these metallic compounds.
00:23:51 Akshith Dass
The side effects, you know, rare side effects of CNS effects or tendon rupture, neuropathy or dysglycemia, keep an eye out for that, especially in your older patients.
00:23:56 Akshith Dass
Maybe with those with poor renal function, renal clearance of these fluoroquinolones, so keep an eye out for that.
00:24:01 Akshith Dass
But for the short period of time, again, these fluoroquinolones should be OK in that sense.
00:24:07 Akshith Dass
But trimethoprim-sulfamethoxazole, something to watch out for would be potassium as well as renal function, especially in your older adults who already have
00:24:23 Akshith Dass
poor renal function, and it could be on an ACE inhibitor, angiotensin receptor blocker, or spironolactone, because the risk of hyperkalemia goes up.
00:24:33 Akshith Dass
So your potassium can increase.
00:24:35 Akshith Dass
Typically, from a teaching standpoint, what I like to tell the students is, you know, watch out for those little old ladies that come back to the ER, maybe complaining of muscle pain or some abnormal heart beating in their chest, because that could be signs that their potassium
00:24:52 Akshith Dass
could have increased because of the trimethoprim-sulfamethoxazole prescription.
00:24:56 Akshith Dass
Nitrofurantoin for the short term could be something like a dark urine or brown urine, which is expected or harmful.
00:25:04 Akshith Dass
But keep an eye out for patients who may develop some shortness of breath.
00:25:08 Akshith Dass
But those are very rare side effects for any pulmonary or hepatic side effects, overall very rare, not in the short-term period.
00:25:17 Akshith Dass
And then
00:25:19 Akshith Dass
for oral beta-lactams like cephalexin, the usual counseling point is going to be GI upset, diarrhea, nausea, vomiting.
00:25:24 Akshith Dass
Again, that has to do with how much cephalexin they have to end up taking in order to meet their prescription.
00:25:30 Akshith Dass
So some counseling points related to the UTI antibiotics, but overall, all of them should be, again, short duration.
00:25:38 Akshith Dass
So the adverse effects experienced from them also should be very helpful.
00:25:45 Craig D. Williams
Those are all good points.
00:25:46 Craig D. Williams
I’ll just add, if we’re sticking to the short durations we should be sticking to, fortunately, these generally are pretty well-tolerated agents.
00:25:53 Craig D. Williams
So on the inpatient side, we have the luxury of watching the patient for a day or two.
00:25:57 Craig D. Williams
On the outpatient side, the big thing is just to expect a pretty quick clinical response.
00:26:02 Craig D. Williams
You definitely want that patient to be letting someone know if two days into therapy, they’re still not feeling good, or now they’re having fevers they weren’t having the day before or fevers haven’t abated.
00:26:12 Craig D. Williams
But I mean, there are some drug interactions as were enumerated, but if you’re sticking to short durations of therapy, we don’t use much warfarin anymore.
00:26:19 Craig D. Williams
It’s always a big one for quinolones and Bactrim kind of back in the day.
00:26:23 Craig D. Williams
The biggest thing that prompts warnings from our prescribers, we get called all the time for the QT prolongation warnings for quinolones, especially on one other agent.
00:26:31 Craig D. Williams
So we have that discussion a lot.
00:26:33 Craig D. Williams
But fortunately, for just the kind of five to seven or even three-day duration, generally pretty well tolerated.
00:26:38 Craig D. Williams
So our big advice on the outpatient side is like, let us know if you’re not getting better really quick.
00:26:44 Steve Small
That’s a great list of side effects to share with patients during counseling.
00:26:47 Steve Small
And some other general counseling points include recommending patients drink enough fluids.
00:26:52 Steve Small
And we know sharing isn’t caring when it comes to antibiotics.
00:26:56 Steve Small
Advise against sharing any antibiotic supply with others since this can increase resistance in the community.
00:27:01 Steve Small
And similarly, patients should throw away any remaining pills if they have any left over, perhaps after their therapy.
00:27:09 Steve Small
And Akshith, when is it appropriate to use antibiotic prophylaxis if a patient has recurrent UTIs?
00:27:15 Steve Small
Are there any specific antibiotics you should use and specific durations that we should be looking at?
00:27:21 Akshith Dass
Yeah, so antimicrobial prophylaxis to prevent recurrent UTIs is typically considered after two or more UTIs in the past six months.
00:27:31 Akshith Dass
or at least three occurrences of UTIs in the past year.
00:27:36 Akshith Dass
So those are generally the timelines on when you should start thinking about antibiotic prophylaxis.
00:27:40 Akshith Dass
But then the prophylaxis, again, should be a shared decision making between the provider as well as the patient, because one, now you’re subjecting the patient to a long-term antibiotic regimen.
00:27:51 Akshith Dass
And with that comes the risk of adverse effects and the risk of resistance, plus it’s just added cost for the patient as well.
00:27:59 Akshith Dass
How long should you use it?
00:28:00 Akshith Dass
Typically, the studies have done prophylaxis between six months to a year.
00:28:06 Akshith Dass
And then the studies have shown that once the prophylaxis is taken away, the UTI could recur at the same rate as if you’re not taking prophylaxis.
00:28:14 Akshith Dass
So that’s also something to consider in that shared decision-making process.
00:28:19 Akshith Dass
Antibiotics that have been used, you may see things like nitrofurantoin at a lower dose, about 50 to 100 milligrams given once daily.
00:28:29 Akshith Dass
maybe trim sulfa at like half dose or a tablet three times a week.
00:28:34 Akshith Dass
Low-dose cephalexin is an option of around 125 to 250 milligrams daily.
00:28:39 Akshith Dass
Or there’s also an option of giving fosfomycin 3 gram sachet every 10 days.
00:28:45 Akshith Dass
So yeah, overall, shared decision making, thinking about the risks of adverse effects, risk of resistance, increase cost to the patient, but the benefit of preventing those recurrent UTIs.
00:28:59 Akshith Dass
for that 6 to 12 month duration.
00:29:04 Craig D. Williams
Yeah, I’ll add, Steve, this is a tough topic.
00:29:07 Craig D. Williams
So we’re seeing less this now than we’re seeing a decade ago, just because it’s, you know, anything systemic, you’re just going to get resistance to and promote more resistance.
00:29:16 Craig D. Williams
So but if you need to use something, nitrofurantoin is the best agent.
00:29:19 Craig D. Williams
And virtually all UTIs start as cystitis and are ascending infections.
00:29:23 Craig D. Williams
So if you prevent cystitis, you can almost always prevent
00:29:26 Craig D. Williams
pyelonephritis, especially important in patients who might be doing intermittent catheterizations at home for a variety of reasons.
00:29:33 Craig D. Williams
And when we do occasionally use nitrofurantoin, we like bedtime dosing, longer retention time in the bladder, typically overnight or whatever is kind of the bedtime period for that patient.
00:29:43 Craig D. Williams
But it’s a tough thing to operationalize just because systemic therapies, you’re just going to promote resistance to.
00:29:49 Craig D. Williams
So we’re big on some kind of recurrence, like can we find a trigger
00:29:53 Craig D. Williams
for it, or is there an anatomic abnormality?
00:29:55 Craig D. Williams
Is this the time for imaging to find something?
00:29:58 Craig D. Williams
So trying to find the reason and maybe do intermittent prophylaxis, continuous prophylaxis with systemic agents, just as kind of a setup for failure long-term, as Akshith kind of alluded to.
00:30:11 Sara Klockars
Thank you.
00:30:12 Sara Klockars
Can you comment on the use of estrogen to prevent UTIs in postmenopausal women?
00:30:19 Dana Bowers
Yes, this is
00:30:21 Dana Bowers
can be very beneficial for some people.
00:30:24 Dana Bowers
It’s going to be intravaginal, so more localized topical estrogen.
00:30:30 Dana Bowers
And the way that this works is it’s going to normalize the vaginal flora and it will reduce the risk of recurrent UTI.
00:30:38 Dana Bowers
And just me personally, I also just love a good microbiome restoration approach because if we’re normalizing the vaginal flora, then we can help prevent this colonization with these other bacteria, which can then lead to symptomatic UTI.
00:30:51 Dana Bowers
The other thing I think is important to think about for this is we try to recommend behavioral modification sort of as a blanket statement.
00:31:01 Dana Bowers
And I think sometimes people forget, especially in postmenopausal women, that estrogen can be beneficial.
00:31:08 Dana Bowers
So I think, you know, keeping in mind when patients have exhausted these sort of behavioral modifications and they still keep getting these recurrent UTIs, that might be a good time to try sort of a low dose localized estrogen in a postmenopausal.
00:31:24 Sara Klockars
Excellent.
00:31:24 Sara Klockars
And then we’re getting a ton of questions about supplements.
00:31:27 Sara Klockars
So Akshit, what supplements can be used to prevent or treat UTIs?
00:31:33 Sara Klockars
And specifically people are asking about cranberry products or juice, probiotics.
00:31:39 Sara Klockars
Are there any supplements that have evidence to support their use?
00:31:46 Akshith Dass
Yeah, so the one supplement that comes to mind for at least
00:31:49 Akshith Dass
prevention of UTI.
00:31:51 Akshith Dass
In these supplements, I haven’t come across one that can be used to treat a UTI, but at least to prevent recurrence of UTI, one supplement that comes to mind would be the cranberry supplements.
00:32:03 Akshith Dass
The reason why cranberry has become popular in the UTI field is because the mechanism of action is such that they have these things called the proanthocyanidins in them.
00:32:17 Akshith Dass
So the proanthocyanidins or PACs help reduce bacterial adhesion to the urinary bladder, which then makes it harder for your gram-negative organisms like E.
00:32:27 Akshith Dass
coli to then establish infection.
00:32:31 Akshith Dass
So the cranberry supplements, whether it’s juice or when it comes as a tablet or capsules, are now recommended by the American Urological Association
00:32:43 Akshith Dass
as an option for prophylaxis in women with recurrent urinary tract infections.
00:32:49 Akshith Dass
The FDA also has a newer language that’s out there as a qualified health claim that they have attached to certain cranberry products saying that, yes, the evidence is limited and maybe some inconsistency in the evidence, but there is generally a trend towards the cranberry products helping with prevention of urinary tract infections.
00:33:13 Akshith Dass
When picking up cranberry supplements, look carefully at the label.
00:33:17 Akshith Dass
One of the studies said that you should have at least 36 milligrams of this PAC being taken daily for about three to six months for the cranberry to have any impact.
00:33:30 Akshith Dass
What 36 milligram PACs could translate to would be around 500 milligrams of cranberry dietary supplements or cranberry powder.
00:33:42 Akshith Dass
based on what the labeling is saying, or around 8 ounces of cranberry juice.
00:33:48 Akshith Dass
When you’re considering the juice, make sure it’s the unsweetened version of the juice because you don’t want to exacerbate any comorbid conditions by drinking a sweetened juice on a daily basis for three to six months.
00:34:00 Akshith Dass
Overall, there’s very low risk of adverse effects when it comes to cranberry supplements themselves.
00:34:06 Akshith Dass
So that could be a consideration.
00:34:08 Akshith Dass
So again, if you were to pick one,
00:34:10 Akshith Dass
to take as a non-antimicrobial option, this could be something to consider.
00:34:16 Akshith Dass
But again, read that labeling very carefully and pick up that unsweetened juice if you were to do that.
00:34:23 Akshith Dass
On the probiotic sides, not as much evidence and inconsistent evidence for probiotics to help in any prevention of recurrent UTIs.
00:34:36 Akshith Dass
So I think the data is still not strong enough to recommend this as compared to cranberry supplements.
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