What the AUA Guidelines Actually Say ...

 

Not exactly Christmas fare, I know, but I'm growing a bit tired of being quoted "the guidelines" by physicians, at least here in Lexington, regarding recurring/chronic urinary tract infections, without understanding them.

This puts the patient in a situation where they have to rebuttal the doctor with what the guidelines they skimmed actually say, which is never a good position to be in.

Yes, the AUA Guidelines DO say this: 

5. Clinicians should obtain urinalysis, urine culture and sensitivity with each symptomatic acute cystitis episode prior to initiating treatment in patients with rUTIs. (Moderate Recommendation; Evidence Level: Grade C)

But then immediately afterwards, they say this ..

6. Clinicians may offer patient-initiated treatment (self-start treatment) to select rUTI patients with acute episodes while awaiting urine cultures. (Moderate Recommendation; Evidence Level: Grade C)

Which means, doctors of Kentucky and others in America -  you DO treat the patient with something when they're symptomatic while awaiting culture results -  at least first-line therapy to keep them at bay, but usually based on evidential effectiveness of the last culture and sensitivity results - you do NOT just let them sit there for another 5 days getting sicker and sicker!

Also, THIS ???

Antibiotic Prophylaxis

12. Following discussion of the risks, benefits, and alternatives, clinicians may prescribe antibiotic prophylaxis to decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs. (Conditional Recommendation; Evidence Level: Grade B) 

Non–Antibiotic Prophylaxis 

13. Clinicians may offer cranberry prophylaxis for women with rUTIs. (Conditional Recommendation; Evidence Level: Grade C

And THIS ...???

Estrogen 

16. In peri– and post–menopausal women with rUTIs, clinicians should recommend vaginal estrogen therapy to reduce the risk of future UTIs if there is no contraindication to estrogen therapy. (Moderate Recommendation; Evidence Level: Grade B)

I am taking cranberry and D-mannose daily (helpful in some women) and I'm just about to start estrogen (which was suggested by my OB/GYN, not my urologist - but where's my prophylactic antibiotic after at least 4 UTIs a year, hmm?

And then of course there's this, AUA ...

If I have to leave work every time I have a UTI and come in and get a suprapubic cath specimen and wait 5 days for treatment, I will lose my job - not to mention, a kidney infection, and as I age, confusion symptoms.

Also, the only places that do catheter specimens are urologists and the ER - are you really gonna make me go to the ER, when I can't get into my urologist - for a UTI?

Lastly, if you could change "self-start the patient on treatment while awaiting cultures" from moderate recommendation to "strong," that would be super helpful. 

We all understand the risk of antibiotic resistant infections, but are we doing all we can to prevent them?

Because many women DO require prophylactic antibiotic treatment, and even estrogen after menopause. 

If I have more than 4 a year and am postmenopausal, I should be on prophylactic antibiotics and estrogen - period.

You cannot just not treat symptomatic women with a proven UTI through clean catch specimen and allow them to get sicker and sicker, just to avoid community antibiotic resistance, when they ARE sick. 

End of rant! 

😂