Other




Infection Treatment Other
Bacterial vaginosis

(BV)
2015 CDC recommendations
  • Bacterial Vaginosis (BV) is a condition where the normal vaginal flora (Lactobacillus sp) is replaced with a high concentrations of anaerobic bacteria, G. vaginalis, Ureaplasma, Mycoplasma, and numerous fastidious or uncultivated anaerobes.
  • Symptoms of BV include vaginal discharge and malodor. Most women with BV are asymptomatic.
  • The cause of BV is not well-understood. It has been linked to douching, sexual intercourse, and lack of vaginal lactobacilli.
  • Diagnosis is made by gram stain of vaginal secretions. Clue cells on microscopic exam is also used.
  • Treatment is only recommended for women with symptoms
  • Treatment of male sex partners has not been shown to prevent recurrence [1]

Infection Treatment Other
Epididymitis 2015 CDC recommendations
  • Epididymitis likely caused by gonorrhea or chlamydia

  • Epididymitis likely caused by enteric or urinary tract pathogen (one of the following)

  • Epididymitis that may be caused by gonorrhea, chlamydia, and/or enteric organisms (insertive anal intercourse)

NOTE: Empiric treatment is recommended
  • Epididymitis typically presents with pain that localizes to the posterior testicle. The pain may radiate to the lower abdomen. Symptoms such as fever, urinary frequency, hematuria, and dysuria may also be present.
  • In men aged 14 - 35 years, it is most commonly caused by gonorrhea and chlamydia
  • In men > 35 years, it is most commonly caused by urinary tract pathogens such as E. coli. Patients with bladder outlet obstruction (ex. BPH), recent prostate biopsy, urinary tract instrumentation or surgery may be at greater risk.
  • Chronic epididymitis (≥ 6 weeks) is typically caused by Mycobacterium tuberculosis (TB)
  • In men who give insertive anal intercourse, enteric pathogens like E. coli are possible pathogens
  • Urine tests including urinalysis, culture, and nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia can help to make the diagnosis [1,2]

Infection Treatment Other
Prostatitis Acute prostatitis
Chronic prostatitis
  • There is a lack of professional consensus on what defines a diagnosis of prostatitis
  • Symptoms of prostatitis include both inflammatory urinary symptoms (urinary frequency, urgency, dysuria) and obstructive urinary symptoms (hesitancy, poor stream, incomplete emptying). Symptoms are often accompanied by genitourinary, pelvic, or rectal pain. Sexual dysfunction (ejaculatory discomfort and hematospermia) may also be present. In acute bacterial prostatitis, systemic signs of infection (fever, nausea, tachycardia) are often present.
  • Acute prostatitis is marked by sudden onset of fever, pain, and urinary symptoms. Sicker patients may require intravenous antibiotics.
  • Chronic prostatitis is marked by recurrent pain and urinary symptoms that last greater than 3 months
  • Laboratory testing in prostatitis has limited diagnostic value. All patients should have a urinalysis with culture. Prostatic massage tests are cumbersome, have not been adequately validated, and are rarely performed.
  • Patients with risk factors for STDs should be tested for chlamydia and gonorrhea
  • Diagnosis of prostatitis is typically based on symptoms. In practice, < 10% of men diagnosed with prostatitis have a proven bacterial infection while about 50% of these patients receive antibiotics.
  • Risk factors for prostatitis include recent urinary tract instrumentation, urethral stricture, and urinary tract infection
  • Bacterial prostatitis is typically caused by E. Coli [3,4]

Infection Treatment Other
Pyelonephritis

(kidney infection)
2011 IDSA recommendations

  • Symptoms of pyelonephritis include urinary urgency, frequency, and dysuria accompanied by fever, flank pain, and nausea and vomiting
  • Urinalysis and urine culture should be performed
  • In otherwise healthy patients, most cases of pyelonephritis can be managed on an outpatient basis
  • E. coli causes up to 95% of cases of pyelonephritis. Other pathogens include Klebsiella pneumoniae and Staphylococcus saprophyticus [5,6]

Infection Treatment Other
Urinary tract infection, ADULTS

(UTI)
(Cystitis)
2011 IDSA recommendations
Prophylactic therapy for recurrent UTIs
  • UTI symptoms include burning with urination, urinary frequency, blood in urine, urgency, and suprapubic pain and pressure
  • After first UTI, 25% of women have recurrence within 6 months
  • A positive urinalysis for leukocyte esterase or nitrites has a sensitivity of 75% and a specificity of 82%
  • Asymptomatic bacteriuria should not be treated in most patients (exceptions - pregnant women, patients undergoing urological procedures)
  • E. coli causes up to 95% of cases of UTI. Other pathogens include Klebsiella pneumoniae and Staphylococcus saprophyticus

Recurrent UTIs
  • For women with ≥ 3 UTIs in 12 months, preventative therapy may be tried
  • Imaging studies (e.g. ultrasounds, CT scans) and urological referrals have low yield in women and are not recommended
  • For continuous antibiotic therapy, a six month trial is recommended. After 6 months, stop and observe. About 50% of women will have a return to recurrent UTIs. Antibiotics may be restarted if needed.

    • Measures that may help prevent recurrent UTIs include:
      • Reduction in intercourse
      • Avoid spermicides
      • Urinate after intercourse
      • Drink plenty of fluids
      • Avoid douching
      • Wipe front to back
      • Avoid tight-fitting underwear
      • Cranberry juice, capsules, or tablets - no clear benefit in studies (23076891, 21148516, 22305026 27787564)
      • Topical estrogen in postmenopausal women
      • D-mannose - in one unblinded study, 2 grams once daily was found to be effective (see PubMed abstract)

    • NOTE: None of these interventions have been conclusively proven to reduce infections [5,6]

Recent studies:
  • Fosfomycin vs ibuprofen in uncomplicated UTI - A double-blind, placebo-controlled trial published in the BMJ in 2015 compared a single dose of fosfomycin 3 grams (N=243) to ibuprofen 400 mg three times a day for 3 days (N=241) in women presenting with acute symptoms of uncomplicated UTI. The coprimary outcomes were total number of courses of antibiotics received on days 0 - 28, and burden of symptoms on days 0 - 7. RESULTS: At day 28, 35% of women in the ibuprofen group had received antibiotics (65% of UTIs resolved without antibiotics). Burden of symptoms (dysuria, frequency, urgency, abdominal pain) were significantly greater in the ibuprofen group during the first 7 days of therapy. Pyelonephritis occurred in 5 patients in the ibuprofen group and 1 in the fosfomycin group. PubMed abstract

Infection Treatment Other
Urinary tract infection, PEDIATRIC

(UTI)
(Cystitis)
Typical regimens
  • Sulfamethoxazole-trimethoprim - 6 - 12mg/kg/day (trimethoprim component) given in 2 divided doses for 7 - 14 days ($)
  • Augmentin - 20 - 40mg/kg/day given in 3 divided doses for 7 - 14 days ($)
  • Cefixime - 8mg/kg/day (max 400mg/day) given once daily for 7 - 14 days ($)
  • Cefpodoxime - 10mg/kg/day (max 400mg/day) given in 2 divided doses for 7 - 14 days ($$)
  • Cefuroxime - 20 - 30mg/kg/day (max 1000mg/day) given in 2 divided doses for 7 - 14 days ($)
  • Cephalexin - 50 - 100mg/kg/day (max 2000mg/day) given in 4 divided doses for 7 - 14 days ($)
Other
Prophylaxis (children with vesicoureteral reflux)
Notes on Prophylaxis:
  • Treatment of children with Vesicoureteral Reflux (VUR) is controversial
  • VUR ranges from Grade I (mild) to Grade V (severe)
  • Treatment options include surveillance, antibiotic prophylaxis, surgical repair, and endoscopic injection of bulking agent
  • Studies comparing surgery to antibiotic prophylaxis have found no significant difference between the two (1433585, 11343739, 2888509)
  • The RIVUR trial (NEJM 2014) compared prophylaxis with sulfamethoxazole-trimethoprim to placebo in children 2 to 71 months with grade I - IV reflux. The trial found that antibiotic prophylaxis halved the risk of recurrent UTI over 2 years, but had no effect on renal scarring.
  • The optimal duration of prophylaxis has not been determined. In trials, it has typically been for 1 - 2 years [7,8,9]
  • Approximately 7-8% of girls and 2% of boys have a UTI during the first 8 years of life.
  • Children 2 months to 2 years with first febrile UTI should have a renal and bladder ultrasound. Voiding Cystourethrography (VCUG) is not routinely recommended in these children.
  • For children 2 months to 2 years, urine specimen should be obtained through catheterization or suprapubic aspiration. Infection is confirmed by presence of pyuria and/or bacteriuria, and the presence of at least 50,000 colony-forming units (CFUs) per mL of a uropathogen cultured from a urine specimen. [7,8]

Studies
  • Uropathogens and Pyuria - A study in Pediatrics (2016) looked at the prevalence of pyuria with different uropathogens. The study found that compared to E.Coli, children with Enterococcus species, Klebsiella species, and Pseudomonas aeruginosa urinary tract infections were much less likely to have pyuria with their infection. [PubMed abstract]

Infection Treatment Other
Yeast infection

(Vulvovaginal candidiasis)
2015 CDC recommendations
  • Over-the-counter
    • Clotrimazole (Lotrimin®) - cream; use as directed ($)
    • Miconazole (Monistat®) - cream, vaginal suppository; use as directed ($)
    • Tioconazole - cream; use as directed ($)
  • Prescription
    • Butoconazole 2% cream (Gynazole®) - one applicatorful of cream (approximately 5 grams of the cream) intravaginally for one dose ($$)
    • Terconazole (Terazol®)
      • 0.4% cream 5g intravaginally for 7 days ($)
      • 0.8% cream 5 g intravaginally for 3 days ($)
      • 80mg vaginal suppository, one suppository daily for 3 days ($)
    • Fluconazole - 150mg one time dose ($)

  • Prolonged episodic therapy (for recurrent cases)
    • Prolonged topical therapy - 7 - 14 days of therapy
    • Fluconazole - 100 - 200mg every third day for a total of 3 doses ($)

  • Maintenance therapy (for recurrent cases)
    • Fluconazole - 100 - 200mg once weekly for 6 months ($)
  • An estimated 75% of women have at least one yeast infection during their lifetime, and 40 - 45% will have ≥ 2 episodes
  • Symptoms of a yeast infection include vaginal itching, soreness, pain with intercourse, painful urination, redness, and thick, white, curdy discharge
  • Typically caused by Candida albicans
  • Definitive diagnosis is made by observing hyphae or pseudohyphae on a wet preparation. 10% KOH solution improves the visualization of yeast and mycelia by disrupting cellular material that might obscure the yeast or pseudohyphae.
  • Creams and suppositories are oil-based and might weaken latex condoms
  • Yeast infections are not acquired through sexual intercourse and sex partners should not be treated
  • Recurrent vulvovaginal candidiasis is defined as ≥ 4 episodes in 1 year
  • Recurrent vulvovaginal candidiasis can be treated with prolonged episodic therapy or maintenance therapy for 6 months. 30 - 50% of women will have recurrent disease after maintenance therapy is discontinued.

Studies
  • Oral fluconazole during pregnancy and risk of spontaneous abortion and stillbirth (JAMA 2016) - cohort study found a significant increase in risk of spontaneous abortion in women exposed to oral fluconazole when compared to unexposed women and women exposed to topical azoles. [PubMed abstract]