Urinary Tract Infections: Diagnostic and Management Issues
Kalpana Gupta, MD, MPH Editor
It has been over a decade since the last Infectious Disease Clinics of North America issue dedicated to UTI was published. During this time, the approach to this broad clinical syndrome has been impacted by ever-increasing antibacterial resistance, political and financial ramifications, and an evolving understanding about the role of the human microbiome in the prevention of infectious diseases. In this issue, well-recognized experts have contributed articles aimed at optimizing the diagnosis, management, and prevention of UTI. The infection remains exceedingly common, being one of the primary reasons for an emergency room visit made by otherwise healthy women. The risk factors and burden of disease vary by patient population and the specific urinary tract syndrome. Characterization of the specific syndrome remains important for appropriate diagnosis and management. The concept of asymptomatic bacteriuria and candiduria as conditions not warranting therapy in most situations is increasingly being accepted and incorporated into clinical practice guidelines and stewardship programs. The diagnosis of UTI in the hospital setting, especially in patients with urinary catheters, has taken on new significance in the past several years. Prevention of catheter-associated UTI is now a Joint Commission National Patient Safety Goal, making accurate diagnosis of infection versus colonization a critical issue. In addition, hospitals are no longer reimbursed for catheter-associated UTIs that occur in the hospital, and rates are being publically reported in some cases, creating political and financial pressures to reduce these infections. Appropriate management of UTI in different patient care settings including primary care, the emergency department, and acute and long-term care inpatient settings is becoming more challenging. Resistance among uropathogens is now not only an issue for complicated hospital-associated UTIs, but for simple community-acquired infections as well. With rising resistance across multiple classes of drugs, oral options for UTI are limited and sometimes nonexistent. Choosing an empiric oral therapy regimen that is likely to be active for outpatient cystitis is necessitating the use of older drugs such as nitrofurantoin and fosfomycin rather than the more familiar sulfa- and fluoroquinolone classes of agents. Oral options for more invasive UTI are even further
Infect Dis Clin N Am 28 (2014) ix–x http://dx.doi.org/10.1016/j.idc.2013.11.001 0891-5520/14/$ – see front matter Ó 2014 Published by Elsevier Inc.
constrained, resulting in the need for intravenous therapy for infections that have traditionally been managed in the outpatient setting. Prevention of infection and judicious use of antimicrobials are concepts that have come to the forefront and directly impact the management of UTI. Non-antimicrobial approaches to prevention are being prioritized over the traditional use of suppressive antibiotics by some patients because avoiding antibiotics and sparing the gut microbiome is now recognized as a desirable benefit outweighing the potential risk of lower efficacy. Understanding of the pathogenesis of UTI has also evolved; both microbiological and genomics-based studies demonstrate the importance of Lactobacillus spp in the vaginal microbiota. Therapeutic interventions to address alterations in the urogenital microbiota and prevent UTI are currently being studied. Thus, the overall approach to diagnosis and management of UTI has markedly shifted in the past decade. I am grateful to the editors of the Infectious Disease Clinics of North America for giving me the opportunity to serve as guest editor and to the distinguished group of colleagues who have contributed their expertise to make this issue an informative and valuable resource for years to come. Kalpana Gupta, MD, MPH Infectious Diseases VA Boston HCS West Roxbury, MA, USA Infectious Diseases Boston University School of Medicine Boston, MA, USA E-mail address: [email protected]