Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole/ and today we're highlighting the Infectious Diseases Society of America's guidelines on the management of complicated urinary tract infections. In this panel, we have Dr. Jennifer Yu Miles Thomas. She's the Vice Chair of Regional Integration and Innovation, and she's an assistant professor of urology at Northwestern Medicine.

Dr. Miles Thomas will be moderating today's discussion. Joining Dr. Miles Thomas is Dr. Anthony Schafer. He's the Herman Held Kretchma professor of urology at Northwestern Medicine, and he also served on the guidelines panel, Dr. Miles Thomas. I turn it over to you.

Dr Jennifer Miles-Thomas: Welcome to Insights in the Clinical guidelines for complicated UTI Treatment and Management.

My guest today is Dr. Anthony Schaefer. Welcome.

Dr Anthony Schaeffer: Thank you. It's good to be here.

Dr Jennifer Miles-Thomas: Well, frequently in urology and in medicine we see a lot of patients with urinary tract infections. Uh, a lot of times these patients will just go to either an ICC or urgent care and get treated. Why is this something that we should even address in the first place?

Dr Anthony Schaeffer: Well, it's the most common infection in women and a very common infection in men. And I think the problem that I see is that, as you just pointed out, most people treat these as isolated events and don't see the patient again. And what we've learned is that if you. Really wanna make progress with solving the patient's problem, you need to step back and look at the pattern that they've established and try to figure out what the cause of the problem is, rather than just keep treating each event as a single event.

Dr Jennifer Miles-Thomas: Well, I think a lot of times it's um, it's difficult, right? Because patients will choose how they're seeking care, right? But as someone, let's say I'm a PCP or a urologist, if I'm seeing that patient multiple times, what you're basically saying is. I need to stop and kind of look at the history That's right.

And try to figure it out. Right. Well, one of the things that, um, you've contributed to the world of urology in the literature is recently a complicated UTI guideline that came out from the IDSA. Can you talk a little bit about it, just like what even motivated you to work on this?

Dr Anthony Schaeffer: Well, I'm the only urologist actually who was invited, but these are folks that are infectious disease specialists and they.

Uh, decided that they needed to come out with a new guidelines. We've had prior experience with asymptomatic bacteria and uncomplicated infections. So the thinking was that because of the emergence of resistant organisms and the more, uh, serious consequences of infection guidelines would be appropriate.

Um. One of the challenges they faced was really defining what is a complicated urinary tract infection. Historically, they've been defined as infections occurring in individuals where the infection is severe and the host is compromised with structural functional abnormality of the urinary tract. Uh, in this instance.

The IDSA guidelines committee decided to only focus on febrile urinary tract infections. In other words, those that are occurring outside the bladder, presumably the kidney primarily. Um, and the idea was that these are infections that can be discerned by the treating physician. The patient has a fever and the urinary tract has bacteria in it.

Uh. But the pH uh, the treating individual does not know the status of the urinary tract. And so that, I think is a strength and a weakness of these guidelines. But the focus really is on what to do right away, how to proceed when you first see the patient.

Dr Jennifer Miles-Thomas: All right. So uncomplicated is, is just basically the bladder, right?

Right. There's nothing else involved. All right. So then you're saying that complicated. There's either some other structural problem or like the patient presents with a fever chills.

Dr Anthony Schaeffer: Well, what I'm saying is mm-hmm. Uh, in this particular guidelines, it's fevers, okay. Out infection outside the bladder. It's, it's a much more focused subset of what traditionally was considered complicated.

So, um. We can come back to that, but I think it's important to keep that in mind when you look at this. They're really looking at how do you treat an individual with a fever and a urinary tract infection and they don't address complicating factors that I think are important.

Dr Jennifer Miles-Thomas: Okay. What other, outside of the guideline, what other complicated factors do you think are important?

Dr Anthony Schaeffer: Well, the way I look at it is, Jennifer, if you have a. Structural or functional abnormality, it can compound the severity of the current infection. Mm-hmm. But as, or more importantly, it can influence subsequent events. So the patients who come back again and again, and as I alluded to earlier, most people or many people tend to treat these as single events.

And don't ask the question, why are these recurring? Because they don't want to delve into that. And so, um, we can. We look at the complicated infections, both from the acute event mm-hmm. And the underlying problems that tend to contribute to the events.

Dr Jennifer Miles-Thomas: I think what you just said is very important too. Um, everyone in medicine is very, very busy, and it takes a minute to step back and ask, why are these recurring?

Why are these happening over and over again? And then take some time to, to delve into the, the actual cause. Can you provide us some kind of. Guidance, um, regarding like the overview of what we should be doing, what we should be looking at, because sometimes it's, it's challenging, right? We're seeing these patients, um, we have limited time.

If they have a fever, we understand that we need to do something actively. Is there a way that we can kind of think about this in a structured way?

Dr Anthony Schaeffer: Well, I think let's just focus on the acute event. Okay? So when someone has a febrile UTI, um. The, the main question that's being asked now is what antibiotics should be utilized and how should I use them?

And one of the strengths of the guidelines is to recommend a limited use of antibiotics, uh, primarily the cephalosporins, third and fourth generation, uh, carbapenem. And, um, using these limited drugs. You wanna then ask the question and any. Acute event, how severe is the illness? Is this just fair by UTI or is there evidence of sepsis?

The next question you wanna ask is more patient specific. Is there anything about this patient that could have engendered a resistant infection? And primarily we're looking at here as prior exposure. To antibiotics. And the good clue that the clinician can get is if you have a prior culture, you should look at the biogram on that culture, even if it was three, four or five months ago.

And if there's resistant organisms present, you should not use the antibiotic. That would not be effective today. Um. Okay. And then another question you can ask is, has the patient had exposure, particularly to fluoroquinolones? Even if you don't have a culture, if the answer is yes, you should avoid fluoroquinolones.

And then the third thing we like to think about is are there other obvious risk factors, drug, drug interactions, allergies, and so forth. So those three things should help guide you selecting among the antibiotics that we alluded to initially. Um. The fourth step that, that, that comes into play, and this would be only for patients who are septic mm-hmm.

Is to ask the question, can I glean any information from what's called the, uh, the antibiogram, the local resistance? And that's a little bit tricky because the cultures that you're looking at are usually a, uh, a combination of cultures arise from a variety of sources. So the relevance may be. Um, minimal.

But nevertheless, in acute septic situation, you might learn something from knowing what drugs are or are not very effective in a particular environment. And that can help guide your, your decision making. Um, so that gets you started. And, um, that's one of the strengths of the guidelines, I think, to get, uh, get the patient on the right track.

Dr Jennifer Miles-Thomas: Well, that makes sense. And I think overall, we, we may not, um, those of us who are not in maybe internal medicine or. Um, do as much acute care. Take a look at those regional and hospital specific antibiotic grams to see what the resistance is in the community. And your point is, is well taken of, a lot of times patients are pretty transient.

They'll go here and there and then trying to figure out, but it only takes a few minutes to look back at the prior cultures. And I, I think that's something that's like straightforward and easy for all of us to do. Well, can you kind of go back and talk about, well, what motivated the IDSA in the first place to even develop these guidelines?

And then how are they different between uncomplicated and complicated?

Dr Anthony Schaeffer: Well, the motivation I think has been, uh, based primarily on the severity of the illness, but also on the emergence of resistant organisms and the absence of efficacy by many of the drugs that were. Used fluoroquinolones are the classic example.

So overuse of these drugs has led to resistant organisms. And so, um, you have to be much more precise now and careful in your selection of antibiotics. And that's where the guidelines are designed to do, give the clinicians some insights as to what drugs to use, how long to use them, uh, when to switch from oral to or, uh, from IV to oral antibiotics, et cetera.

Dr Jennifer Miles-Thomas: Right. It sounds like there's a stepwise process that we should be taking. Can you talk about these approaches and how, how we should think about that as a kind of a pathway?

Dr Anthony Schaeffer: Well, I think I alluded to the selection of the drug, so the severity of the illness, the patient's potential resistance and other factors that gets you started.

And then presumably you're on IV antibiotics with a rebell UTI. Um. You're gonna be treating empirically, and the first question that comes up, what should I do when the sensitivity data comes back? And the evidence is you should switch to from empiric to a specific agent when the data is available, if it's a different drug switch.

The next question is, um. Can I convert the patient from IV to oral antibiotics? And the answer is yes, that's recommended when an oral drug is available. And then the next question is, how long should I treat? And one of the strengths of the guidelines, I think, is to indicate that in most instances, seven days of therapy is satisfactory.

It used to be 14 days. Mm-hmm. But the data suggests that seven days is adequate. Um. And so those are the things I think that the guidelines have strengthened our thinking about how to treat infections.

Dr Jennifer Miles-Thomas: That makes sense. I do recall, like in training, it was always 14 days, right? So it's important to say that seven days, um, especially since now we're seeing a lot more multi-drug resistance.

Um, and sometimes we are kind of questioning what our empiric therapies should be. Okay. Well what other, um. What other aspects of the guidelines really should impact management? So you've already said empiric therapy, then based upon the sensitivities, begin with IV therapy, switch to oral as soon as possible.

And duration of therapy should be around seven days. Right.

Dr Anthony Schaeffer: And what we've talked about is the ideal patient who's doing well. Okay. And this is, I think, something that the guidelines obliquely address, but not. Uh, as, uh, much as I'd like that, that they should have, and that is what do you do when patients aren't responding properly or even initially, what degree of investigation should you pursue to determine if the patient does in fact have an underlying abnormality that's not really addressed?

They sort of say something like, if the patient isn't doing well, you should start to look for why. Mm-hmm. I think this is a really important urologic question. Um, I've been of the opinion that in a patient who's febrile, um, an ultrasound to make sure there's no obstruction of the upper tract is one of the first things I would do, even, even if the patient appears to be responding to therapy.

Um, because if you have an obstructing ureteral stone, that's a major. Risk factor

Dr Jennifer Miles-Thomas: mm-hmm.

Dr Anthony Schaeffer: That the guidelines don't specifically address. So as a urologist, I would say if, if you're consulted on a patient, uh, I would ask the question, is there obstruction? And at the very least, get ultrasounds, maybe CT scans and so forth.

Because if you do identify obstruction, then the key thing is to pro. Intervene with percutaneous or other means, ureteroscopic, uh, catheters and so forth to alleviate the obstruction. That's really a key role of the urologist in the acute situation. Um, and that I think is something that's a little bit overlooked in these guidelines.

Dr Jennifer Miles-Thomas: That makes complete sense. Um, again, we're moving from the spot treatment of the individual and then trying to overall assess. What the risk factors were and is there anything else complicating with this patient? Right. So that makes complete sense. Um, and frequently urology is consulted to collaborate.

And I, and I think that should continue, um, because yes, an obstructing ureteral stone with sepsis is, is life threatening. And I don't think everyone has always seen how quickly patient status changes.

Dr Anthony Schaeffer: Right. And that, I think, is a key role for the urologist. I

Dr Jennifer Miles-Thomas: agree. So let's talk about the future and future research.

Um, what else should we be looking at? Um, just what are your thoughts? You, you, you are a world renowned expert, um, in infections in the, in the GU tract. What else should we be looking at?

Dr Anthony Schaeffer: What are some things that I think in a day-to-day basis, we should look at? Potentially identifying factors that contribute to the infection.

So in the complex UTI clinic we established at Northwestern, as you alluded to earlier, we take a look at the infections and what we call the pattern of infections. And so if a woman or a man has infections that are recurring at somewhat long intervals and the bacteria are not the same each time, that's a recurring infection that we call reinfection.

Which by definition means it's a new event each time. And so those are treated, uh, you know, female perhaps by using vaginal estrogen to mitigate ascent bacteria into the bladder. Uh, you can, as a urologist, you can look at risk factors such as, uh, poor pouring of the bladder, so you get a post forward residual.

Um. Yeah, and then you might also want to look at systemic factors that could be improved, diabetes control and so forth. So that would be a large majority of the patients, particularly women with recurrent reinfection. Now, if you're looking at the cultures and you're seeing the same bacteria over and over again, and particularly if it comes back really quickly.

That should be a red flag that the patient has what we call bacterial persistence, which means a NIUs of infection within the urinary tract. And that's a urologic, um, task to figure out where this NIUs is. Obviously if you get imaging and see stones, uh, you see a UPJ obstruction, you see a, uh, unexpected, a trophic kidney and so forth.

The urologist's job is to identify whether or not that particular radiographic abnormality is in fact the source of infection. And you can do that by selective catheterization, and then you can remove the offending problem, the NIUs of infection. So a lot of patients through the medical community see as recurring infections are in fact.

Uh, patients that can have their recurrent infections terminated by removing the infecting NIUs. And that is something that I think the research has disclosed, uh, and something that urologists should be keenly aware of.

Dr Jennifer Miles-Thomas: Well, that makes sense. So let's say we are able to find the NIUs. How should we monitor those patients afterwards?

Should we be getting. A series of follow up cultures and tell they're negative. Like how should we monitor 'em if the patient,

Dr Anthony Schaeffer: well, if you, if you have this pattern of recurrence with the same strain, there has to be a NIUs and you have to identify it and potentially remove it if you can't remove it. A common example would be a woman with an infected.

Urethral sling. Okay. So you know, that's the NIUs and in that case, the choice might be not to remove it, but to rather put the patient on suppressive therapy. But as I alluded to, you know, patient with a proteus infection stone, you take out the stone. Once those, once the stone is removed, then your patient should be infection free and your next task is just to maintain contact with the patient to assure that they don't have relapse with a new infection.

Dr Jennifer Miles-Thomas: Uh, can we talk about just the oral therapies that are available?

Dr Anthony Schaeffer: Well, um, you know, I think when we're talking about the traditional uncomplicated infection mm-hmm. You should stick with Trimeth, sulfa Nitro, or Anin and Phosphomycin. Mm-hmm. Fluoroquinolones, as I alluded to earlier, have generated a lot of resistance, and so we tend to keep those in the band unless we have more severe fibrile infection.

The only key insect, uh, example would be a patient with acute bacterial prostatitis or fluoroquinolones are the drug of choice because they penetrate into the prostate. And I should have mentioned at the beginning, Jennifer, that these guidelines specifically do not include men with febrile UTIs and acute bacterial prostatitis.

Uh, and as a urologist know, those are life-threatening. That's a life-threatening condition that needs to be treated very aggressively.

Dr Jennifer Miles-Thomas: Well, as a urologist, this is something that we see pretty commonly. What else should we know about these guidelines? What else should we know about? Treating the acute as well as the complicated, uh, UTI patient.

Dr Anthony Schaeffer: I think the main thing to do is to think about each patient as a vigil and look at the data that you have. And one of the key things we mentioned at the beginning is the patient themselves will tell you. What you should or shouldn't use when you look at their prior cultures and antibiotic antibiograms, that will help you a lot to make the right initial decision.

And from that point on, I would say treat the infection, make sure the patient recovers, but then take the time to ask the question, why did you get this infection? And if they have been, um. Prevalent. Ask the question, can I do something to prevent that from happening? That is, I think, a key role that the urologist can play.

Dr Jennifer Miles-Thomas: Well, thank you. Is there anything else you would like to share?

Dr Anthony Schaeffer: Um, no. I think it's a, it's an evolving problem and I think we all need to keep aware of. The challenges, but it's a exciting time to be treating patients with urinary tract infections.

Dr Jennifer Miles-Thomas: I agree. Well, thank you very much for all of your insight and your knowledge and your dedication to this field.

Dr Anthony Schaeffer: Thank you very much, Jennifer.

Melanie Cole, MS (Host): Thank you both so much for such a lively discussion. To refer your patient or for more information, please visit our website@breakthroughsforphysicians.mm.org slash urology to get connected with one of our providers. That concludes today's episode of Bettered a Northwestern Medicine Podcast for physicians.

I'm Melanie Cole.