Evidence-Based Medicine for Student Health Services
Robert J. Flaherty, MD
Swingle Student Health Service
Montana State University
Bozeman, MT 59717

Cystitis/Urinary Tract Infection
 

Etiology	Monitoring
Epidemiology	Prognosis
Diagnosis	Prevention
Treatment	Patient Education

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Etiology  No evidence is cited.     Epidemiology  No evidence is cited.     Diagnosis  Clinical Diagnosis For the treatment of UTI in symptomatic young women, the following strategies are listed in order of decreasing cost-effectiveness: Most cost-effective (least expensive) strategy: Empirical treatment of symptomatic women Less cost-effective (more expensive) strategy: Treatment based on full urinalysis Treatment with office culture to confirm sensitivity Treatment with reference lab culture to confirm sensitivity Treatment after office culture results available Treatment after reference lab results available Least cost-effective (most expensive) strategy: Treatment based on dipsticks Since all treatment strategies were very effective in terms of cure rate and quality of life, the empirical treatment of symptomatic women is judged the most cost-effective strategy. Caveats Age group studied: Young adult  Type/size: Decision analysis  Population characteristics: Healthy woman with dysuria for <1 week without vaginal discharge, signs of pyelonephritis or predisposing factors such as diabetes Outcome measures: cure without complications, pyelonephritis, persistent dysuria requiring reassessment, urethritis, vaginitis, other medication side-effects, quality adjusted life months Only grossly different assumptions regarding the cost of lab tests, physician time, drugs and hospital care would change the results Citations Office management of suspected UTI: Review of Barry HC et al, Evaluation of suspected urinary tract infection in ambulatory women: A cost-utility analysis of office-based strategies. J Fam Pract 1997;44:49-60 - Reviewed by POEMS/JFP     Laboratory/X-ray Diagnosis No evidence is cited.      Treatment   Antibiotics Trimethoprim-sulphamethoxazole (160 mg/800 mg, twice daily x 3d) was more effective and least costly in treating UTI in young women than were macrocrystalline nitrofurantoin (100 mg four times a day x 3d), cefadroxil (500 mg twice daily x 3d) or amoxicillin (500 mg three times daily x 3d). In another study trimethoprim alone was as effective as trimethoprim-sulphamethoxazole. Caveats Age group studied: Young women Type/size: RCT of 149 patients Population characteristics: students presenting to a student health center with symptoms of acute cystitis including dysuria, frequency, urgency and/or suprapubic pain Outcome measures: Cure at 6 weeks Citations Antimicrobial Treatment of Cystitis - Reviewed by Bandolier   Trimethoprim alone: Antimicrobial treatment of cystitis (2) - Reviewed by Bandolier   Cefprozil, cefpodoxime proxetil, loracarbef, cefixime, and ceftibuten appear to be as clinically effective as (but not more effective than) conventional therapies (usually amoxicillin/clavulanate, cefaclor or cephalexin) for the treatment of common community-acquired infections, including acute otitis media, pharyngitis, sinusitis, bronchitis, pneumonia, urinary tract infection and skin and skin-structure infections.  Caveats Age group studied: Unknown Type/Size: Analytical review of studies: acute otitis media: 19 studies, pharyngitis: 13 studies, sinusitis: 4 studies, bronchitis: 10 studies, pneumonia: 7 studies, urinary tract infection: 11 studies, skin and skin-structure infections: 4 studies. Most studies consisted of 30-50 patients in each arm Population: Unknown Outcome measure: Clinical response to therapy For some of these infections other studies show that there is no evidence that any antibiotic therapy is beneficial Citations Comparison of cefprozil, cefpodoxime, proxetil, loracarbef, cefixime, and ceftibuten - Reviewed by DARE      Seven days of antibiotic therapy for symptomatic UTI in young healthy women is more cost-effective than 1- or 3-day regimens. Caveats Age group studied: Young adult  Type/size: Decision analysis  Population characteristics: Healthy woman with dysuria for <1 week without vaginal discharge, signs of pyelonephritis or predisposing factors such as diabetes Outcome measures: cure without complications, pyelonephritis, persistent dysuria requiring reassessment, urethritis, vaginitis, other medication side-effects, quality adjusted life months Only grossly different assumptions regarding the cost of lab tests, physician time, drugs and hospital care would change the results Citations  Office management of suspected UTI: Review of Barry HC et al, Evaluation of suspected urinary tract infection in ambulatory women: A cost-utility analysis of office-based strategies. J Fam Pract 1997;44:49-60 - Reviewed by POEMS/JFP  Single dose antibiotic treatment (amoxicillin, bacampicilin, cefaclor, cefadroxil, cefuroxime, doxycycline, nitrofurantoin, pefloxacin, pivnecilinam, trimethoprim/sulfamethoxazole) of urinary tract infection in women is less effective than conventional treatment (five days or more), but causes fewer side effects.  Caveats Age group studied: Adults Type/size: Meta-analysis (25 trials = 2397 patients) Population characteristics: Ambulatory women with symptomatic, uncomplicated urinary tract infections Outcome measures: Cure rates Citations Single-dose antibiotic treatment for symptomatic urinary tract infections in women: a meta-analysis of randomized trials - Reviewed by DARE       Monitoring No evidence is cited.   Prognosis   No evidence is cited.      Prevention  300 mL of a cranberry juice cocktail every day reduces bacteriuria and pyuria and prevents UTI in high risk groups.  Blueberry juice may have a similar effect.   Caveats Age group studied: Mean age 79 y Type/size: RCT of 153 patients (= 818 urine specimens) Population characteristics: Women in whom bacteriuria with pyuria was likely to have a high incidence (above 30%); both inside (44) and outside (109) long-term care institutions Outcome measures: Presence of bacteriuria (defined as more than 100,000 organisms per mL) with pyuria Citations Drug Watch: Cranberry juice reduces bacteriuria and pyuria - Reviewed by Bandolier   Also: Howell A et al, Inhibition of the Adherence of P-Fimbriated Escherichia coli to Uroepithelial-Cell Surfaces by Proanthocyanidin Extracts from Cranberries, NEJM, October 8, 1998, Volume 339, Number 15  Also: Kontiakari T et al, Randomised Trial of Cranberry-Lingonberry Juice and Lactobacillus GG Drink for the Prevention of Urinary Tract Infections in Women, BMJ, June 30 2001, 322:1571-1573    Patient Education The following patient education materials are consistent with the available evidence. Painful Urination - From the AAFP  Urinary Tract Infection in Adults - From NIDDK Bladder Infection (UTI) - From LSU Family Practice Department Rev. 12/5/01

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