Official Urologist Protocol for Treating UTIs
By Board Certfied Urologist, Dr. Yana Barbalat
There is no “official” protocol. As a urology community, we have guidelines that can help guide our management but very often doctors differ in their practice based on their experience and training. There is also a constant influx of new data that can guide us one way or another.
I often do not treat patients based on a urine dipstick. I find dipsticks unreliable with false positives for UTIs. This leads to overtreatment with antibiotics. For example, many patients use over the counter phenazopyridine (Azo) to help alleviate the symptoms of a UTI, but pneynazopiridine will typically make a dipstick positive for nitrites, even in the absence of bacteria. Also, a positive LE, generally means some degree of inflammation, but not necessarily infection. Inflammation can come from certain foods and other environmental factors, as well as a recent history of UTI. Finally, positive dipstick for blood is really non-specific and may be a results of eating red colored food or having myoglobin in the urine.
Most often, when a patient presents with symptoms of a UTI, I get a UA first. That generally takes only a few hours to result. Then, I look at the amount of WBC, bacteria, and squamous epithelial cells in the urine. If I know the patient well and have multiple previous cultures documenting multiple infections with the same bacteria that is sensitive to all antibiotic options, I will start a patient on an empiric antibiotic based on a suspicious UA and previous cultures. If that’s not the case, then I wait for cultures and sensitivities to come back before initiating antibiotic treatment. Generally, patients with an infection will have many bacteria and greater than 20 WBC on the UA. A good, non-contaminated sample will have a very low amount of squamous epithelial cells.
If the patient is very symptomatic with multiple WBC and bacteria on UA but a “mixed” or very low count urine culture, I get a catheterized urine sample.
Finally, some patients will have a lot of RBCs in their urine sample, mild symptoms of a UTI, but not much WBC (< 20) in the UA. Many physicians assume it’s a UTI and treat patients with antibiotics. Very often, that is not the case, and final urine cultures come back negative. I encourage primary care physicians to wait for the final culture results in these patients. If the cultures come back negative, the patient should see a urologist to be evaluated for other causes of blood in the urine, such as a urinary stones or urinary malignancy.
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My attention was drawn to your statement that although the urological community has recommendations that might assist direct our care, clinicians frequently vary in their practices based on their education and experience. My sister, who has been worrying about UTI issues since the beginning of the year, sprang to mind when I read this. I will urge her to contact a urology center as soon as this week is through since she wants to discover the optimum therapy available. http://www.medicalcenterurology.com/
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