Thursday, April 11, 2024

When To Repeat Urine Culture After Antibiotics

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Urine Culture: How To Interpret Count

Yes. While taking antibiotics is still considered the gold standard of UTI treatments, there are some things you can do at home that help relieve symptoms, as well. These include:

  • Drink plenty of water. Consuming at least six to eight 8-ounce glasses of water daily can help flush away UTI-causing bacteria, setting you up for a quicker recovery. Plus, the more you drink, the more youll have to urinate.
  • Urinate often. Each time you empty your bladder, youre helping to flush bacteria out of your system.
  • Try heat. Applying a heating pad to your pubic area for 15 minutes at a time can help soothe the pressure and pain caused by UTI-related inflammation and irritation.
  • Tweak your wardrobe. Wearing loose cotton clothing and underwear can help you recover from a UTI.
  • Go fragrance-free. Make sure your personal hygiene products are fragrance-free to sidestep further irritation, notes the National Institute of Diabetes and Digestive and Kidney Diseases.
  • Cut out certain irritants. Caffeine, alcohol, spicy food, raw onions, citrus fruits, carbonated drinks, artificial sweeteners, and nicotine can further irritate your bladder, making it more difficult for your body to heal, per the Cleveland Clinic.

RELATED: 8 Home Remedies for Urinary Tract Infections Symptoms

The Tendency To Repeat Cultures

Current literature lacks strong evidence for repeating previously positive blood cultures collected appropriatelyie, 10 mL of blood for aerobic culture and 10 mL for anaerobic culture from 2 different sites, and a positive result from both sets. However, because of the risk of serious complications of bacteremia, particularly in critically ill patients, many clinicians order multiple, repeated sets of blood cultures.

Tabriz et al found that one-third of hospitalized patients got repeat cultures after an initial set, regardless of the result of the first set. Most of those cultures yielded no growth, 9.1% grew the same pathogen, and 5.0% were contaminated. Finding a new pathogen was rare, occurring in only 2.5% of repeated cultures.

Wiggers et al reported an even higher number of repeat cultures ordered for patients who had an initially positive culture: 38.9%. And in another study, half of the patients received more than 2 consecutive cultures.

Box : Diagnostic Points For Men Aged Under 65 Years10

Diagnostic points for men under 65 years

  • Asymptomatic bacteriuria is rare in men < 65 years

Consider other genitourinary causes of urinary symptoms

  • In sexually active, check sexual history for STIs for example chlamydia and gonorrhoea
  • Urethritis due to urethral inflammation post sexual intercourse, irritants, or STIs

Check for pyelonephritis, prostatitis, systemic infection, or suspected sepsis using local policy

  • Urinary symptoms with fever or systemic symptoms in men are strongly suggestive of prostatic involvement or pyelonephritis
  • Acute prostatitis may present with feverish illness of sudden onset, symptoms of prostatitis , symptoms of UTI , or exquisitely tender prostate on rectal examination
  • Recurrent or relapsing UTI in men should prompt referral to urology for investigation

Diagnostic points in men

  • Always send a mid-stream urine sample for culture, collected before antibiotics are given
  • Dipsticks are poor at ruling out infection. Positive nitrite makes UTI more likely . Negative for both nitrite and leucocyte makes UTI less likely, especially if symptoms are mild
  • If suspected UTI, offer immediate treatment according to NICE/PHE guideline on Lower UTI: antimicrobial prescribing and review choice of antibiotic with pre-treatment culture results

STI=sexually transmitted infection UTI=urinary tract infection NICE=National Institute for Health and Care Excellence PHE=Public Health England

Figure 2: Flowchart for men and women aged over 65 years with suspected UTI10

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Persistent Or New Infection

Persistence of fever, leukocytosis, or other signs of infection 72 hours after appropriate antibiotic therapy is started requires follow-up blood cultures.

New episode of sepsis. A new episode of sepsis should be confirmed using the systemic inflammatory response syndrome criteria, the newer definition of Sepsis-related Organ Failure Assessment in the intensive-care unit, or the quick SOFA in general units. If the patient develops new signs of sepsis after response to treatment for initial bacteremia, repeat blood cultures should be considered.

Central line-associated bloodstream infection requires repeat cultures. Persistence of bacteremia in this type of infection extends the duration of therapy, as most clinicians determine treatment duration from the last negative culture. Persistent bacteremia also influences the decision to salvage or remove the catheter. Microbiologic clearance of bacteremia on blood culture can also guide the time of reinsertion if the catheter was removed.

Concern for an unresolved focus of infection such as abscess, joint infection, or retained catheter is an indication for repeat blood cultures.

Bacteremia of unknown source. In clinical practice, we encounter scenarios in which blood cultures are positive but no source can be identified. In those situations, it is important to repeat blood cultures to document clearance. If bacteremia persists, we need to continue searching for the source.

Recurrent Urinary Tract Infections In Women: Diagnosis And Management

Characteristics of 533 episodes by results of repeat urine ...

CHARLES M. KODNER, MD, University of Louisville School of Medicine, Louisville, Kentucky

EMILY K. THOMAS GUPTON, DO, MPH, Primary Care Medical Center, Murray, Kentucky

Am Fam Physician. 2010 Sep 15 82:638-643.

Recurrent urinary tract infections are common in women and associated with considerable morbidity and health care use. The clinical features, diagnostic testing, and causative organisms are often similar to those of single cases of UTI, although there are additional treatment strategies and prevention measures to consider with recurrent UTIs.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

A urine culture with greater than 102 colony-forming units per mL is considered positive in patients who have symptoms of UTI.

Clinical recommendation Evidence rating References

Continuous and postcoital antimicrobial prophylaxis have demonstrated effectiveness in reducing the risk of recurrent UTIs.

Cranberry products may reduce the incidence of recurrent symptomatic UTIs.

Use of topical estrogen may reduce the incidence of recurrent UTIs in postmenopausal women.

Treatment of complicated UTIs should begin with broad-spectrum antibiotic coverage, with adjustment of antimicrobial coverage guided by culture results.

Prophylactic antimicrobial therapy to prevent recurrent UTIs is not recommended for patients with complicated UTIs.

UTI = urinary tract infection.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

UTI = urinary tract infection.

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Antibiotics Used For Uncomplicated Utis

If you are a healthy individual whose urinary tract is anatomically and functionally normal and you have no known heightened UTI susceptibility youve got whats dubbed an uncomplicated UTI, according to guidelines published in August 2019 in the Journal of Urology. For these individuals, antibiotics are considered the first-line of treatment.

The type of antibiotics you are prescribed and for how long is contingent on the type of bacteria detected in your urine, your current health status, and whether your UTI is uncomplicated or complicated. Depending on which antibiotic your doctor prescribes, women may need a single dose or up to a five-day course. For men, antibiotics are usually given for a slightly longer period of time, notes UpToDate.

Typically, if you are diagnosed with an uncomplicated UTI, one of the following will be prescribed as first-line treatment:

The following antibiotics are considered second-line treatments for UTI. They are generally chosen because of resistance patterns or allergy considerations:

RELATED: The Connection Between E. Coli and UTIs

Repeat Urine After Antibiotics

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Box : Sending Urine For Culture And Interpreting Results In All Adults10

Review need for culture when considering treatment

  • Send a urine for culture in:
  • over 65 year olds if symptomatic and antibiotic given
  • pregnancy: for routine antenatal tests, or if symptomatic
  • suspected pyelonephritis or sepsis
  • failed antibiotic treatment or persistent symptoms
  • recurrent UTI
  • if prescribing antibiotic in someone with a urinary catheter
  • as advised by local microbiologist
  • Consider risk factors for resistance and send urine for culture if:
  • abnormalities of genitourinary tract
  • hospitalisation for > 7 days in last 6 months
  • recent travel to a country with increased resistance
  • previous UTI resistant
  • If prescribing an antibiotic, review choice when culture and antibiotic susceptibility results are available
  • Sampling in all men and women

    How do I interpret a urine culture result if I suspect a UTI?

    • Culture should be interpreted in parallel to severity of signs/symptoms. False negatives/positives can occur
    • Do not treat asymptomatic bacteriuria unless pregnant as it does not reduce mortality or morbidity
    • Urine culture results in patients with urinary symptoms that usually indicate UTI:
    • many labs use growth of 107108 cfu/l to indicate UTI
    • lower counts can also indicate UTI if patient symptomatic:
    • strongly symptomatic womensingle isolate > 105 cfu/l in voided urine
    • in men counts as low as 106 cfu/l of a pure or predominant organism
    • any single organism > 107 cfu/l
    • Escherichia coli or Staphylococcus saprophyticus> 106 cfu/l
    • > 108 cfu/l mixed growth with 1 predominant organism

    Frequency Of Repeat Blood Cultures

    Urine Culture in females – when to arrange in 80 seconds

    There are no evidence-based guidelines for the frequency of repeating cultures. The Infectious Diseases Society of America recommends repeating blood cultures 2 to 4 days after the index positive culture in the case of multidrug-resistant S aureus bacteremia, and every day or every other day for candidemia.,,

    A study evaluating the practice patterns of repeating cultures after an initial bacteremia showed that 34.7% were done within 24 hours and 44.7% were done in 2 to 4 days. There is no evidence that repeating blood cultures daily is necessary in these patients. As a general rule, it should be done 48 to 72 hours after a positive culture.

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    What About Cranberry Juice For Uti

    Its a long-held belief that consuming cranberry juice may help prevent and treat urinary tract infections. While its true that cranberries contain an active ingredient that can prevent adherence of bacteria to the urinary tract, there is still no evidence that cranberry products can treat a UTI.

    One of the reasons: Products like cranberry juice or cranberry capsules are not explicitly formulated with the same amount of PACs that have shown potential in lab studies. Moreover, a 2019 report in the Journal of Urology noted that the availability of such products to the public is a severe limitation to the use of cranberries for UTI prophylaxis outside the research setting.

    In all, theres actually very little high-quality research on the topic of prevention. For instance, a 2016 study in The Journal of the American Medical Association, found that among female nursing home residents, daily consumption of cranberry capsules resulted in no significant prevention of UTIs.

    While consuming cranberry juice or supplements is not considered a first-line treatment of urinary tract infections, in most cases, it cant hurt. After all, drinking plenty of liquids does dilute your urine and help spur more frequent urination, which flushes bacteria from the urinary tract. The exception: Those who are taking blood-thinning medication, such as warfarin, should not consume cranberry juice. And those with diabetes should be mindful of the high-sugar content of fruit juices.

    When Is Treatment With Antimicrobials Appropriate

    Urinary tract infections are among the most common infections in primary care, but predicting the probability of UTIs using symptoms and point-of-care tests can be inaccurate, leading to inappropriate antimicrobial use. The aim of the quick reference tool is to improve the management of UTIs in the community by: providing an effective, economical, and empirical approach to diagnosis clarifying when it is appropriate to prescribe an antimicrobial and minimising the emergence of antibiotic resistance in the community.

    The new diagnostic flowcharts and diagnostic points include:

    • women aged under 65 years
    • men aged under 65 years
    • older people aged over 65 years
    • infants and children aged under 16 years with suspected UTI .

    Key changes from previous PHE guidance include:

    • for women aged under 65 years, use three specific indicators to increase diagnostic certainty of a UTI rather than any of the three symptoms
    • for men and women aged over 65 years:
    • do not perform a urine dipstick test
    • use PINCH ME to exclude other causes of delirium
  • always exclude vaginal and urethral causes of urinary symptoms, including urethritis and genitourinary syndrome of menopause.
  • Figure 1: Flowchart for women aged under 65 years with suspected UTI10

    Source: Public Health England. Diagnosis of urinary tract infections. Quick reference tool for primary care: for consultation and local adaptation. PHE, 2018. Available at: www.gov.uk/government/publications/urinary-tract-infection-diagnosis.

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    Asymptomatic Bacteriuria And Dipstick Tests

    Diagnosing suspected UTIs in older people is made more complex by an increasing prevalence of dementia and asymptomatic bacteriuria. Up to half of all older people, and most with a urinary catheter, will have bacteria present in the bladder/urine without an infection. Although this asymptomatic bacteriuria will test positive on a urine dipstick and is associated with pyuria, it is not harmful and therefore antibiotics are not beneficial and may only contribute to increasing antibiotic resistance.1114 For this reason, dipstick tests are no longer recommended by PHE in people aged over 65 years.

    Top Papers Of The Month: Repeat Cultures In Uti

    Analysis of various factors associated with a positive ...

    Is it necessary to test for cure during therapy for urinary tract infection ?

    Each year in this country, UTI is diagnosed and treated in numerous children younger than 18 years some are hospitalized as a result. Affected children have positive urine cultures and are treated with antibiotics. Is it necessary to prove that the infection is being cured by repeating the urine culture after 48 hours of treatment?

    This is the question raised by Oreskovic and Sembrano1 in a recent paper published in Pediatrics. The authors conducted a retrospective chart review of 328 patients under age 19 who were hospitalized with UTI during a 6-year period. Their goal was to determine the frequency of positive cultures after 2 days of treatment. The authors included patients who had a positive urine culture on admission and who had a repeat culture done 2 to 3 days after admission. Cultures were considered positive if they had more than 100,000 colony-forming units /mL of a single organism on a clean-catch specimen, more than 10,000 CFU/mL of a single organism on a catheterized specimen, or any number of a single organism on a specimen from a suprapubic aspiration.

    The bottom line: for most children with UTI, a repeat culture is not needed to prove that the infection is being cured.

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    Antibiotics Used For Complicated Utis

    Before getting into how to best treat a complicated UTI, its important to understand which UTIs are considered complicated. Here are some guidelines:

    • Urinary tract abnormalities are present
    • Youre pregnant
    • The patient is a child
    • A comorbidity is present that increases risk of infection or treatment resistance, such as poorly controlled diabetes
    • Youre a man, since most UTIs in men are considered complicated
    • Youre elderly

    Kidney infections are often treated as a complicated UTI as well, notes the Merck Manual.

    If a UTI is complicated, a different course of antibiotics may be required. And the initial dose of antibiotics may be started intravenously in the hospital. After that, antibiotics are given orally at home. In addition, follow-up urine cultures are generally recommended within 10 to 14 days after treatment. Not all of the antibiotics approved for uncomplicated UTIs are appropriate for the complicated version. Some that are considered appropriate, include:

    Causative Factors And Pathogenesis

    Escherichia coli is the predominant uropathogen isolated in acute community-acquired uncomplicated UTIs, followed by Staphylococcus saprophyticus . Enterococcus, Klebsiella, Enterobacter,and Proteus species are less common causes.7

    In recurrent uncomplicated UTIs, reinfection occurs when the initially infecting bacteria persist in the fecal flora after elimination from the urinary tract, subsequently recolonizing the introitus and bladder.1 A number of host factors appear to predispose otherwise healthy young women to recurrent UTIs. These include local pH and cervicovaginal antibody changes in the vagina greater adherence of uropathogenic bacteria to the uroepithelium and possibly pelvic anatomic differences, such as shorter urethra-to-anus distance.

    Diabetes mellitus, neurologic conditions, chronic institutional residence, and chronic indwelling urinary catheterization are important predisposing factors for complicated UTIs. In affected patients, organisms that are typically less virulent may cause marked illness, although E. coli infection remains the most common organism in nearly all patient groups. Klebsiella and group B streptococcus infections are relatively more common in patients with diabetes, and Pseudomonas infections are relatively more common in patients with chronic catheterization. Proteus mirabilis i s a c ommon u ropathogen i n p atients with indwelling catheters, spinal cord injuries, or structural abnormalities of the urinary tract.7

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    What Is A Recurrent Urinary Tract Infection

    Recurrent urinary tract infections are diagnosed when a person gets 3 or more UTIs in a 1-year period. In some cases, these infections can be resistant to treatment, so its important to accurately identify the type of bacteria responsible for causing the infection. This allows your doctor to prescribe the most effective antibiotic for your particular type of urinary tract infection.

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    Useful Sources Of Patient Information

    URINE CULTURE AND SENSITIVITY TEST

    Public Health England has produced several TARGET treating your infection leaflets, which will help practitioners share this new guidance with patients during consultation.18 They aim to facilitate communication between the prescriber and the patient, and increase the patients confidence in self-care. The TYI leaflets include information on common symptoms of UTIs, illness duration, and advice on self-care, prevention, and when to reconsult.

    For older people who are at risk of UTI, are experiencing urinary symptoms, or who have been diagnosed with UTI.

    Other antimicrobial stewardship tools can be downloaded from the TARGET section of on the RCGP website: www.rcgp.org.uk/TARGETantibiotics.

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