Urinary Tract Infection Pharmacotherapy

Listen in as our expert panel unpacks updated definitions of complicated vs. uncomplicated urinary tract infections, navigates antibiotic selection and duration, and shares the latest evidence-based strategies to stop recurrent UTIs in their tracks.

Special guests:

• Dana Bowers, PharmD, BCPS, BCIDP
  • Associate Professor
  • Washington State University
• Akshith Dass, PharmD, MPH, BCPS, BCIDP
  • Assistant Professor of Pharmacy Practice
  • Northeast Ohio Medical University
  • Pharmacy Clinical Specialist 
  • Cleveland Clinic Mercy Hospital

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Craig D. Williams, PharmD, FNLA, BCPS
  • Clinical Professor of Pharmacy Practice
  • Oregon Health and Science University

None of the speakers have anything to disclose. 

This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in April 2026.

🏷️Use code mt1026 at checkout for 10% off a new or upgraded subscription.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

Claim Credit

The clinical resources related to this podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Article: Keep Boosting Antibiotic Stewardship for Complicated UTIs
• Article: Antimicrobial Stewardship: Separate Facts From Fiction
•  Chart: Urinary Tract Infections
• Chart: Antibiotics in Pregnancy and Lactation
• FAQ: Antibiotic Therapy: When Are Shorter Courses Better?
• Toolbox: Antimicrobial Stewardship

Email us: ContactUs@trchealthcare.com.

The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

Find the show on YouTube by searching for ‘TRC Healthcare’ or clicking here.

Learn more about our product offerings at trchealthcare.com.

Transcript

Copy Transcript Copied

This transcript is automatically generated. 

00:00:07 Akshith Dass

So asymptomatic bacteriuria means that the bacteria are present in the urine, but the person does not have any symptoms of a urinary tract infection. Importantly, this can also be true if the patient's urine analysis shows pyuria or white blood cells in the urine, because pyuria alone does not equal infection.

00:00:31 Craig D. Williams

So the guidelines are progressively shrinking the durations recommended for some time and we're beginning to change and increasingly not even adding on any transition antibiotics when patients leave the hospital. Potentially as soon as just three days into effective treatment regimens or certainly by 5 days. You know what's common we would give that extra 3, 4, 5 days of outpatient antibiotics to complete their 7, 10, 14 day course and we're just not doing that anymore.

00:01:00 Narrator

Welcome to Medication Talk, an official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, and the most trusted clinical resources. On this episode, join our expert panel as they unpack updated definitions of complicated versus uncomplicated urinary tract infections, navigate antibiotic selection and duration, and share the latest evidence-based strategies to stop recurrent UTIs in their tracks. Our guests today are Dr. Dana Bowers,

00:01:30 Narrator

an associate professor for the College of Pharmacy and Pharmaceutical Sciences at Washington State University, and Dr. Akshith Dass, an assistant professor of pharmacy practice at Northeast Ohio Medical University and a pharmacy clinical specialist at the Cleveland Clinic Mercy Hospital. You'll also hear practical advice from TRC's editorial advisory board member, Dr. Craig Williams from the Oregon Health and Science University.

00:01:57 Narrator

This podcast is an excerpt from one of TRC's monthly live CE webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.

00:02:13 CE Narrator

And now, the CE information.

00:02:16 Narrator

This podcast offers continuing education credit for pharmacists, pharmacy technicians, physicians, and nurses.

00:02:23 Narrator

Please log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses. None of the speakers have anything to disclose. Now let’s join TRC editors and clinical pharmacists, Dr. Stephen Small and Sara Klockars, and start our discussion.

00:02:48 Steve Small

To start us off, Dana, how do we differentiate complicated versus uncomplicated UTIs and how have the definitions changed over time?

00:02:59 Dana Bowers

The definition of UTI has recently been updated with the most recent complicated UTI guidelines from IDSA.

00:03:07 Dana Bowers

Previous definitions for complicated versus uncomplicated relied more heavily on biological sex, female versus male, and then the presence of certain conditions like diabetes. A person had to be non-pregnant, premenopausal female without diabetes, and no urological abnormalities to be considered uncomplicated UTI. Then there was this sort of designation of acute pyelonephritis, which was sort of its own definition that included complicated

00:03:37 Dana Bowers

UTI characteristics, but infection within the kidney. And then everything else that didn't fit into those two boxes then fell under this term, this nebulous term of sort of complicated UTI. And now what we see with the more recent updated guidelines from the IDSA is a more focused approach that looks

00:03:58 Dana Bowers

at the site of infection. And infections that are confined to the bladder in an afebrile patient, either male or female, is now defined as uncomplicated UTI.

00:04:09 Dana Bowers

To meet the definition of complicated UTI for the IDSA, this can include pyelonephritis, which is that infection in the kidney, and then patients who have systemic symptoms. So these will present outside of the bladder. So this is what we're thinking, such as patients who are febrile or if they have bacteremia with UTI, catheter-associated UTI is also included in that, and prostatitis. All of those together

00:04:39 Dana Bowers

are now under this definition of complicated UTI. And one of the reasons that the definition was updated was to simplify it and make it easier and more straightforward for practicing clinicians. And another way was to help guide treatment options through clinical decision pathways. And so not sort of focusing on the diagnosis part of it, but really using complicated and uncomplicated to help guide treatment decisions.

00:05:12 Steve Small

Great contrast there between the two definitions. And as we talk about UTI symptoms, I'm sure some of our audience is also wondering what is asymptomatic bacteria or ASB?

00:05:25 Akshith Dass

So asymptomatic bacteriuria means that the bacteria are present in the urine, but the person does not have any symptoms of a urinary tract infection.

00:05:35 Akshith Dass

Importantly, this can also be true if the patient's urine analysis shows pyuria or white blood cells in the urine, because pyuria alone does not equal infection. So when we think about it, we already reviewed the symptoms of a urinary tract infection, and based on that, we can differentiate between complicated and uncomplicated. But if those symptoms are absent and the bacteria is just present in the urine,

00:06:03 Akshith Dass

it could more often represent colonization rather than a true infection. So asymptomatic bacteriuria is quite common and the prevalence increases with age, and it is generally more common in women than in men. Some risk factors for asymptomatic bacteriuria are generally the same thing that make urinary colonization more likely. Some big ones include being female, increasing in age, pregnancy,

00:06:33 Akshith Dass

chronic catheter use, any impaired bladder emptying, whether that's from a neurogenic bladder or a spinal cord injury, having comorbidities such as diabetes, or living in a long-term care facility. In terms of how common it is, asymptomatic bacteriuria can be seen in about 1 to 5% of healthy premenopausal women. The risk then doubles during pregnancy.

00:07:02 Akshith Dass

When we talk about long-term care residents, here's where the numbers rise sharply. Around 25% to 50% of women and 15% to 50% of men can experience asymptomatic bacteriuria. And to think about the flora, the flora in those patients with asymptomatic bacteriuria isn't really different from those with symptomatic urinary tract infections.

00:07:27 Akshith Dass

So when we're seeing asymptomatic bacteriuria, it's still the same flora such as E. coli, Klebsiella pneumoniae, Proteus mirabilis, Enterococcus, and even sometimes Group B strep. So it becomes a really important clinical distinction focusing on the patient's symptoms when you find bacteria in the urine.

00:07:52 Steve Small

Great points there. And now we can dig deeper into how we can treat UTIs appropriately with antibiotics. For example, Dana, are there cases where you should use antibiotics for asymptomatic bacteria?

00:08:07 Dana Bowers

Yes. So there are specific cases where you would use antibiotics for asymptomatic bacteriuria. And pregnancy is really the main one that we think about because ASB is very common during pregnancy, as Akshith already mentioned. And this is going to increase the risk of symptomatic UTI and particularly pyelonephritis. And pyelonephritis is dangerous not only for the person who is pregnant, but also for the fetus. And so this can

00:08:36 Dana Bowers

cause preterm birth, it can cause anemia and sepsis. And so these are the reasons why pregnant people are recommended to be screened using a urine culture at least once during their pregnancy. And if it's positive, then you would want to treat the asymptomatic bacteriuria in that case. And when these cultures are positive, even though the risk of pyelonephritis, those are things that we need to be concerned about, this isn't something that requires

00:09:04 Dana Bowers

immediate attention at that moment. We can wait until we get a culture and we get the culture results to really determine our therapy based on culture results. The other group that we would want to screen and treat are patients that are undergoing urological interventions where we are expecting there to be a high degree of mucosal

00:09:27 Dana Bowers

bleeding. So an example of this would be a TURP, so transurethral resection of the prostate. And then also if patients are getting renal stones removed or kidney stones removed, there's bacteria that can be involved in that. And so we would want to make sure that we screen these patients and then treat them for prior to the surgery. And then this is an addition to the perioperative antibiotic prophylaxis that they'll get prior to whatever procedure they're undergoing.

00:09:55 Steve Small

Which empiric antibiotics are preferred then for complicated versus uncomplicated UTIs? Are there differences we need to think about? And perhaps what antibiotics are typically avoided in certain cases?

00:10:09 Akshith Dass

Yeah, so in this situation, the IDSA has laid out, at least in your guidelines, have helped determine this. First we can start with the uncomplicated cystitis. So the traditional agents that we think of for uncomplicated cystitis

00:10:24 Akshith Dass

are typically nitrofurantoin for five days, trimethoprim-sulfamethoxazole for three days, or a single dose of fosfomycin. And these are longstanding IDSA guidelines for uncomplicated cystitis in women, where again, the usual target organism is E. coli. A few stewardship caveats for these typically first-line agents would be that for trimethoprim-sulfamethoxazole or trim sulfa,

00:10:52 Akshith Dass

the guidelines have mentioned it should generally be avoided for empiric use if the patient has had it recently for a UTI or if the local E. coli resistance exceeds 20%. So just an example of that, at my institution, again, we don't produce a urine isolate only antibiogram, but for what we are working with so far, around 79% of all E. coli isolates in 2024 were susceptible to trim sulfa.

00:11:20 Akshith Dass

So again, 21% resistance at my institution. So we're at the cusp which patients visiting our maybe for a simple cystitis may not qualify for empiric trim sulfa use. You see that fluoroquinolones are also listed. Again, these are very effective, especially oral options that can be used both in the inpatient as well as the outpatient setting. But the fluoroquinolone stewardship that's being harped upon

00:11:50 Akshith Dass

and really paying attention to it, they're considered as alternative or reserve agents for uncomplicated cystitis, mainly because of the collateral damage and resistance concerns and safety warnings, those that have been put out by both the FDA in 2016 and recently across the pond. The United Kingdom also released a very similar message in 2024 advising that fluoroquinolone should be reserved for situations

00:12:17 Akshith Dass

where other recommended antibiotics are not appropriate because of the irreversible side effects of the fluoroquinolone antimicrobials. And then oral beta-lactams can be preferred when your typical first-line agents are not appropriate, but overall they're generally considered less effective than your preferred first-line agents. And then moving on to the complicated urinary tract infection picture.

00:12:43 Akshith Dass

Here we have to determine what the extent of infection is. The patient has sepsis with or without any shock. Then your preferred empiric antimicrobials from a list that you could choose from includes third or fourth generation cephalosporins. So in the hospital setting, this is mainly going to be ceftriaxone or cefepime, or you can choose a carbapenem, piptazo,

00:13:10 Akshith Dass

or your fluoroquinolones, levofloxacin, or ciprofloxacin. And the agent that we pick from this list then depends on additional factors, such as the patient's list of microbiological history, the local antibiogram, maybe their allergy list. And then these agents are preferred over your relatively newer or novel beta-lactam, beta-lactamase agents, such as, for example, ceftazidime-avibactam, ceftolozane-tazobactam,

00:13:40 Akshith Dass

or cefiderocol, or your aminoglycosides, including plazomicin, for example, gentamicin, amikacin, et cetera. On the other hand, if the patient does not experience sepsis and they cannot take oral meds, again, this is where your IV antimicrobials are going to come into play. So your list includes agents like third or fourth generation cephalosporins, piptazo, or your fluoroquinolones. And then if the patient can't take oral medications,

00:14:10 Akshith Dass

again, fluoroquinolones and trim sulfa become really good options in this scenario, mainly because they're thought to have really good bioavailability and good systemic exposure in the kidney as well as the bladder. Agents to avoid in this scenario, especially when we're talking about complicated urinary tract infections, would be nitrofurantoin as well as oral fosfomycin. These agents are useful

00:14:39 Akshith Dass

mainly for uncomplicated cystitis because they don't have good kidney tissue penetration or bloodstream concentrations. So those are the agents that we would want to avoid for complicated UTIs.

00:14:54 Steve Small

Great review. Dana, anything to add from your perspective given the options that we have?

00:15:00 Dana Bowers

so where I live in the West, we don't have as much resistance as sort of other places, maybe more so towards the East Coast. I think I've been fortunate in that way. So I really like nitrofurantoin and trimethoprim-sulfamethoxazole for uncomplicated UTI and then for, even for complicated when they don't have sepsis. I also personally like the beta-lactams. They have sort of this complicated history where, you know, people have traditionally thought of them

00:15:30 Dana Bowers

as having inferior efficacy for UTI, but I think that we use them a lot clinically and especially the oral cephalosporins. And there's more literature coming out and we could go on and on about the literature and sort of the problems with the studies that have been coming out and how to compare different, let's say, cephalosporins, for example. But I think that these do get used clinically and we'll be having more and more data to come and support that we

00:16:00 Dana Bowers

perhaps can use the oral cephalosporins more than perhaps we have in the past.

00:16:07 Steve Small

I think it's great to hear these different experiences and it shows how UTI management depends on so many factors. And with that, I'll hand over the mic to Sara.

00:16:18 Sara Klockars

Thank you. And we're going to shift gears. We've talked a lot about the different antibiotics, the different types of infections. Sometimes we have cultures, sometimes we don't.

00:16:27 Sara Klockars

So, Craig, what are some common issues or errors you see with UTI prescriptions?

00:16:35 Craig D. Williams

I mean, a lot of it does get to what we talked about in the first part, just kind of making sure you're considering the patient when making your initial selection. So, and the big decision point being complicated or uncomplicated, you know, are there any systemic symptoms? Akshith just said looking at recent history can be useful if you have that on the patient.

00:16:53 Craig D. Williams

But then really once you've chosen an agent, we've talked a little bit about dose. For some agents, that's easy. For some agents, that's less easy. And then duration is kind of big. So for those of us on the hospital side where we're helping transition patients, we're having a lot more conversations about how long do patients really need therapy for. So the guidelines are progressively shrinking the durations recommended for some time and we're beginning to change.

00:17:20 Craig D. Williams

Some of the advice that we give patients, and increasingly not even adding on any transition antibiotics when patients leave the hospital, potentially as soon as just three days into effective treatment regimens or certainly by 5 days, you know, it's common we would give that extra 3, 4, 5 days of outpatient antibiotics to complete their 7, 10, 14 day course. And we're just not doing that anymore. So that's become a big area of focus for antimicrobial stewardship. But if that person's looking a whole lot better,

00:17:49 Craig D. Williams

in two days, they do not need 14 or 10 or even seven days now commonly of antibiotics depending on what you use. So duration has become a big focus as you highlight on the slide.

00:18:04 Dana Bowers

I also agree that

00:18:05 Dana Bowers

Duration of therapy, this is a main one that I see especially for transitions of care. And so this is where antimicrobial stewardship is really stepped in and then pharmacists who specialize in transitions of care to making sure that as patients are discharged, that they are not getting an additional 5 days of therapy, that they looked at what they got in the hospital and then seeing, do we still need more antibiotics after that?

00:18:30 Dana Bowers

Another common thing that I see with UTI prescription is sort of automatically reaching for the fluoroquinolones. I think as stewardship pharmacists, we've done a lot of education on this and this has gotten better. But I think, you know, there may be some practitioners out there who are just really familiar with the fluoroquinolones and just

00:18:48 Dana Bowers

they know that they work in this disease state, and so they'll automatically reach for those instead of thinking about from a stewardship perspective, what is going to be a good sort of overall agent that we can use that will decrease resistance development over time.

00:19:03 Craig D. Williams

We all still teach, certainly, nitrofurantoin, fosfomycin, generally not for pyelonephritis. Interestingly, they will work a fair amount of time for uncomplicated pyelonephritis, otherwise healthy person, but they fail

00:19:15 Craig D. Williams

enough that that's still certainly a valid point. And that's one of the things I can always rely on the medical students and residents to reliably get in medical school is don't use nitrofurantoin and fosfomycin for pyelonephritis. That's still a good rule of thumb. Do not use those agents for what we're now calling complicated or pyelonephritis infections.

00:19:35 Sara Klockars

Excellent. Thank you.

00:19:37 Steve Small

And then Akshith, what criteria do you use to switch from IV to oral antibiotics in complicated UTIs? Is there any sort of maybe check boxes that you check off in your mind when determining whether to make that transition?

00:19:54 Akshith Dass

So to switch from IV to oral, what I usually look for are three main conditions. So one, is the patient clinically improving? That I think has to be the top priority.

00:20:05 Akshith Dass

The second one would be, can the patient take and absorb any oral medications by mouth?

00:20:11 Akshith Dass

So that could be like scanning the medication list, asking the nurse, seeing what the patient's taking.

00:20:16 Akshith Dass

Are they consuming any diet by mouth?

00:20:19 Akshith Dass

And then thirdly, is there an effective oral antibiotic that is available?

00:20:24 Akshith Dass

So typically what a patient scenario could be, they maybe come to the hospital for a complicated urinary tract infection.

00:20:32 Akshith Dass

They get started on everyone's favorite

00:20:35 Akshith Dass

antibiotic of choice, ceftriaxone, IV medication.

00:20:39 Akshith Dass

And it's now day two, day three of your therapy.

00:20:43 Akshith Dass

The patient again should be getting better with the effective empiric antimicrobial choice.

00:20:48 Akshith Dass

By day three, typically is when your microbiology lab can chime in and help you out with some urine culture and susceptibility reports.

00:20:57 Akshith Dass

So at that point then now you can look at the susceptibility report, see if the patient is able to

00:21:04 Akshith Dass

take any medications by mouth if they're clinically improving, such as no fevers, stable blood pressure, good heart rate, maybe their mental status is now improving if that was an issue in the past.

00:21:18 Akshith Dass

And overall symptom reduction, so no more dysuria, no more flank pain, or overall systemic illnesses.

00:21:25 Akshith Dass

And they're willing to take medications by mouth.

00:21:28 Akshith Dass

Then when you scan

00:21:29 Akshith Dass

your susceptibility report and you can see there are effective oral agents available, then you want to make sure that you can look at more patient-specific factors like allergy lists, intolerances, any renal dose adjustments, and then pick an agent from that list which is optimally dosed for the given scenario.

00:21:49 Akshith Dass

So for example, if you know your patient's experiencing a complicated urinary tract infection,

00:21:55 Akshith Dass

but the only oral agent available, for example, is nitrofurantoin,

00:22:00 Akshith Dass

you're not going to go for that option, even though it is an oral option that's available.

00:22:05 Akshith Dass

It's not going to be an effective oral option for this complicated urinary tract infection picture.

00:22:13 Craig D. Williams

Yeah, those are great points.

00:22:14 Craig D. Williams

Another thing I'll add briefly, this mostly is referring to beta-lactams, as Akshith said.

00:22:18 Craig D. Williams

On the inpatient side, that's often what's being started intravenously.

00:22:22 Craig D. Williams

Also for quinolones, they're the same oral as they are IV.

00:22:27 Craig D. Williams

The other thing is, it's not that uncommon for your blood cultures to turn positive.

00:22:31 Craig D. Williams

Bacteremia happens in probably at least 10% of hospitalized patients with complicated urinary tract infections.

00:22:39 Craig D. Williams

And the fact that your blood culture might have been positive, assuming it's the same organism in the urine and it's almost always gram-negative, does not need to change when you switch.

00:22:47 Craig D. Williams

If the patient's clinically improving and stable and your culture says you have something, you have a good oral option you feel comfortable with based on your culture, you can still make that transition.

00:22:58 Steve Small

Great points there.

00:22:59 Steve Small

And what are important counseling points when we're talking with patients about their UTI antibiotic therapy?

00:23:05 Steve Small

Are there any maybe side effects or interactions that you commonly watch for that maybe you keep top of mind with some of these classes or specific meds?

00:23:14 Steve Small

Akshith, what's your take on that?

00:23:18 Akshith Dass

Yeah, so overall, the antimicrobials for urinary tract infections are typically well tolerated.

00:23:26 Akshith Dass

Some counseling points

00:23:28 Akshith Dass

for fluoroquinolones or things to watch out for, at least for the short term, would be any drug interactions.

00:23:34 Akshith Dass

So if your patient's taking fluoroquinolones with any metallic compounds, any like multivitamins that may contain iron, calcium, magnesium of those sorts, watching out for those drug interactions and not, you know, separating the fluoroquinolones from these metallic compounds.

00:23:51 Akshith Dass

The side effects, you know, rare side effects of CNS effects or tendon rupture, neuropathy or dysglycemia, keep an eye out for that, especially in your older patients.

00:23:56 Akshith Dass

Maybe with those with poor renal function, renal clearance of these fluoroquinolones, so keep an eye out for that.

00:24:01 Akshith Dass

But for the short period of time, again, these fluoroquinolones should be OK in that sense.

00:24:07 Akshith Dass

But trimethoprim-sulfamethoxazole, something to watch out for would be potassium as well as renal function, especially in your older adults who already have

00:24:23 Akshith Dass

poor renal function, and it could be on an ACE inhibitor, angiotensin receptor blocker, or spironolactone, because the risk of hyperkalemia goes up.

00:24:33 Akshith Dass

So your potassium can increase.

00:24:35 Akshith Dass

Typically, from a teaching standpoint, what I like to tell the students is, you know, watch out for those little old ladies that come back to the ER, maybe complaining of muscle pain or some abnormal heart beating in their chest, because that could be signs that their potassium

00:24:52 Akshith Dass

could have increased because of the trimethoprim-sulfamethoxazole prescription.

00:24:56 Akshith Dass

Nitrofurantoin for the short term could be something like a dark urine or brown urine, which is expected or harmful.

00:25:04 Akshith Dass

But keep an eye out for patients who may develop some shortness of breath.

00:25:08 Akshith Dass

But those are very rare side effects for any pulmonary or hepatic side effects, overall very rare, not in the short-term period.

00:25:17 Akshith Dass

And then

00:25:19 Akshith Dass

for oral beta-lactams like cephalexin, the usual counseling point is going to be GI upset, diarrhea, nausea, vomiting.

00:25:24 Akshith Dass

Again, that has to do with how much cephalexin they have to end up taking in order to meet their prescription.

00:25:30 Akshith Dass

So some counseling points related to the UTI antibiotics, but overall, all of them should be, again, short duration.

00:25:38 Akshith Dass

So the adverse effects experienced from them also should be very helpful.

00:25:45 Craig D. Williams

Those are all good points.

00:25:46 Craig D. Williams

I'll just add, if we're sticking to the short durations we should be sticking to, fortunately, these generally are pretty well-tolerated agents.

00:25:53 Craig D. Williams

So on the inpatient side, we have the luxury of watching the patient for a day or two.

00:25:57 Craig D. Williams

On the outpatient side, the big thing is just to expect a pretty quick clinical response.

00:26:02 Craig D. Williams

You definitely want that patient to be letting someone know if two days into therapy, they're still not feeling good, or now they're having fevers they weren't having the day before or fevers haven't abated.

00:26:12 Craig D. Williams

But I mean, there are some drug interactions as were enumerated, but if you're sticking to short durations of therapy, we don't use much warfarin anymore.

00:26:19 Craig D. Williams

It's always a big one for quinolones and Bactrim kind of back in the day.

00:26:23 Craig D. Williams

The biggest thing that prompts warnings from our prescribers, we get called all the time for the QT prolongation warnings for quinolones, especially on one other agent.

00:26:31 Craig D. Williams

So we have that discussion a lot.

00:26:33 Craig D. Williams

But fortunately, for just the kind of five to seven or even three-day duration, generally pretty well tolerated.

00:26:38 Craig D. Williams

So our big advice on the outpatient side is like, let us know if you're not getting better really quick.

00:26:44 Steve Small

That's a great list of side effects to share with patients during counseling.

00:26:47 Steve Small

And some other general counseling points include recommending patients drink enough fluids.

00:26:52 Steve Small

And we know sharing isn't caring when it comes to antibiotics.

00:26:56 Steve Small

Advise against sharing any antibiotic supply with others since this can increase resistance in the community.

00:27:01 Steve Small

And similarly, patients should throw away any remaining pills if they have any left over, perhaps after their therapy.

00:27:09 Steve Small

And Akshith, when is it appropriate to use antibiotic prophylaxis if a patient has recurrent UTIs?

00:27:15 Steve Small

Are there any specific antibiotics you should use and specific durations that we should be looking at?

00:27:21 Akshith Dass

Yeah, so antimicrobial prophylaxis to prevent recurrent UTIs is typically considered after two or more UTIs in the past six months.

00:27:31 Akshith Dass

or at least three occurrences of UTIs in the past year.

00:27:36 Akshith Dass

So those are generally the timelines on when you should start thinking about antibiotic prophylaxis.

00:27:40 Akshith Dass

But then the prophylaxis, again, should be a shared decision making between the provider as well as the patient, because one, now you're subjecting the patient to a long-term antibiotic regimen.

00:27:51 Akshith Dass

And with that comes the risk of adverse effects and the risk of resistance, plus it's just added cost for the patient as well.

00:27:59 Akshith Dass

How long should you use it?

00:28:00 Akshith Dass

Typically, the studies have done prophylaxis between six months to a year.

00:28:06 Akshith Dass

And then the studies have shown that once the prophylaxis is taken away, the UTI could recur at the same rate as if you're not taking prophylaxis.

00:28:14 Akshith Dass

So that's also something to consider in that shared decision-making process.

00:28:19 Akshith Dass

Antibiotics that have been used, you may see things like nitrofurantoin at a lower dose, about 50 to 100 milligrams given once daily.

00:28:29 Akshith Dass

maybe trim sulfa at like half dose or a tablet three times a week.

00:28:34 Akshith Dass

Low-dose cephalexin is an option of around 125 to 250 milligrams daily.

00:28:39 Akshith Dass

Or there's also an option of giving fosfomycin 3 gram sachet every 10 days.

00:28:45 Akshith Dass

So yeah, overall, shared decision making, thinking about the risks of adverse effects, risk of resistance, increase cost to the patient, but the benefit of preventing those recurrent UTIs.

00:28:59 Akshith Dass

for that 6 to 12 month duration.

00:29:04 Craig D. Williams

Yeah, I'll add, Steve, this is a tough topic.

00:29:07 Craig D. Williams

So we're seeing less this now than we're seeing a decade ago, just because it's, you know, anything systemic, you're just going to get resistance to and promote more resistance.

00:29:16 Craig D. Williams

So but if you need to use something, nitrofurantoin is the best agent.

00:29:19 Craig D. Williams

And virtually all UTIs start as cystitis and are ascending infections.

00:29:23 Craig D. Williams

So if you prevent cystitis, you can almost always prevent

00:29:26 Craig D. Williams

pyelonephritis, especially important in patients who might be doing intermittent catheterizations at home for a variety of reasons.

00:29:33 Craig D. Williams

And when we do occasionally use nitrofurantoin, we like bedtime dosing, longer retention time in the bladder, typically overnight or whatever is kind of the bedtime period for that patient.

00:29:43 Craig D. Williams

But it's a tough thing to operationalize just because systemic therapies, you're just going to promote resistance to.

00:29:49 Craig D. Williams

So we're big on some kind of recurrence, like can we find a trigger

00:29:53 Craig D. Williams

for it, or is there an anatomic abnormality?

00:29:55 Craig D. Williams

Is this the time for imaging to find something?

00:29:58 Craig D. Williams

So trying to find the reason and maybe do intermittent prophylaxis, continuous prophylaxis with systemic agents, just as kind of a setup for failure long-term, as Akshith kind of alluded to.

00:30:11 Sara Klockars

Thank you.

00:30:12 Sara Klockars

Can you comment on the use of estrogen to prevent UTIs in postmenopausal women?

00:30:19 Dana Bowers

Yes, this is

00:30:21 Dana Bowers

can be very beneficial for some people.

00:30:24 Dana Bowers

It's going to be intravaginal, so more localized topical estrogen.

00:30:30 Dana Bowers

And the way that this works is it's going to normalize the vaginal flora and it will reduce the risk of recurrent UTI.

00:30:38 Dana Bowers

And just me personally, I also just love a good microbiome restoration approach because if we're normalizing the vaginal flora, then we can help prevent this colonization with these other bacteria, which can then lead to symptomatic UTI.

00:30:51 Dana Bowers

The other thing I think is important to think about for this is we try to recommend behavioral modification sort of as a blanket statement.

00:31:01 Dana Bowers

And I think sometimes people forget, especially in postmenopausal women, that estrogen can be beneficial.

00:31:08 Dana Bowers

So I think, you know, keeping in mind when patients have exhausted these sort of behavioral modifications and they still keep getting these recurrent UTIs, that might be a good time to try sort of a low dose localized estrogen in a postmenopausal.

00:31:24 Sara Klockars

Excellent.

00:31:24 Sara Klockars

And then we're getting a ton of questions about supplements.

00:31:27 Sara Klockars

So Akshit, what supplements can be used to prevent or treat UTIs?

00:31:33 Sara Klockars

And specifically people are asking about cranberry products or juice, probiotics.

00:31:39 Sara Klockars

Are there any supplements that have evidence to support their use?

00:31:46 Akshith Dass

Yeah, so the one supplement that comes to mind for at least

00:31:49 Akshith Dass

prevention of UTI.

00:31:51 Akshith Dass

In these supplements, I haven't come across one that can be used to treat a UTI, but at least to prevent recurrence of UTI, one supplement that comes to mind would be the cranberry supplements.

00:32:03 Akshith Dass

The reason why cranberry has become popular in the UTI field is because the mechanism of action is such that they have these things called the proanthocyanidins in them.

00:32:17 Akshith Dass

So the proanthocyanidins or PACs help reduce bacterial adhesion to the urinary bladder, which then makes it harder for your gram-negative organisms like E.

00:32:27 Akshith Dass

coli to then establish infection.

00:32:31 Akshith Dass

So the cranberry supplements, whether it's juice or when it comes as a tablet or capsules, are now recommended by the American Urological Association

00:32:43 Akshith Dass

as an option for prophylaxis in women with recurrent urinary tract infections.

00:32:49 Akshith Dass

The FDA also has a newer language that's out there as a qualified health claim that they have attached to certain cranberry products saying that, yes, the evidence is limited and maybe some inconsistency in the evidence, but there is generally a trend towards the cranberry products helping with prevention of urinary tract infections.

00:33:13 Akshith Dass

When picking up cranberry supplements, look carefully at the label.

00:33:17 Akshith Dass

One of the studies said that you should have at least 36 milligrams of this PAC being taken daily for about three to six months for the cranberry to have any impact.

00:33:30 Akshith Dass

What 36 milligram PACs could translate to would be around 500 milligrams of cranberry dietary supplements or cranberry powder.

00:33:42 Akshith Dass

based on what the labeling is saying, or around 8 ounces of cranberry juice.

00:33:48 Akshith Dass

When you're considering the juice, make sure it's the unsweetened version of the juice because you don't want to exacerbate any comorbid conditions by drinking a sweetened juice on a daily basis for three to six months.

00:34:00 Akshith Dass

Overall, there's very low risk of adverse effects when it comes to cranberry supplements themselves.

00:34:06 Akshith Dass

So that could be a consideration.

00:34:08 Akshith Dass

So again, if you were to pick one,

00:34:10 Akshith Dass

to take as a non-antimicrobial option, this could be something to consider.

00:34:16 Akshith Dass

But again, read that labeling very carefully and pick up that unsweetened juice if you were to do that.

00:34:23 Akshith Dass

On the probiotic sides, not as much evidence and inconsistent evidence for probiotics to help in any prevention of recurrent UTIs.

00:34:36 Akshith Dass

So I think the data is still not strong enough to recommend this as compared to cranberry supplements.

00:34:45 Narrator

We hope you enjoyed and gained practical insights from listening to this discussion.

00:34:50 Narrator

Now that you've listened, pharmacists, pharmacy technicians, physicians, and nurses can receive CE credit.

00:34:56 Narrator

Just log into your pharmacist letter, pharmacy technician's letter, or Prescriber Insights account, and look for the title of this podcast in the list of available CE courses.

00:35:05 Narrator

On those websites, you'll also be able to access and print out additional materials on this topic, like charts and other quick reference tools.

00:35:13 Narrator

If you're not yet a pharmacist letter, pharmacy technician's letter, or prescriber insight subscriber, now's the time.

00:35:19 Narrator

Sign up today to stay ahead with trusted, unbiased insights and continuing education.

00:35:25 Narrator

And as a listener, you can save 10% on a new or upgraded subscription with code MT1026 at checkout.

00:35:34 Narrator

Be sure to follow or subscribe, rate, and review this show in your favorite podcast app, or find the show on YouTube by searching for TRC Healthcare or clicking the link in the show notes.

00:35:46 Narrator

You can also reach out to provide feedback or make suggestions by emailing us at contactus at trchealthcare.com.

00:35:55 Narrator

Thanks for listening to Medication Talk.