What should be included in a consult note for a patient with recurrent Urinary Tract Infections (UTIs)?

Comprehensive Consult Note for Recurrent UTI Patient

A comprehensive consult note for a patient with recurrent UTIs should include detailed assessment of risk factors, diagnostic evaluation, and a clear treatment and prevention plan to reduce morbidity and mortality associated with recurrent infections. 1, 2

Patient Assessment Components

History

• Definition of recurrence: Document if patient meets criteria for recurrent UTI (≥3 episodes in 12 months or ≥2 episodes in 6 months) 1, 3
• Infection pattern:
  • Timing of previous infections
  • Relationship to sexual activity
  • Previous culture results and antibiotic responses
  • Differentiation between reinfection vs. relapse 1

Risk Factor Assessment

• Sexual habits: Frequency, new partners, use of spermicides 1, 4
• Hygiene practices: Wiping technique, douching 4
• Voiding habits: Post-coital voiding, delayed urination, fluid intake 2, 4
• Medical conditions: Diabetes, immunosuppression 1, 5
• Anatomical factors: History of urinary tract surgery/trauma, prior calculi 1
• Menopausal status: Presence of atrophic vaginitis 1, 2
• Functional issues: Urinary incontinence, cystocele, high post-void residuals 1

Physical Examination

• Focused pelvic exam to assess for:
  • Atrophic vaginitis in postmenopausal women
  • Cystocele or other pelvic organ prolapse
  • Signs of fistula formation

Diagnostic Evaluation

• Urine studies:

  • Urinalysis and culture with susceptibility testing 2
  • Document organism(s) and resistance patterns
  • Note: E. coli causes approximately 75% of recurrent UTIs 1

• Imaging considerations:

  • Note that imaging is generally low yield in uncomplicated recurrent UTIs 1
  • Consider imaging only if:
    • Rapid recurrence (within 2 weeks of treatment)
    • Bacterial persistence despite therapy
    • Recurrent pyelonephritis
    • Gross hematuria after infection resolution
    • Symptoms of pneumaturia or fecaluria 1

• Post-void residual measurement: Especially important in older women 1

Treatment and Management Plan

Acute Episode Management

• Antibiotic selection:
  • Document selected antibiotic based on culture results and local resistance patterns
  • First-line options: Nitrofurantoin, TMP-SMX (if local resistance <20%) 2
  • Alternative: Fosfomycin (note: lower clinical and microbiologic resolution compared to nitrofurantoin) 2, 6
  • Reserve fluoroquinolones for complicated cases due to side effects 2
  • Treatment duration: 5-7 days for uncomplicated cystitis 2

Prevention Strategy

• Non-antimicrobial measures:

  • Increased fluid intake (additional 1.5L water daily) 2
  • Urge-initiated and post-coital voiding 1, 2
  • Avoidance of spermicide-containing contraceptives 1, 2
  • For postmenopausal women: Vaginal estrogen therapy if appropriate 1, 2
  • Consider cranberry products containing 36mg proanthocyanidin 2, 7

• Antimicrobial prophylaxis options (if ≥3 UTIs in 12 months):

  • Post-coital prophylaxis: Single dose within 2 hours of intercourse (if UTIs related to sexual activity) 2, 8
  • Continuous low-dose prophylaxis: 6-12 months duration (for UTIs unrelated to sexual activity) 2
  • Self-start therapy: For reliable patients who can obtain urine specimens before starting antibiotics 2
  • Non-antibiotic option: Methenamine hippurate 1g twice daily 2

Follow-up Plan

• Timing of follow-up appointment
• Indications for repeat urine culture (not necessary if asymptomatic) 2
• Criteria for specialist referral if no improvement
• Duration of prophylaxis (typically 6 months minimum) 8

Patient Education

• Explanation of UTI pathophysiology and recurrence risk
• Self-care measures and lifestyle modifications
• Warning signs requiring immediate medical attention
• Instructions for self-start therapy if prescribed

Pitfalls to Avoid

• Overuse of imaging: Not routinely indicated for uncomplicated recurrent UTIs 1
• Inadequate treatment duration: Too short courses may lead to relapse 2
• Fluoroquinolone overuse: Reserve for complicated cases due to side effect risks 2
• Treating asymptomatic bacteriuria: May increase risk of antibiotic resistance 1, 2
• Failure to address modifiable risk factors: Such as spermicide use, inadequate hydration 1, 4
• Missing complicated UTI: Watch for signs of pyelonephritis, structural abnormalities 1

By including these comprehensive elements in your consult note, you will provide a thorough assessment and management plan that addresses both the immediate infection and long-term prevention strategies to reduce morbidity and improve quality of life for patients with recurrent UTIs.