CAN YOU POSTPONE YOUR DATE WITH CANCER AND MI

Do you have prostate cancer ? Will you get prostate cancer ? Do you have colon cancer ? Or get one sooner or later ? What about breast cancer ?

Even when you develop cancer excess vitamin D increases apoptosis and you survive longer. Not debatable.

Every one of your patients and ourselves and our spouses should be on vitamin D 2000 units a say for ever. There is no down side to it. Mind you I said vitamin D, not vitamin D with calcium.

Vitamin D decreases the incidence of all kind of cancers further all cancer patients should be on vitamin D also. Even after the diagnosis is made vitamin D increases the life span and it increases apoptosis. Remember there is no down side to vitamin D ingestion at that dose or even multiples of that dose, below may be a dose of 10,000 units a day
.

Milk from even well fed cows , how much vitamin D is there ? Zilch, zero- point is milk has no vitamin D unless you add it to milk. How many of you know that ?


Did you know that if you live in Atlanta , SanAntonio you have less chance of getting all kinds of cancers than in Boston .

FROM NEJM Volume 357:266-281 July 19, 2007 Number 3

Vitamin D Deficiency

Michael F. Holick, M.D., Ph.D.


Once foods were fortified with vitamin D and rickets appeared to have been conquered, many health care professionals thought the major health problems resulting from vitamin D deficiency had been resolved. However, rickets can be considered the tip of the vitamin D–deficiency iceberg. In fact, vitamin D deficiency remains common in children and adults. In utero and during childhood, vitamin D deficiency can cause growth retardation and skeletal deformities and may increase the risk of hip fracture later in life. Vitamin D deficiency in adults can precipitate or exacerbate osteopenia and osteoporosis, cause osteomalacia and muscle weakness, and increase the risk of fracture.

The discovery that most tissues and cells in the body have a vitamin D receptor and that several possess the enzymatic machinery to convert the primary circulating form of vitamin D, 25-hydroxyvitamin D, to the active form, 1,25-dihydroxyvitamin D, has provided new insights into the function of this vitamin. Of great interest is the role it can play in decreasing the risk of many chronic illnesses, including common cancers, autoimmune diseases, infectious diseases, and cardiovascular disease. In this review I consider the nature of vitamin D deficiency, discuss its role in skeletal and nonskeletal health, and suggest strategies for its prevention and treatment.

Sources and Metabolism of Vitamin D

Humans get vitamin D from exposure to sunlight, from their diet, and from dietary supplements. A diet high in oily fish prevents vitamin D deficiency. Solar ultraviolet B radiation (wavelength, 290 to 315 nm) penetrates the skin and converts 7-dehydrocholesterol to previtamin D3, which is rapidly converted to vitamin D 3 (Figure 1). 1 Because any excess previtamin D3 or vitamin D3 is destroyed by sunlight ( Figure 1), excessive exposure to sunlight does not cause vitamin D 3 intoxication.


During exposure to solar ultraviolet B (UVB) radiation, 7-dehydrocholesterol in the skin is converted to previtamin D3, which is immediately converted to vitamin D3 in a heat-dependent process. Excessive exposure to sunlight degrades previtamin D 3 and vitamin D3 into inactive photoproducts. Vitamin D2 and vitamin D3 from dietary sources are incorporated into chylomicrons and transported by the lymphatic system into the venous circulation. Vitamin D (hereafter "D" represents D 2 or D3) made in the skin or ingested in the diet can be stored in and then released from fat cells. Vitamin D in the circulation is bound to the vitamin D–binding protein, which transports it to the liver, where vitamin D is converted by vitamin D-25-hydroxylase to 25-hydroxyvitamin D [25(OH)D]. This is the major circulating form of vitamin D that is used by clinicians to determine vitamin D status. ..................

Few foods naturally contain or are fortified with vitamin D. The "D" represents D2 or D3 ( Figure 1). Vitamin D2 is manufactured through the ultraviolet irradiation of ergosterol from yeast, and vitamin D3 through the ultraviolet irradiation of 7-dehydrocholesterol from lanolin. Both are used in over-the-counter vitamin D supplements, but the form available by prescription in the United States is vitamin D2.

Vitamin D from the skin and diet is metabolized in the liver to 25-hydroxyvitamin D ( Figure 1), which is used to determine a patient's vitamin D status. 25-hydroxyvitamin D is metabolized in the kidneys by the enzyme 25-hydroxyvitamin D-1 -hydroxylase (CYP27B1) to its active form, 1,25-dihydroxyvitamin D. The renal production of 1,25-dihydroxyvitamin D is tightly regulated by plasma parathyroid hormone levels and serum calcium and phosphorus levels. Fibroblast growth factor 23, secreted from the bone, causes the sodium–phosphate cotransporter to be internalized by the cells of the kidney and small intestine and also suppresses 1,25-dihydroxyvitamin D synthesis. The efficiency of the absorption of renal calcium and of intestinal calcium and phosphorus is increased in the presence of 1,25-dihydroxyvitamin D It also induces the expression of the enzyme 25-hydroxyvitamin D-24-hydroxylase (CYP24), which catabolizes both 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D into biologically inactive, water-soluble calcitroic acid.

Definition and Prevalence of Vitamin D Deficiency

Although there is no consensus on optimal levels of 25-hydroxyvitamin D as measured in serum, vitamin D deficiency is defined by most experts as a 25-hydroxyvitamin D level of less than 20 ng per milliliter (50 nmol per liter).
Hydroxyvitamin D levels are inversely associated with parathyroid hormone levels until the former reach 30 to 40 ng per milliliter (75 to 100 nmol per liter), at which point parathyroid hormone levels begin to level off (at their nadir). Furthermore, intestinal calcium transport increased by 45 to 65% in women when 25-hydroxyvitamin D levels were increased from an average of 20 to 32 ng per milliliter (50 to 80 nmol per liter). 13 Given such data, a level of 25-hydroxyvitamin D of 21 to 29 ng per milliliter (52 to 72 nmol per liter) can be considered to indicate a relative insufficiency of vitamin D, and a level of 30 ng per milliliter or greater can be considered to indicate sufficient vitamin D. 14 Vitamin D intoxication is observed when serum levels of 25-hydroxyvitamin D are greater than 150 ng per milliliter (374 nmol per liter).

With the use of such definitions, it has been estimated that 1 billion people worldwide have vitamin D deficiency or insufficiency. According to several studies, 40 to 100% of U.S. and European elderly men and women still living in the community (not in nursing homes) are deficient in vitamin D. More than 50% of postmenopausal women taking medication for osteoporosis had suboptimal levels of 25-hydroxyvitamin D — below 30 ng per milliliter (75 nmol per liter).

Children and young adults are also potentially at high risk for vitamin D deficiency. For example, 52% of Hispanic and black adolescents in a study in Boston 23 and 48% of white preadolescent girls in a study in Maine 24 had 25-hydroxyvitamin D levels below 20 ng per milliliter. In other studies, at the end of the winter, 42% of 15- to 49-year-old black girls and women throughout the United States had 25-hydroxyvitamin D levels below 20 ng per milliliter, 25 and 32% of healthy students, physicians, and residents at a Boston hospital were found to be vitamin D–deficient, despite drinking a glass of milk and taking a multivitamin daily and eating salmon at least once a week.

In Europe, where very few foods are fortified with vitamin D, children and adults would appear to be at especially high risk. People living near the equator who are exposed to sunlight without sun protection have robust levels of 25-hydroxyvitamin D — above 30 ng per milliliter. However, even in the sunniest areas, vitamin D deficiency is common when most of the skin is shielded from the sun. In studies in Saudi Arabia, the United Arab Emirates, Australia, Turkey, India, and Lebanon, 30 to

50% of children and adults had 25-hydroxyvitamin D levels under 20 ng per milliliter. Also at risk were pregnant and lactating women who were thought to be immune to vitamin D deficiency since they took a daily prenatal multivitamin containing 400 IU of vitamin D (70% took a prenatal vitamin, 90% ate fish, and 93% drank approximately 2.3 glasses of milk per day) .73% of the women and 80% of their infants were vitamin D–deficient (25-hydroxyvitamin D level, <20 ng per milliliter) at the time of birth.

Calcium, Phosphorus, and Bone Metabolism

Without vitamin D, only 10 to 15% of dietary calcium and about 60% of phosphorus is absorbed. The interaction of 1,25-dihydroxyvitamin D with the vitamin D receptor increases the efficiency of intestinal calcium absorption to 30 to 40% and phosphorus absorption to approximately 80%

In one study, serum levels of 25-hydroxyvitamin D were directly related to bone mineral density in white, black, and Mexican-American men and women, with a maximum density achieved when the 25-hydroxyvitamin D level reached 40 ng per milliliter or more.8 When the level was 30 ng per milliliter or less, there was a significant decrease in intestinal calcium absorption 13 that was associated with increased parathyroid hormone. Parathyroid hormone enhances the tubular reabsorption of calcium and stimulates the kidneys to produce 1,25-dihydroxyvitamin D. Parathyroid hormone also activates osteoblasts, which stimulate the transformation of preosteoclasts into mature osteoclasts (Figure 1). Osteoclasts dissolve the mineralized collagen matrix in bone, causing osteopenia and osteoporosis and increasing the risk of fracture.

Deficiencies of calcium and vitamin D in utero and in childhood may prevent the maximum deposition of calcium in the skeleton. As vitamin D deficiency progresses, the parathyroid glands are maximally stimulated, causing secondary hyperparathyroidism. Hypomagnesemia blunts this response, which means that parathyroid hormone levels are often normal when 25-hydroxyvitamin D levels fall below 20 ng per milliliter. Parathyroid hormone increases the metabolism of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D, which further exacerbates the vitamin D deficiency. Parathyroid hormone also causes phosphaturia, resulting in a low-normal or low serum phosphorus level. Without an adequate calcium–phosphorus product (the value for calcium times the value for serum phosphorus), mineralization of the collagen matrix is diminished, leading to classic signs of rickets in children and osteomalacia in adults.

Whereas osteoporosis is unassociated with bone pain, osteomalacia has been associated with isolated or generalized bone pain. The cause is thought to be hydration of the demineralized gelatin matrix beneath the periosteum; the hydrated matrix pushes outward on the periosteum, causing throbbing, aching pain. Osteomalacia can often be diagnosed by using moderate force to press the thumb on the sternum or anterior tibia, which can elicit bone pain. One study showed that 93% of persons 10 to 65 years of age who were admitted to a hospital emergency department with muscle aches and bone pain and who had a wide variety of diagnoses, including fibromyalgia, chronic fatigue syndrome, and depression, were deficient in vitamin D.

Osteoporosis and Fracture

Approximately 33% of women 60 to 70 years of age and 66% of those 80 years of age or older have osteoporosis. It is estimated that 47% of women and 22% of men 50 years of age or older will sustain an osteoporotic fracture in their remaining lifetime. Chapuy et al. reported that among 3270 elderly French women given 1200 mg of calcium and 800 IU of vitamin D3 daily for 3 years, the risk of hip fracture was reduced by 43%, and the risk of nonvertebral fracture by 32%. A 58% reduction in nonvertebral fractures was observed in 389 men and women over the age of 65 years who were receiving 700 IU of vitamin D3 and 500 mg of calcium per day.

A meta-analysis of seven randomized clinical trials that evaluated the risk of fracture in older persons given 400 IU of vitamin D3 per day revealed little benefit with respect to the risk of either nonvertebral or hip fractures (pooled relative risk of hip fracture, 1.15; 95% confidence interval [CI], 0.88 to 1.50; pooled relative risk of nonvertebral fracture, 1.03; 95% CI, 0.86 to 1.24). In studies using doses of 700 to 800 IU of vitamin D3 per day, the relative risk of hip fracture was reduced by 26% (pooled relative risk, 0.74; 95% CI, 0.61 to 0.88 ), and the relative risk of nonvertebral fracture by 23% (pooled relative risk, 0.77; 95% CI, 0.68 to 0.87) with vitamin D3 as compared with calcium or placebo. 8 A Women's Health Initiative study that compared the effects of 400 IU of vitamin D3 plus 1000 mg of calcium per day with placebo in more than 36,000 postmenopausal women confirmed these results, reporting an increased risk of kidney stones but no benefit with respect to the risk of hip fracture.

The Women's Health Initiative study also showed that serum levels of 25-hydroxyvitamin D had little effect on the risk of fracture when levels were 26 ng per milliliter (65 nmol per liter) or less. However, women who were most consistent in taking calcium and vitamin D3 had a 29% reduction in hip fracture. 43 Optimal prevention of both nonvertebral and hip fracture occurred only in trials providing 700 to 800 IU of vitamin D3 per day in patients whose baseline concentration of 25-hydroxyvitamin D was less than 17 ng per milliliter (42 nmol per liter) and whose mean concentration of 25-hydroxyvitamin D then rose to approximately 40 ng per milliliter.

Evaluation of the exclusive use of calcium or vitamin D3 (RECORD trial) showed no antifracture efficacy for patients receiving 800 IU of vitamin D3 per day. However, the mean concentration of 25-hydroxyvitamin D increased from 15.2 ng per milliliter to just 24.8 ng per milliliter (37.9 to 61.9 nmol per liter), which was below the threshold thought to provide antifracture efficacy.8 Porthouse and colleagues, 45 who evaluated the effect of 800 IU of vitamin D3 per day on fracture prevention, did not report concentrations of 25-hydroxyvitamin D. Their study had an open design in which participants could have been ingesting an adequate amount of calcium and vitamin D separate from the intervention. This called into question the conclusion that vitamin D supplementation had no antifracture benefit. 8

Muscle Strength and Falls

Vitamin D deficiency causes muscle weakness.Skeletal muscles have a vitamin D receptor and may require vitamin D for maximum function.

Performance speed and proximal muscle strength were markedly improved when 25-hydroxyvitamin D levels increased from 4 to 16 ng per milliliter (10 to 40 nmol per liter) and continued to improve as the levels increased to more than 40 ng per milliliter (100 nmol per liter).8 A meta-analysis of five randomized clinical trials (with a total of 1237 subjects) revealed that increased vitamin D intake reduced the risk of falls by 22% (pooled corrected odds ratio, 0.78; 95% CI, 0.64 to 0.92) as compared with only calcium or placebo. 8 The same meta-analysis examined the frequency of falls and suggested that 400 IU of vitamin D3 per day was not effective in preventing falls, whereas 800 IU of vitamin D3 per day plus calcium reduced the risk of falls (corrected pooled odds ratio, 0.65; 95% CI, 0.4 to 1.0).8 In a randomized controlled trial conducted over a 5-month period, nursing home residents receiving 800 IU of vitamin D2 per day plus calcium had a 72% reduction in the risk of falls as compared with the placebo group (adjusted rate ratio, 0.28%; 95% CI, 0.11 to 0.75).

Nonskeletal Actions of Vitamin D

Brain, prostate, breast, and colon tissues, among others, as well as immune cells have a vitamin D receptor and respond to 1,25-dihydroxyvitamin D, the active form of vitamin D. In addition, some of these tissues and cells express the enzyme 25-hydroxyvitamin D-1 -hydroxylase.

Directly or indirectly, 1,25-dihydroxyvitamin D controls more than 200 genes, including genes responsible for the regulation of cellular proliferation, differentiation, apoptosis, and angiogenesis. It decreases cellular proliferation of both normal cells and cancer cells and induces their terminal differentiation. One practical application is the use of 1,25-dihydroxyvitamin D3 and its active analogues for the treatment of psoriasis.

1,25-Dihydroxyvitamin D is also a potent immunomodulator.

Latitude, Vitamin D Deficiency, and Chronic Diseases

Cancer ---LET ME HIGHLIGHT SOME OF THE POINTS AGAIN

People living at higher latitudes are at increased risk for Hodgkin's lymphoma as well as colon, pancreatic, prostate, ovarian, breast, and other cancers and are more likely to die from these cancers, as compared with people living at lower latitudes.

More than 50% of postmenopausal women taking medication for osteoporosis had suboptimal levels of 25-hydroxyvitamin D — below 30 ng per milliliter (75 nmol per liter).
-............healthy students, physicians, and residents at a Boston hospital were found to be vitamin D–deficient, despite drinking a glass of milk and taking a multivitamin daily and eating salmon at least once a week.
Also at risk were pregnant and lactating women who were thought to be immune to vitamin D deficiency since they took a daily prenatal multivitamin containing 400 IU of vitamin D
Directly or indirectly, 1,25-dihydroxyvitamin D controls more than 200 genes, including genes responsible for the regulation of cellular proliferation, differentiation, apoptosis, and angiogenesis.It decreases cellular proliferation of both normal cells and cancer cells and induces their terminal differentiation."

Is 30- 50% higher incidence of cancer good enough to convince us to take more vitamin D ?

"People living at higher latitudes are at increased risk for Hodgkin's lymphoma as well as colon, pancreatic, prostate, ovarian, breast, and other cancers and are more likely to die from these cancers, as compared with people living at lower latitudes.Both prospective and retrospective epidemiologic studies indicate that levels of 25-hydroxyvitamin D below 20 ng per milliliter are associated with a 30 to 50% increased risk of incident colon, prostate, and breast cancer,
along with higher mortality from these cancers.

In a study of men with prostate cancer, the disease developed 3 to 5 years later in the men who worked outdoors than in those who worked indoors. Pooled data for 980 women showed that the highest vitamin D intake, as compared with the lowest, correlated with a 50% lower risk of breast cancer . Children and young adults who are exposed to the most sunlight have a 40% reduced risk of non-Hodgkin's lymphoma 65 and a reduced risk of death from malignant melanoma once it develops , as compared with those who have the least exposure to sunlight.

To answer your question what is the dose needed to prevent cancer my answer is whtever it takes to bring the blood 25 OH D3 level to 30 or higher. That is the scientific answer.

""Cardiovascular Disease
Living at higher latitudes increases the risk of hypertension and cardiovascular disease . In a study of patients with hypertension who were exposed to ultraviolet B radiation three times a week for 3 months, 25-hydroxyvitamin D levels increased by approximately 180%, and blood pressure became normal (both systolic and diastolic blood pressure reduced by 6 mm Hg). Vitamin D deficiency is associated with congestive heart failure 54 and blood levels of inflammatory factors, including C-reactive protein and interleukin-

ARE YOU TREATING UNCOMPLICATED UTIs CORRECTLY ?

I support this paper's conclusions and recommendations.

Main points.

This is for outpatients, or clinic patients, not inpatients, not for nosocomial infections.
It is scientific and evidence based in 2007 not to order urine culture and sensitivity for suspected uncomplicated UTIs, if people dispute you remember this article.
Three days is the duration of treatment not seven days not fourteen says- I have seen all these being done.
The medication is Bactrim DS for below the age of say 60 and single strength BID for older folks in my opinion . In renal insufficiency do not use Bactrim at all.

In sulfa allergic patients use Cipro.

Amoxicillin or Keflex is not the right choice as it kills too many other bacteria also which causes other problems, like vaginitis etc etc. Nitrofurnatoin may be.

But do not lose the focus, the treatment of choice is Bactrim for three days. For uncomplicated UTIs. You need a urine dipstck in all cases at least in this paper unless you know the patient from before and has had previous UTI. You can debate that point but do not lose the focus

The treatment is for three days not 10- 14 days.

It is perfectly kosher to order three days treatment any thing more is an over kill, and too expensive and is for no scientific reason. It is our job to highlight the right answer. Probably no one has seen the reference #1 given below

KK










ORIGINAL ARTICLE

Assessing Adherence to Evidence-Based Guidelines for the Diagnosis and Management of Uncomplicated Urinary Tract Infection
MICHAEL L. GROVER, DO; JESSE D. BRACAMONTE, DO; ANUP K. KANODIA, MD; MICHAEL J. BRYAN, MD; SEAN P. DONAHUE, DO; ANNE-MARIE WARNER, MD; FREDERICK D. EDWARDS, MD; AMY L. WEAVER, MS
From the Department of Family Medicine, Mayo Clinic College of Medicine, Scottsdale, Ariz (M.L.G., J.D.B., A.K.K., M.J.B., S.P.D., A.-M.W., F.D.E.); and Division of Biostatistics, Mayo Clinic College of Medicine, Rochester, Minn ( A.L.W.). Dr Kanodia is now with Osher Institute, Harvard Medical School, Boston, Mass. Dr Bryan is in private practice in Prescott, Ariz. Dr Donahue is now with the Stanford University, Stanford, Calif. Dr Warner is now with Maricopa Integrated Health Systems and Medpro Associates, Phoenix, Ariz.




Abstract


OBJECTIVE: To assess adherence to evidence-based guidelines for the diagnosis and management of uncomplicated urinary tract infection (UTI) in a family medicine residency clinic setting.

PATIENTS AND METHODS: We retrospectively reviewed the medical records of female patients seen in 2005 at the Mayo Clinic Family Medicine Center in Scottsdale, Ariz, who were identified by International Classification of Diseases, Ninth Revision code 599.0 (UTI). We assessed documentation rates, use of diagnostic studies, and antibiotic treatments. Antibiotic sensitivity patterns from outpatient urine culture and sensitivity analyses were determined.

RESULTS: Of 228 patients, 68 (30%) had uncomplicated UTI. Our physicians recorded essential history and examination findings for most patients. Documentation of the risk of sexually transmitted disease differed between residents and attending physicians and was affected by patient age. Urine dipstick and urine culture and sensitivity analyses were ordered in 57 (84%) and 52 (76%) patients, respectively. Eighty percent of patients with positive results on urine dipstick analyses also had urine culture and sensitivity analyses. Sulfamethoxazole-trimethoprim (SMX-TMP) was used as initial therapy in 26 patients (38%). Sixty-one percent of SMX-TMP and ciprofloxacin prescriptions were appropriately provided for 3 days. Escherichia coli was sensitive to SMX-TMP in 33 (94%) of 35 cultures. Treatment was not changed in any patient with an uncomplicated UTI because of results of urine culture and sensitivity analyses. Antibiotic sensitivity patterns for outpatients were significantly different from those for inpatients.

CONCLUSION: Only 30% of our patients had uncomplicated UTI, making their management within clinical guidelines appropriate. However, of those patients with uncomplicated UTI, less than 25% received empirical treatment as suggested. Urine culture and sensitivity analyses were performed frequently, even in patients who already had positive results on a urine dip-stick analysis. Although SMX-TMP is effective, it is underused. On the basis of these findings, we hope to provide interventions to increase SMX-TMP prescription, decrease use of urine culture and sensitivity analyses, and increase the frequency of 3-day antibiotic treatments at our institution.

Mayo Clin Proc. 2007;82(2):181-185


EMR=electronic medical record; SMX-TMP=sulfamethoxazole-trimethoprim; STD=sexually transmitted disease; UTI=urinary tract infection



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Urinary tract infection (UTI) is a common chief complaint at primary care offices, accounting for approximately 8.3 million physician visits per year. 1 Because UTI is a common illness, its diagnosis and treatment have important implications for patient health, development of antibiotic resistance, and health care costs. Several evidence-based guidelines and reviews have provided diagnostic and management strategies. 2-5 These guidelines argue against performance of urine culture and sensitivity analyses in patients with classic signs and symptoms of uncomplicated UTI. Furthermore, sulfamethoxazole-trimethoprim (SMX-TMP) for 3 days is advocated as the antibiotic of choice because of its low cost and efficacy.

With this information available, it would seem logical that physician practice would conform to published practice guidelines. However, the reality is that many physicians continue to practice largely independent of these recommendations. 6-11 One study in 1999 of more than 2100 physicians found great variability in UTI management. 6 Many physicians continued to obtain urine cultures. Nearly 30% did not use SMX-TMP as the first-line agent, and almost half of obstetrician-gynecologists used nitrofurantoin as their antibiotic of choice in nonpregnant, low-risk patients. Only about half of physicians treated patients with antibiotics for the recommended 3-day duration. In 2003, a study analyzing more than 10,000 insurance claims found that physicians generally did not use SMX-TMP as the first-line agent, and the duration of treatment was often much longer than the recommended 3 days. 7 Studies have shown that urologists appear to have the best adherence to guidelines. 9 Nonadherence can profoundly affect health care costs.10

We hypothesized that a similar gap between national guidelines and physician practice patterns existed at our primary care practice. Thus, we retrospectively reviewed medical records to evaluate our physicians' practices for diagnosing uncomplicated UTI in female patients. The objectives of this study were to determine (1) the frequency of appropriate documentation of patient histories and essential physical examination findings, (2) the frequency of urine culture and sensitivity analysis being used as a diagnostic tool, (3) the efficacy of SMX-TMP as empirical treatment in this population of patients, and (4) the frequency of short-course (3-day) antibiotic treatments.


PATIENTS AND METHODS


We selected a cohort of women who were patients of the Mayo Clinic Scottsdale Family Medicine Center in Arizona in 2005. Patients were identified by using the diagnosis of UTI (International Classification of Diseases, Ninth Revision code 599.0). We reviewed medical charts and evaluated the first visit of the year in which a UTI was diagnosed. The visit was included for further analysis if the patient was seen in the physician's office for evaluation of symptomatic complaints. Visits were not included for further analysis if patients were being seen at follow-up for a previous evaluation performed elsewhere, were managed by telephone contact, or had urine testing performed for screening or other asymptomatic purposes. Patients with complicated UTI, as defined by the Institute for Clinical Systems Improvement guidelines, 3 were excluded. Exclusion criteria included age younger than 18 years and older than 65 years, symptoms for more than 7 days, documented or reported fever (temperature ≥38.3°C), nausea or vomiting, concomitant symptoms or diagnosis of vaginitis, reported or reproduced flank pain, a history of 4 UTIs in the past 12 months, or failure of SMX-TMP treatment of a UTI in the preceding 4 weeks. Pregnant women, nursing home residents, and individuals with functional or anatomical abnormality (polycystic renal disease, nephrolithiasis, neurogenic bladder, diabetes mellitus, immunosuppression, indwelling Foley catheter, or recent urinary tract instrumentation) were not included in this study. Therefore, patients who were not excluded on the basis of these criteria were considered to have had an uncomplicated UTI (ie, no signs or symptoms of upper urinary tract disease or markers of medical complications).

Data Collection

History and Physical Examination. We recorded the presence or absence of documentation from our electronic medical record (EMR) regarding potential signs and symptoms of uncomplicated UTI (dysuria, frequency, urgency, and hematuria). We collected data on the exclusion of upper urinary tract disease (patient denied fever and flank pain and the absence of fever or flank tenderness on examination) and vaginitis (absence of vaginal discharge or irritability symptoms and sexually transmitted disease [STD] risks). Whether physicians used an available documentation tool within our EMR for recording UTI patient visits was assessed. We also determined whether care was provided by a resident or an attending physician.

Diagnostic Studies. We collected information about performance and results of urine dipstick analyses, microscopic urinalyses, and urine culture and sensitivity analyses.

Treatment. Data collection on treatment included the antimicrobial prescribed and duration of therapy.

Statistical Analyses

We developed a data collection sheet on which to record information from our medical chart review. Data from these sheets were entered into an Excel database and analyzed using the SAS software package (Version 8.2, SAS Institute Inc, Cary, NC).

We used descriptive statistics to present frequencies, percentages, means, SDs, and ranges. We used the 2-sided χ2 test and the Fisher exact test to compare documentation rates, test utilization, and treatments provided between groups (eg, did vs did not use EMR documentation tool, attending physicians vs residents). We determined the antibiotic sensitivity patterns of Escherichia coli bacteria to SMX-TMP based on available urine culture and sensitivity analyses. A 2-sided 1-sample binomial test was used to compare the observed urine culture sensitivities for patients with uncomplicated UTI in the outpatient setting with rates reported for inpatients. All calculated P values were 2-sided, and P<.05 was considered statistically significant. This study was approved by the Mayo Foundation Institutional Review Board.


RESULTS


We identified 332 female patients who had a UTI diagnosis recorded in 2005. Of these 332 patients, 104 were excluded because they did not have an office visit for evaluation of symptomatic complaints (ie, they had initial evaluations elsewhere, were managed by telephone contact, or had testing performed for screening or other asymptomatic reasons). Thus, 228 patients met inclusion criteria, and their initial UTI visits were evaluated for exclusion criteria to determine whether their infections were uncomplicated or complicated. Sixty-eight patients (30%) had uncomplicated UTI ( Figure 1). The remaining 160 patients (70%) were determined to have complicated UTI and were excluded from further analysis.

The reasons for exclusion are listed in Table 1. The most common reason for exclusion was patient age older than 65 years (106/160 patients [66%]). The mean (SD) age of the 68 patients with an uncomplicated UTI was 41.2 (14.7) years, with a median age of 44.5 years and an interquartile range of 28 to 54 years. Forty-six patients (68%) were seen by a resident and 22 (32%) by an attending physician.

Documentation of History and Physical Examination Findings

Our physicians recorded essential history and examination findings for most patients (Table 2). For instance, the presence or absence of dysuria was documented in 64 (94%) of the 68 medical records. However, absence of vaginal discharge or irritation and absence of STD risks were documented less often (51% and 24%, respectively).


FIGURE 1. Inclusion and exclusion criteria. UA=urinalysis; UTI=urinary tract infection.





Use of our EMR documentation tool improved documentation rates for some aspects of the UTI history. Documentation of absence of vaginal irritation increased from 41% in the 53 encounters in which this tool was not used to 87% in the 15 encounters in which this tool was used ( P=.003). Residents were more likely to use this tool than were attending physicians (28% vs 9%, respectively; P=.12).

Residents documented some of the history and physical examination findings more often than did attending physicians. Residents were more likely to document absence of STD risks (30% vs 9%; P=.07), absence of flank tenderness (87% vs 55%; P=.006), and presence of suprapubic tenderness (96% vs 73%; P=.01).

Documentation of STD risk was affected by patient age. In the 14 patients who were 25 years of age or younger, a history of STD risk was documented in 6 (43%). However, in the 54 patients older than 25 years, this information was documented only in 10 (19%). Although this appears to be a clinically important difference, it was not statistically significant ( P=.08), most likely because of the small number of young patients.

Diagnostic Testing

We analyzed the performance and results of urine dipstick analyses, microscopic urinalyses, and urine culture and sensitivity analyses. In 57 (84%) of 68 patients with uncomplicated UTI, urine dipstick tests were ordered. Of these 57 patients, 41 (72%) had positive results on dipstick analyses for either leukocyte esterase or nitrites. Of the patients with positive results on urine dipstick analyses, 8 (20%) also had formal microscopic urinalyses performed in our laboratory, and 33 (80%) also had a urine culture performed.

Of 68 patients with uncomplicated UTI, 52 (76%) had a culture ordered during their office visits. Thirty-eight (73%) of the 52 cultures grew pathogens; 10 cultures had mixed flora (ie, were contaminated), and 4 had no growth. Thirty-five of the 38 urine cultures that grew pathogens were positive for E coli (ie, 92% of positive cultures had E coli). Nearly all E coli bacteria in our patients with uncomplicated UTI were sensitive to SMX-TMP (33/35 [94% sensitive]). In these patients with uncomplicated UTI, no E coli resistance was found to nitrofurantoin, ciprofloxacin, or cephalexin. E coli was sensitive to ampicillin-amoxicillin in only 25 (71%) of the 35 cultures. No study patient with uncomplicated UTI had treatment changed because of bacterial resistance found on her urine culture.



TABLE 1. Reasons for Exclusion as a Function of Patient Age*
Exclusion criteria
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TABLE 2. Documentation of UTI History and Physical Examination Findings in the 68 Patients With Uncomplicated UTI*
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Antibiotic Treatment

All 68 patients received antibiotic treatment. Twenty-six patients (38%) were prescribed SMX-TMP, and 36 patients received ciprofloxacin (53%). The mean treatment duration was 3.5 days with SMX-TMP and 4.3 days with ciprofloxacin. Sixty-one percent of SMX-TMP and ciprofloxacin prescriptions (38/62) were appropriately provided for 3 days. A similar proportion of attending physicians and residents prescribed the recommended 3-day course of antibiotics (13/22 [59%] and 26/46 [57%], respectively). There was a statistically significant difference between residents and attending physicians in the type of antibiotic used. Attending physicians prescribed ciprofloxacin for most of the patients they treated (14 [64%]) of the 22 prescriptions they wrote), whereas residents prescribed either SMZ-TMP or ciprofloxacin with equal frequency (22 [48%] of the prescriptions for each antibiotic) ( P=.01).

Comparing Outpatient to Inpatient Urine Culture and Sensitivity Patterns

We determined that urine culture sensitivity patterns for uncomplicated UTI in outpatients were significantly different from those of inpatients. E coli bacteria were sensitive to SMX-TMP in 94% of outpatient cultures, whereas they were sensitive in only 76% of inpatient cultures ( P=.01). E coli was also significantly more sensitive to other antibiotics for outpatient cultures (ciprofloxacin, 100% vs 81%; P=.001; cephalexin, 100% vs 90%; P=.05). Ampicillin-amoxicillin was a poor treatment choice for E coli UTI because of high rates of resistance. Sensitivity patterns between outpatients and inpatients were not significantly different (71% vs 59%; P=.18).


DISCUSSION


Evaluating and treating patients with UTI symptoms is a common situation for primary care physicians. National guidelines have advocated identification of patients with uncomplicated UTI through risk stratification and empirical therapy with SMX-TMP if resistance rates to E coli are low.2,3 Only 30% of our patients had uncomplicated UTI, making their management within clinical guidelines appropriate. However, of those patients with uncomplicated UTI, less than 25% received empirical treatment as suggested. Our patient population is older, with many having complicating medical problems. Most patients in our practice require office-based evaluation and confirmation of effectiveness of the chosen antibiotic based on urine culture and sensitivity results.

For patients with uncomplicated UTI, our documentation of essential history and physical examination findings appeared adequate. For example, the documentation rates of dysuria and frequency symptoms were good. Residents performed slightly better in some aspects of providing documentation in patient medical records compared with attending physicians; those using our EMR documentation tool performed best. We suggest use of a prompted or formatted guide for medical record documentation or dictation.

Consistent with physician behaviors seen in prior studies,5- 7 our attending physicians were not judicious in ordering urine dipstick analyses, formal urine analyses, or urine cultures. Many dipstick tests were ordered for patients who, based on history and examination, already had a 90% probability of UTI. 5 Despite the high probability of disease evident from positive results on urine dipstick testing, physicians frequently ordered urine culture and sensitivity testing. Furthermore, despite the associated cost, time, and effort, urine culture results did not necessitate change in treatment for any of our patients with uncomplicated UTI.

Treatment with SMX-TMP was not provided for most of our patients even though this has been recommended as the first-line antimicrobial agent by multiple guidelines. For example, the Infectious Diseases Society of America recommends that SMX-TMP is the treatment of choice in areas where the rate of E coli sensitivity is 80% or greater.2 Our results were similar to those of McEwen et al, 7 who reported that 37% of physicians prescribe SMX-TMP for uncomplicated UTI. We not only underprescribed SMX-TMP but also overprescribed fluoroquinolones. This was especially true among our attending physicians.

Our prescribed duration of therapy was often longer than the recommended 3 days. Of the 62 patients treated with SMX-TMP or ciprofloxacin, 24 (39%) were given antibiotic courses for more than 3 days. Kahan et al 11 reported that, even when physicians choose an appropriate antibiotic, duration of therapy was incorrect a vast majority of the time.

Physicians may be using sensitivity data from their hospitalized patients to guide empirical treatment of their outpatients with UTI. Although we have seen increasing resistance of E coli to SMX-TMP in the inpatient setting, our findings in the outpatient setting for uncomplicated UTI were significantly different. It has been recommended that physicians monitor resistance patterns in their own patient populations to determine whether SMX-TMP is an appropriate choice in their setting. 8,12

Simple changes in our practice environment may decrease costs and simplify care. Having the ability to order a formal urinalysis with completion of culture only when the number of epithelial cells seen on microscopy is small would be helpful (ie, a urinalysis with reflex culture). Eleven (21%) of 52 cultures in this low-risk patient group had mixed flora, indicating contamination.

Limitations

Our physicians ordered urine cultures frequently and did not prescribe SMX-TMP appropriately. These behaviors may be explained by the fact that our patient population is older and medically complicated. It appears that we often treat patients with uncomplicated UTI in a manner advocated for complicated UTI. Our rate of SMX-TMP use may be artificially low due to the fact that we did not account for the presence of medication allergies, intolerances, or contraindications. We did not account for the effect of patient preferences or past experiences in the decision about treatment options. One hundred percent compliance with all aspects of clinical guidelines may not be a reasonable or even desirable goal.

Some practice guidelines also allow for the use of telephone triage and empirical treatment of uncomplicated UTI without a clinical visit. 3,13 We excluded these interactions from this analysis and believe that this was an infrequent occurrence in our practice.

Future Research

Now that we have determined our baseline behaviors, we plan to provide educational interventions in hopes of seeing changes in our physicians' practice patterns. We hope to be able to decrease the frequency with which urine culture and sensitivity analysis is being used as a diagnostic tool in uncomplicated UTI and increase the frequency of 3-day treatment with SMX-TMP. Also, we plan to evaluate our management of patients older then 65 years as they account for nearly half of our patients with UTI. Determining whether antibiotic resistance on urine culture and sensitivity analysis is a function purely of age or instead is due to the medical complications of a specific patient would be helpful in making decisions about the utility of diagnostic testing.


CONCLUSION


Discrepancies exist between physician practice behaviors and published guidelines. Using these evidence-based algorithms for the diagnosis and management of UTI can be helpful only when one carefully assesses patients for complicating factors. Only 30% of our patients had uncomplicated UTI, making their management within clinical guidelines appropriate. However, of those patients with uncomplicated UTI, less than 25% received empirical treatment as suggested. Urine culture and sensitivity analyses were performed frequently, even in patients who already had positive results on a urine dipstick analysis. Although SMX-TMP is effective, it is underused. We hope to improve adherence to published guidelines through education and practice support. We suggest that medical groups review their own patient populations and practice behaviors through similar quality improvement processes.

REFERENCES

Centers for Disease Control and Prevention, US Department of Health and Human Services. Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: United States, 1999-2000. Available at: www.cdc.gov/nchs/data/series/sr_13/sr13_157.pdf. Accessed December 21, 2006.


Warren JW, Abrutyn E, Hebel JR, Johnson JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women: Infectious Diseases Society of America (IDSA). Clin Infect Dis. 1999;29:745-758.


Kasten MJ, Gravley E, Olson D, et al. ICSI Health Care Guideline: Uncomplicated Urinary Tract Infection in Women. Bloomington, MN: Institute for Clinical Systems Improvement. Available from: www.icsi.org/knowledge/detail.asp?catID=29&itemID=200 . Accessed December 21, 2006.


Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. Am Fam Physician. 2005;72:451-456.


Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute uncomplicated urinary tract infection? JAMA. 2002;287:2701-2710.


Wigton RS, Longenecker JC, Bryan TJ, Parenti C, Flash SD, Tape TG. Variation by specialty in the treatment of urinary tract infection in women. J Gen Intern Med. 1999;14:491-494.


McEwen LN, Farjo R, Foxman B. Antibiotic prescribing for cystitis: how well does it match published guidelines? Ann Epidemiol. 2003;13:479-483.


Raz R, Chazan B, Kennes Y, et al, Israeli Urinary Tract Infection Group. Empiric use of trimethoprim-sulfamethoxazole (TMP-SMX) in the treatment of women with uncomplicated urinary tract infections, in a geographical area with high prevalence of TMP-SMX-resistant uropathogens. Clin Infect Dis. 2002 May 1;34:1165-1169. Epub 2002 Apr 4.


Kahan NR, Friedman NL, Lomnicky Y, et al. Physician specialty and adherence to guidelines for the treatment of unsubstantiated uncomplicated urinary tract infection among women. Pharmacoepidemiol Drug Saf. 2005;14:357-361.


Kahan NR, Chinitz DP, Waitman DA, Kahan E. Empiric treatment of uncomplicated UTI in women: wasting money when more is not better. J Clin Pharmacol Ther. 2004;29:437-441.


Kahan NR, Chinitz DP, Kahan E. Physician adherence to recommendations for duration of empiric antibiotic treatment for uncomplicated urinary tract infection in women: a national drug utilization analysis. Pharmacoepidemiol Drug Saf. 2004;13:239-242.


Ansbach RK, Dybus K, Bergeson R. Uncomplicated E. coli urinary tract infection in college women: a follow-up study of E. coli sensitivities to commonly prescribed antibiotics. J Am Coll Health. 2005;54:81-84.


Saint S, Scholes D, Fihn SD, Farrell RG, Stamm WE. The effectiveness of a clinical practice guideline for the management of uncomplicated urinary tract infection in women. Am J Med. 1999;106:636-641.