Clinical Practice Guidelines 2019

Approach to uncomplicated recurrent UTIs in women: 10 Key Takeaways

Clinical practice guidelines on the diagnosis and treatment of uncomplicated recurrent urinary tract infections (UTIs) in women were released this year by the American Urological Association (AUA), Canadian Urological Association (CUA), and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) and published online May 1, 2019 in the Journal of Urology. 

Here are 10 key takeaways from the guidelines.

1.     A complete patient history must be elicited along with pelvic examination in women presenting with recurrent UTIs.

2.     Documentation of positive urine cultures associated with prior symptomatic episodes in order to make a diagnosis of recurrent UTI. Repeat urine test if initial urine specimen is suspect for contamination.

3.     Routine cystoscopy and upper tract imaging should be avoided in the index patient (otherwise healthy adult female with an uncomplicated recurrent UTI).

4.     Urine examination, urine culture and sensitivity should be obtained with each episode of symptomatic acute cystitis before starting treatment.

5.     Do not treat asymptomatic bacteriuria in patients.

6.     Use first-line therapy - nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), fosfomycin - depending on the local antibiogram for the treatment of symptomatic UTIs.

7.     Antibiotics should be prescribed for a short duration as is reasonable; usually no longer than 7 days.

8.     In patients with recurrent UTIs experiencing acute cystitis episodes associated with urine cultures resistant to oral antibiotics, treat with short-term (no longer than 7 days) culture-directed parenteral antibiotics.

9.     On follow up, post-treatment test of cure urinalysis or urine culture in asymptomatic patients is not to be done. But, if symptoms persist, then repeat urine cultures should be obtained to guide further management.

10.  In peri– and post–menopausal women with recurrent UTIs, vaginal estrogen therapy may be used to reduce the risk of future UTIs if there is no contraindication to estrogen therapy

(Source: Anger J, et al. Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU Guideline. J Urol. 2019 May 1:101097JU0000000000000296)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Clinical Practice Guidelines 2019 Acute lower gastrointestinal bleeding: 10 Key Takeaways

This year, the British Society of Gastroenterology released clinical practice guidelines on the diagnosis and management of acute lower gastrointestinal bleeding published online April 8, 2019 in the BMJ. 

Here are 10 key takeaways from the guidelines.

1.     Patients who present with low GI bleeding should be first categorized as unstable (shock index >1) or stable. The Oakland score can be used to categorize stable bleeds as minor or major. Patients with minor self-terminating bleed (Oakland score ≤8) can be discharged for urgent outpatient investigation, if there are no indications for hospitalization. But patients with major bleed should be hospitalized for colonoscopy on the next available list.

2.     Before planning endoscopic or radiological therapy, localize the site of bleeding quickly and least invasively via CT angiography in hemodynamically unstable patients or those who have shock index >1 after initial resuscitation and/or in whom active bleeding is suspected.

3.     If not source of bleeding can be identified on initial CT angiography in hemodynamically unstable patients, an upper GI endoscopy should be performed immediately. Gastroscopy may be the first investigation when patient stabilizes after initial resuscitation.

4.     If a source of bleeding is found on CT angiography, a catheter angiography with a view to embolization should be done at the earliest. Centers with a 24/7 interventional radiology service should be capable of performing catheter angiography for hemodynamically unstable patients within 60 minutes of admission

5.     Patients should not proceed to emergency laparotomy unless an exhaustive effort has been made to localize the source of bleeding using radiologic and/or endoscopic modalities.

6.     Restrictive red blood cell (RBC) thresholds (Hb trigger 70 g/L and Hb concentration target of 70-90 g/L post transfusion) should be used in clinically stable patients who need RBC transfusion. The trigger and target should be 80 g/L and 100 g/L, respectively in patients with a history of cardiovascular disease.

7.     Interrupting warfarin therapy at presentation is recommended. In patients with low thrombotic risk, warfarin should be restarted at 7 days after hemorrhage. In patients with high thrombotic risk (ie, prosthetic metal heart valve in mitral position, atrial fibrillation with prosthetic heart valve or mitral stenosis, <3 months after venous thromboembolism, low molecular weight heparin (LMWH) should be considered at 48 hours after the bleeding.

8.     Permanently discontinue aspirin for primary prophylaxis of cardiovascular events. But, restart aspirin for secondary prevention, if stopped, as soon as hemostasis is achieved. 

9.     Routine stopping of dual antiplatelet therapy with a P2Y12 receptor antagonist and aspirin is not recommended in patients with coronary stents in situ; a cardiologist should be part of the management team. Continue aspirin if P2Y12 receptor antagonist is interrupted if unstable hemorrhage; restart P2Y12 receptor antagonist within 5 days.

10.  Direct oral anticoagulant therapy should be interrupted at presentation. Treatment with inhibitors such as idarucizumab or andexanet should be considered for life-threatening hemorrhage in patients on direct oral anticoagulants. Restarting direct oral anticoagulant drug treatment at a maximum of 7 days after the bleeding.

(Source: Oakland K, Chadwick G, East JE, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut. 2019 May;68(5):776-789)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Clinical Practice Guidelines 2019

Treatment of diabetes in older adults: 10 Key Takeaways

This year, the Endocrine Society released clinical practice guidelines on the diagnosis and management of diabetes and its comorbidities in older adults aged 65 years and above published May 1 in the Journal of Clinical Endocrinology & Metabolism. 

Here are 10 key takeaways from the guidelines.

1.     Screen for diabetes and prediabetes (fasting sugar, A1c, 2-hour OGTT) in patients aged 65 years and older without known diabetes.

2.     Periodically screen older patients with diabetes for undiagnosed cognitive impairment. If mild cognitive impairment present, simplify medication regime and glycemic targets to improve compliance.

3.     Lifestyle modification is the first-line treatment of hyperglycemia in ambulatory patients with diabetes.

4.     Assess nutritional status to detect and manage malnutrition. In frail patients, use diets rich in protein and energy to prevent malnutrition and weight loss. Avoid restrictive diets.

5.     Metformin is the first choice oral hypoglycemic agent to treat diabetes, but not for patients who have significantly impaired kidney function (estimated glomerular filtration rate (eGFR) 30 mL/min/1.73 m2) or have a gastrointestinal intolerance. Add other oral hypoglycemic agents and/or insulin if glycemic control is not achieved with metformin and lifestyle management.

6.     Keep target BP140/90 mm Hg in patients with diabetes to reduce risk of cardiovascular disease outcomes, stroke and progressive chronic kidney disease (CKD). Use angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) as the first-line therapy in patients with diabetes and hypertension.

7.     An annual lipid profile and statins are recommended in patients with diabetes to reduce absolute cardiovascular disease (CVD) events and all-cause mortality

8.     Use low dose aspirin (75-162 mg/day) for secondary prevention of CVD after careful evaluation of bleeding risk and collaborative decision-making with the patient, family and other caregivers.

9.     Annual eye examination (by an ophthalmologist) to detect retinal disease; annual screening to detect CKD with eGFR and urine albumin-to-creatinine ratio.

10.  Minimize use of sedative drugs or drugs that promote orthostatic hypotension and/or hypoglycemia in patients with diabetes and advanced chronic sensorimotor distal polyneuropathy; refer to physiotherapy to reduce risk of fractures and fracture-related complications.

(Source: LeRoith D, et al. Treatment of Diabetes in Older Adults: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab. 2019 May 1;104(5):1520-1574).

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA