Thank you for giving us the opportunity to present our research. We have no disclosures. In 2012, the AUA published guidelines on the evaluation and management of microscopic hematuria in adults. But immediately after this publication, there was a bit of an uproar in the urogynecology community, mostly because the implications of microscopic hematuria in women is different than in men. Urological malignancy is about three to four times more common in men. Last year, there was a study that identified several risk factors for malignancy in women, which include having an age greater than 60, smoking history, and gross hematuria. Several months after publication of this study, ACOG and AUGS published a committee opinion that changed some of our guidelines on microscopic hematuria. They advised that we did not need to screen asymptomatic, low-risk women under the age of 50, as long as they had less than 25 red blood cells per high-power field, because cancer risk was less than or equal to 0.5%. Given these different screening criteria, we sought to determine the cost-effectiveness of the two screening strategies currently used for evaluation of asymptomatic microscopic hematuria in non-smoking, low-risk women aged 40 to 59 in a hypothetical population of 10,000 women. We hypothesized that the gender-specific screening criteria proposed by the ACOG-AUGS protocol would be more cost-effective and have improved quality-of-life implications, due to the less likelihood of developing false-positive results, contrast-induced nephropathy, and UTIs. We designed a decision analysis using TreeAge software in the health care third-party payer perspective, with our time horizon terminating at tissue diagnosis. All probabilities, life expectancies, utility scores, and costs were obtained from the literature and translated at $2,018. Sensitivity analyses were performed for all variables in this model. Our primary outcome was incremental cost per cancer diagnosis detected, and our secondary outcome was incremental cost-effectiveness ratios. For our primary outcome, we assumed a cancer rate of 0.7%. In the gender-specific ACOG-AUGS criteria, we would potentially detect 48 cancers at a cost of $4.6 million. This translates to a cost of about $97,000 per cancer case detected. When moving on to the AUA protocol, this protocol would detect 68 cancers at a cost of $17.1 million. These 20 additional cases would cost $626,000 for each additional case detected. When looking at our secondary outcome, which was incremental cost-effectiveness ratio that includes our quality of life benefits, the specific ACOG-AUGS criteria had a quality-adjusted life year of 37.13 compared to an AUA protocol of having a quality of 36.77. Because of the decreased cost and increased quality of life associated with this gender-specific ACOG criteria, this protocol is perceived to be dominant over the AUA protocol. In conclusion, the ACOG-AUGS gender-specific strategy, because it is less costly and improves quality of life, is perceived to be more dominant over the AUA screening strategy, which would have an additional cost of $600,000 per cancer diagnosis detected. Although our model does have an increased number of missed diagnoses in the specific ACOG criteria, we assume a 0.7% cancer rate in this conservative screening strategy. Most studies are now noting that there may be a 0% cancer rate in this specific group. Inherent to our study are limitations that are with cost-effectiveness analysis in general, including that it is driven by retrospective studies, and we've had several simplifying assumptions to run this model. But nevertheless, we are able to show that the ACOG-AUGS criteria is less costly and potentially has more quality of life benefits. Good afternoon. My co-investigators and I appreciate the opportunity to present our work. These are our disclosures. For the nearly 600,000 women who undergo hysterectomy annually in the United States, avoidance of surgical complications is of paramount importance. Among the common intraoperative complications, bladder injury has been reported in up to 4.4%, and ureteral injury in up to 2.7%, depending on the study and mode of hysterectomy. Use of cystoscopy to facilitate intraoperative detection and decrease morbidity is the norm in FPMRS, but the question of how often it should be used in benign hysterectomy without concomitant procedures remains controversial. We decided to update and expand upon the landmark cost-effectiveness analysis done by Visco et al in 2001. That analysis examined ureteral injury only at the time of abdominal, vaginal, or laparoscopically-assisted vaginal hysterectomy. And given changing practice patterns and further study into urinary tract injury, we plan to include both bladder and ureteral injury and to add a model for laparoscopic and robotic hysterectomy with further nuance into the cost of diagnosis and treatment options. We sought to compare the cost of a strategy of routine, selective, or no cystoscopy at the time of benign hysterectomy. This is a simplified version of the decision analysis model created using TriagePro. We created separate models for abdominal, laparoscopic robotic, and vaginal hysterectomy. We modeled bladder and ureteral injuries detected intraoperatively and postoperatively. The risk of cystoscopic false positive or negative for ureteral injury was included. Potential costs of the diagnosis and treatment are seen in the box to the right. This table reflects the results of our analysis. Selective cystoscopy was defined as the practice of performing cysto at the surgeon's discretion for any case in which the risk of urinary tract injury was elevated above baseline. Assuming currently reported risks of injury, performing selective cysto adds between $13 and $26 to the cost of surgery. Routinely performing cysto would add an additional $51 to $57. With increased risk of urinary tract injury, selective cystoscopy and eventually routine cystoscopy become cost-saving strategies. This is particularly true of vaginal hysterectomy, in which selective cystoscopy becomes cost-saving at a relatively low threshold, as it has the lowest cost of adding cystoscopy. Keep in mind that these percentages are not the incidence of urinary tract injury the surgeon has experienced historically, but can be used in a specific surgical case. So that if intraoperatively, during a vaginal hysterectomy, the risk of ureteral injury is estimated at 4%, then the intraoperative decision to selectively perform cystoscopy would be cost-saving. Our study's strengths and weaknesses are directly related to the strengths and weaknesses of the data we incorporated into our model. We believe that in creating a detailed model for each hysterectomy modality using the strongest available literature, we have addressed a timely question that cannot be answered feasibly with a randomized controlled trial. When prospective data were lacking, we did incorporate retrospective data, but then used sensitivity analysis to ensure that variations in our inputs did not significantly change our conclusions. Finally, the model is for benign hysterectomy without concomitant procedures and should not be generalized to GYN surgical subspecialties. Intuitively, we found that cystoscopy becomes cost-saving with increasing risk of injury. That being said, the decision to perform cystoscopy is more than a simple financial calculation. In some cases, urinary tract injury occurs despite meticulous surgical technique, and cystoscopy adds minimally to the cost of hysterectomy. Given the relatively low cost, we recommend that those performing benign hysterectomy in the absence of concomitant procedures have a low threshold to perform selective cystoscopy if there is any concern for increased risk of urinary tract injury. Thank you. Thank you, Dr. Kaddish. Do you have questions from the audience, some from urology? Go ahead. Toby? Toby Chai from Yale. I have a question for Dr. Duda. I noticed you have a specific word in your title. It's the word screening. And I think the problem is we don't know why urinalysis are sent. I don't think screening is necessarily a good word because we don't know what symptoms are. So it's an intent type of purpose. And screening, to me, has a very specific epidemiologic idea of asymptomatic people that you're looking for a certain disease. As far as I know, for urologic malignancy, there is no clear-cut evidence that screening for renal cell urothelial carcinoma using urinalysis is indicated. So I don't know. You run those calculations. Are you talking about a screening program, which I think is a different discussion altogether, or incidental hematuria comes up on somebody that says, I feel something down there? Right. I'm more so thinking about the fact that the reflex that we have when someone is found to incidentally have microscopic hematuria on a urinalysis that was sent, not as a screening tool, but as a follow-up evaluation of that finding. Hi, Dr. Lequette. I have a question for Dr. Kaisman-Schmokler about your post-operative management of the fistula repair. How long do you leave a catheter in? Do you use suprapubic? Do you do double drainage? And do you do any sort of post-procedure imaging before removing the catheters? So we usually would use a ureteral Foley catheter in for about two weeks. And then we typically would do imaging to confirm bladder integrity before. So two weeks in a CT cystogram? Yes. So because I've had two recently where we've actually left it in longer, done the CT cystogram, and the radiologist has called a persistent fistula. And so I left it in. I actually just took it out last week. Left it in for another month, very complicated, bad diabetic, and redid the CT cystogram. It had persistent. They called it again, and I was like, there's just no way. So we did a retrograde fill in the office. It was totally healed, but it was just like a little outpouching. So what you're describing with the LABSCO, just knowing that it can create something that looks like a persistent fistula, is just the residual of that tract. So the office test is helpful. Yeah, that makes sense. I have a question for Dr. Adeta. So for the guidelines, the ABOG guidelines for women are no imaging or renal ultrasound? Less than 50 are no imaging. As long as they're low risk, no smoking history, less than 25. It's hard, because in neurology, if you miss a bladder cancer, it's really, really bad. And that's what drives the guidelines. And I just think this is really an opportunity for the two specialties. Like Dr. Mueller talked about today, the two specialties, we should not have separate guidelines. And I think the other really important point, we were doing a study where we're taking avoided in the calf urine from every woman who comes in with microheme. And only a small percentage actually even have microscopic blood in the urine. And so they really are different animals. But I think we need to be able to come together on this, because it's a really important issue. I agree. And Dr. Adeta, a really nice presentation. And just a thought, because one thing that never enters this equation is the real cost of all those CT urograms possibly causing cancer. And really, when you did the true cost-effective analysis, somehow you've got to get to that data too. And it's particularly a problem in these very young women, in the 35, 45-year-old women who are getting CT urograms. So if you can get more data about that and put that into your cost-effective analysis, it would be very beneficial. Yeah, we were also trying to figure out if there's any way to get the utility score of just the anxiety associated with this whole workup. But that's also a very hard number to find to include in this whole process. So thank you very much to these presenters. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. First is Dr. Elmer Lyam, UTI and drug-resistant UTI after intradetrusor onobotulinum toxin A injection versus sacral neuromodulation. Is that right? Is the? Is that right? Oh, it's fine. Yeah, it's fine. Is that OK? OK. Great. Thank you for the opportunity to present our work. Overactive bladder, or sorry, let's see. I have no disclosures. Overactive bladder and urgency urinary incontinence affect nearly 20% of adults in the United States. Intradetrusor onobotulinum toxin A injections, or Botox, and sacral neuromodulation, or InterStim, are recommended in the 2015 AUA-SUPU guideline amendment as third-line treatments for OAB. Despite the high efficacy rates of Botox, it also has a well-known risk of UTI. Recent studies demonstrate up to 25% risk of UTI following Botox 100 units, and up to 36% risk following Botox 200 units. With higher UTI rates comes the possibility of increased drug resistance. In the most recent summary of data reported to the NHSN at the CDC, catheter-associated E. coli resistance rates increased between 2011 and 2014, and overall multidrug resistance increased from 5.5% to 8%. As health care institutions and payers become increasingly concerned about quality and value-based care, rising antimicrobial drug resistance and its effect on society is an important topic for discussion. Our first primary outcome was the proportion of patients with UTI and multidrug-resistant UTI in each treatment group at different time intervals. MDR-UTI was defined as bacterial resistance to at least one antibiotic per drug category, and at least three predefined drug categories consistent with criteria most recently used by the CDC. For our second primary outcome, we assessed the potential increasing effect of multiple treatments with Botox on UTI rates and MDR-UTI rates. Secondary outcomes included patient risk factors for UTI and MDR-UTI, as well as utilized health care resources in treating UTI and MDR-UTI in these patients. We included female patients 18 years and older undergoing Botox and interstim procedures between January 1, 2012 and December 31, 2016. Patients were excluded if they required pre-procedure bladder catheterization or if the indication for interstim was urinary retention. Other exclusion criteria are listed. 220 patients were assessed for eligibility. 101 patients were included in the study, 28 Botox and 73 interstim. Botox patients were younger and had more neurogenic bladder. Interstim patients were more likely to be diagnosed with interstitial cystitis or bladder pain syndrome. They were otherwise similar in baseline characteristics. The proportion of patients with any treated UTI was similar in both Botox and interstim groups, ranging from 4% to 11% in the first month and 37% to 39% overall in the first year. This was true for all treated UTI at every time interval assessed. Only one MDR UTI was identified occurring after interstim. Risk of UTI did not increase with repeat Botox injections, but overall, the subjects receiving repeat injections were few. Multivariate analysis found an increased odds of any UTI in patients with a history of recurrent UTI with an odds ratio of 2.5, which approached significance, and history of prolapse repair with an odds ratio of 4.5 after either Botox or interstim. This was verified controlling for procedure type. We analyzed resource utilization for treatment of UTIs and found no difference between the groups. In conclusion, UTI occurred in more than one third of patients after both Botox and interstim procedures. Results consistent with the Botox literature, but higher than that reported after interstim. This may reflect our patient population. We included patients with recent or history of recurrent UTI in neurogenic bladder who are often excluded from randomized trials. Reassuringly, MDR UTI was rare. Patients with a history of prolapse repair or recurrent UTI may be at higher risk for UTI after Botox and interstim. Thank you. Thank you for this opportunity. This research was supported by an August Foundation grant, and active study drug was donated by Pfizer. Recurrent urinary tract infection is common in postmenopausal women. In 1993, Ross found a significant decrease in UTI in postmenopausal women with estriol cream compared to placebo. However, the optimal agent and regimen of vaginal estrogen has yet to be concluded. Our objective was to assess the efficacy of vaginal estrogen versus placebo on the prevention of UTI in postmenopausal women with an active diagnosis of recurrent UTI. We hypothesized that vaginal estrogen would be superior to placebo in the prevention of UTI at six months. This is a multi-center, single-blind, placebo-controlled trial, which randomized women to vaginal estrogen in the form of estradiol ring or conjugated estrogen cream versus a placebo. Subjects were blinded from baseline to six months, and then were treated with open-label vaginal estrogen between 6 to 12 months. They could choose which form they wanted. Our primary outcome was a urinary tract infection defined by symptoms and a positive culture. Secondary outcomes including exploring the differences in mode of delivery, quality of life, as well as compliance. Postmenopausal women were included if they had a history of recurrent UTI by the WHO definition, had no recent or planned urologic surgery, no complex UTIs, had the ability to retain a vaginal ring, and they had to wash out of any vaginal hormones or UTI suppression. Our initial sample size calculation showed 23 subjects in each of the three groups. This was based on the ROS data, where 63% of those in the placebo group had a urinary tract infection within six months, and 50% attrition was seen. We ended up amending our study due to difficulties in recruitment and combined both of the estrogen groups and realized that our dropout rate was in actuality 20%, meaning our number needed was 48. Appropriate statistical analyses were conducted. The number referred for the study was 45. The number consented was 38, and 35 were randomized. Of the 35 randomized, 17 were randomized to the vaginal estrogen group, and 17 to placebo. At our six-month primary outcome, 15 remained in the vaginal estrogen group, and 11 in the placebo group. Of those in the ring group, 100% decided to continue on to open label, whereas only 57% in the cream group did, and 91% in placebo. Of those in the ring group, all eight chose to continue on with the ring. In the cream group, one switched over to ring, and three continued with cream. In the placebo group, eight chose ring, and two chose cream. There were no demographic differences in any of the three groups, including the number of urinary tract infections in the year prior to enrollment in the study. In both the intent to treat as well as the as-treated analysis, approximately 50% of those women in the vaginal estrogen group had a urinary tract infection in six months, whereas greater than 90% of those in the placebo group did. When looking at the two modes of delivery, ring was superior to placebo at six months in preventing urinary tract infections. However, there was no difference seen in the cream versus the placebo group in the same time period. Those women treated with vaginal estrogen reported a more than double percent improvement than those in the placebo group, but there were no other differences between estrogen and placebo in any other quality of life measure. Of those 10 women who were initially randomized to placebo who decided to continue on to open label, 90% had a urinary tract infection in their first six months, whereas only 30% had a UTI when treated with vaginal estrogen. Compliance overall with the ring was high. However, only three of those in the cream group continued on and were compliant for 12 months. Two subjects in the placebo group had three UTIs before six months and were unblinded and placed on open label vaginal estrogen per our protocol. Other adverse events were unrelated. Our study was limited by difficult recruitment, which took us three years to not make our sample size. Only two vaginal estrogen options were studied. It was single blind and underpowered for secondary outcomes. However, this was a randomized placebo-controlled multicenter trial that looked at multiple forms of vaginal estrogen in the current doses that we use. And we had significant findings despite our low enrollment. In conclusion, vaginal estrogen is superior to placebo at preventing recurrence of a UTI amongst postmenopausal women. Estrogen ring is superior to placebo, but there's further study needed of the estrogen cream. Perception of improvement with estrogen treatment is greater than placebo. And compliance with the estradiol ring is high, which may account for our observed differences. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you very much for the opportunity to present. And I am a member of the Loyola Urinary Education and Research Collaborative. We have no relevant disclosures for this presentation. So our study aims are to measure bacterial abundance of voided urine samples using a midstream collection of ice called Kizi and compare this to the standard clean catch method. We also aim to measure the efficacy of a wipe prior to voided urine collection in reducing bacterial abundance. Overall, we aim to identify a non-invasive urine collection technique for future female urinary microbiome research. I want to walk us through the Kizi midstream device, as many of us may not have heard of this before. The device looks like a funnel, and the woman needs to have a full bladder to utilize it. You first sit far back on the toilet, and you position the PZ as such. You then begin to urinate into the device. About 10 milliliters of urine flow through initially, and a small sponge engages at the bottom of the device, capturing the remaining portion of the urine. The urine then flows through a one-way valve into the collection tube. Once the tube is filled, the remaining portion of the urine is discarded through the device into the toilet. Our methods include all participants collecting a periurethral swab prior to voided urine collection as a means for control. We then randomized our participants to collect urine and instructed them using a video. They were either in the standard clean catch with a wipe, PZ with wipe, or PZ alone arm. The periurethral swab and voided urine samples were sent for expanded urine culture and colony forming unit analysis. One of our primary outcome measures was the bacteria quantity between the swab and the urine for each woman. In our figure on the x-axis, you see colony forming units per milliliter. And I'll be walking through PZ, PZ with wipe, and standard clean catch data. In maroon is our periurethral swab, and yellow is our voided urine sample. As a reminder, the swabs were collected prior to urine collection as a means of control for each woman. The difference in periurethral colony forming units was not statistically significant between our sample groups. However, we see a statistically significant reduction in bacterial abundance with PZ, with PZ and wipe. And we do not see the same significant reduction in colony forming units in voided urine sample with the standard clean catch. Overall, we have a lower bacterial abundance in voided urine using PZ with or without a pre-void wipe. We wanted to further assess our data using diversity measures to characterize what type of bacteria we were seeing in the voided urine versus the periurethra. We assessed abundance, evenness, and richness of bacterial samples. We compared periurethral swab versus voided urine for each individual woman. PZ with and without the wipe showed us voided urine samples that were distinct from periurethral swabs, whereas the standard clean catch soda samples were the urine was more similar to the periurethra. Strengths of our study include the standardized video based instructions and use of an expanded urine culture technique, which is more sensitive and allows us to capture a wider range of bacteria. Limitations were a sample size of 62, our age range average of 30, and we had fit volunteers, average BMI of 25. In summary, the use of PZ with and without wipe resulted in urine with lower bacterial abundance and more distinct bacterial profiles between the periurethra and the urine. The wipe does not appear to significantly contribute or reduce to bacterial abundance in voided urine samples. We know the bladder is low biomass based on previous research. Therefore, urine samples should be similar. The periurethral mucosa is higher biomass. PZ collected urine samples appear to be more representative of the bladder microbiome based on the low biomass and significant diversity from periurethral bacteria. Therefore, PZ may be better than the standard clean catch for future female urinary microbiome research. However, validation with larger cohort size is needed. And as part of LURAC, we aim to speak for the peas, and we feel that this research is bringing us one step closer to doing that. Thank you. So first, we have Dr. Baird, the effect of catheterization on susceptibility of uropathogens following pelvic reconstructive surgery. Thank you very much for this opportunity to present our work. We have no relevant financial disclosures. Urinary tract infections are the most common adverse event after pelvic reconstructive surgery, likely at least partially due to the post-op catheterization required in many patients. Catheter-associated UTIs can be challenging to diagnose due to the vague symptoms and high rates of asymptomatic bacteria in these patients. While E. coli is the most common uropathogen in uncomplicated UTIs, a recent study by Cowan colleagues found that 40% of UTIs in patients after pelvic reconstructive surgery are caused by non-E. coli uropathogens. However, the effect of catheterization on the speciation of UTIs in this population is unclear. Therefore, our objectives were to determine whether bacterial uropathogens differed between catheterized and non-catheterized patients following pelvic reconstructive surgery and to determine whether antibiotic susceptibility of uropathogens differs between catheterized and non-catheterized patients. We hypothesized that positive urine cultures from catheterized patients are more likely to contain non-E. coli uropathogens that are not susceptible to commonly used first-line antibiotics. For this study, we utilized a single center retrospective cohort of all women with a positive urine culture within one year of pelvic reconstructive surgery. A priori, catheterization was defined as having an indwelling catheter within 48 hours of specimen collection. From microbiological data of each culture, we identified that uropathogen speciation and their antibiotic susceptibility to empiric antibiotics. For our primary outcomes, we categorized each culture as either E. coli positive or E. coli negative. Additionally, we classified each culture as susceptible or not susceptible to each of our antibiotics of interest. During our five-year study period, we identified 427 positive urine cultures from 317 unique patients. Age, BMI, menopausal status, and diabetes were similar between the catheterized and non-catheterized patients. However, vaginal estrogen use was more common in non-catheterized patients. Not surprisingly, we found that catheterized patients were more likely to have longer post-op catheterization and to be discharged home with a catheter. Turning our attention to the microbiological data, the majority of cultures from both catheterized and non-catheterized patients contained a single uropathogen. While E. coli was the most common uropathogen in both groups, it was only found in less than one-third of cultures from catheterized patients, compared to about half of cultures from non-catheterized patients. The most common uropathogen in E. coli negative cultures was enterococcus. After adjusting for age, BMI, diabetes, and vaginal estrogen use, we found that catheterized patients were more likely to have a non-E. coli urine culture, with this risk increasing with age, up to four times in our oldest cohort patients. When we next compared the susceptibility of uropathogens to empiric antibiotics, we found that catheterized samples were more likely to have at least one uropathogen in each group. And more likely to have at least one uropathogen that was not susceptible to sulfamethoxazole trimethoprim, nitrofuranturin, or cefazolin. In our logistic regression of sulfamethoxazole trimethoprim, catheterized patients and diabetics were each twice as likely to have a non-susceptible uropathogen. Next, we found that the effect of catheterization on the susceptibility to nitrofuranturin depended on whether the patient was a diabetic. Catheterization increased the risk of a non-susceptible uropathogen seven times in diabetic patients, compared to only a two times increased risk in those without diabetes. Finally, when we studied the susceptibility to cefazolin, we found that the effect of catheterization was enhanced with age, where catheterized patients of mean cohort age were five times as likely to have a non-susceptible uropathogen. But this increased up to 16 times in our oldest cohort patients. In this study, we found that cultures from patients catheterized within 48 hours of specimen collection were more likely to contain non-E. coli uropathogens that were not susceptible to sulfamethoxazole trimethoprim, nitrofuranturin, or cefazolin. Interestingly, we also found that the effect of catheterization was enhanced in the elderly and those with diabetes, indicating that these may be particularly at-risk populations. From these results, we would recommend that care should be taken in empirically treating catheterized patients following pelvic reconstructive surgery, and that susceptibility testing should be performed. Thank you. Thank you for the opportunity. These are our disclosures. UTIs are one of the most common infections. They affect up to 50% of women in their lifetime, and up to 50% of those experience recurrence of their infection in less than 12 months. There's a subset of patients, about two to 5%, that experience recurrent UTIs. The mainstay of treatment is generally antibiotics. However, the widespread use of antibiotics has adverse costs for the patient, including drug side effects, and adverse costs for the community, such as increasing antibiotic resistance. For a long time, the overarching dogma was that urine was sterile, but now we know that there is a microbiome present in the urine, as evidenced by gene sequencing and expanded culture techniques, and that this urobiome can contribute to both bladder health and disease. However, the urobiome of women with recurrent UTI is not well-described, and it could provide insights into the treatment and prevention process. Our objective was to describe the urinary microbiota of women with recurrent UTI using two different urine culture modalities, a standard culture and an expanded culture. This is a prospective observational study of women who met strict diagnostic criteria for recurrent UTI. We excluded anyone who had known abnormalities of the GU tract, any neuro- or immunologic disease, any malignancy, or current systemic infection. And we collected both a voided and a catheterized urine specimen at the same visit. And then these specimens were cultured using both the standard urine culture and the expanded quantitative urinary culture, or EQUC, which employs a greater number of growth conditions over longer periods of time. We collected data from 23 women. The average age was 69, average BMI was 26. Most were Caucasian and post-menopausal. 61% were already on vaginal estrogen, 44% self-reported overactive bladder. At the time of collection, 39% reported UTI symptoms, and a majority, 73%, reported antibiotic use within the last month. The top three symptoms for UTI were frequency, urgency, and dysuria. Other symptoms in this population included cloudiness, odor at 39%, incomplete emptying, low back pain, and hematuria at 9%. This chart shows the species composition identified in voided urine with species on the X-axis and detection frequency on the Y-axis. The blue bars represent expanded culture, which identified 38 unique species. The orange bars represent standard culture, which identified less than half of them. Again, less than half that amount at 14 species. From catheterized urine, the overall detection rate was lower, still with expanded culture identifying 17 unique species and standard identifying, again, less than half that amount at seven species. This chart is showing the uropathogens identified, and here we demonstrate that the culture modality as well as the source of urine can greatly influence the culture results. You see expanded culture on the left and standard culture on the right with catheterized urine on the top and voided on the bottom. If we look at the standard culture, we see that from both catheterized and voided specimens, the same six uropathogens are being identified, and those were Enterobacter, Enterococcus faecalis, E. coli is in the yellow, Klebsiella is in the orange, and then Proteus and Pseudomonas. If we look at the expanded culture, we see that a wider range of uropathogens are being identified, including several that were not identified from standard culture. Enterococcus faecalis was also identified by expanded culture at least four times more frequently than standard. And lastly, expanded culture identified up to two to three times more frequently uropathogens, 17 times versus 10 for cath and 37 versus 13 times for voided. Looking at symptoms and catheterized cultures, we see that 39% of the participants' cultures were dominated by uropathogens on both culture modalities, three were Klebsiella, three were E. coli, and then one each for other typical uropathogens. Surprisingly, 44%, almost half of those were asymptomatic, including all three which were dominated by E. coli. 39% reported UTI symptoms at the time of collection. More than half were negative on standard urine culture, and two of those which were negative on standard culture were actually positive on expanded culture. In conclusion, a minority of this cohort of women for current UTI were E. coli dominant, suggesting that this cohort may not be E. coli-centric. And many women are asymptomatic despite the detection of uropathogens in their urine. In this cohort, expanded culture was more sensitive than standard, displaying more frequent and more diverse uropathogen detection. And we also found that voided urine specimens contained a majority of the uropathogens detected, suggesting that these pathogens may reside in areas distal to the bladder. So given these findings, we can consider expanded culture from a catheterized sample in a symptomatic woman for current UTI with persistently negative standard cultures in order to better understand her pathogen burden. I'll be combining the two presentations, so excuse me if I talk a little fast. Thank you for allowing us to present our two abstracts. Here are our disclosures. UTIs are the most common bacterial infection, and 20% of women will go on to have recurrence. Postmenopausal women are particularly at risk. However, frequent and inappropriate antibiotic use can result in side effects, collateral damage to commensal bacteria, and antibiotic resistance. Yet, identification of recurrent UTI, evaluation for recurrence, and initiation of therapy for prevention of UTIs is often overlooked. The aim of our first abstract was to identify the diagnosis of UTI and recurrence in women aged 45 or older, describe antibiotic prescription patterns in this population, compare initial antibiotic choice to IDSA guidelines, and examine antibiotic-associated adverse events. The aim of our second study was to examine the evaluation of UTI through laboratory testing and imaging, and to identify prescriptions for medications used for UTI prophylaxis in women who meet criteria for recurrence. We used the MarketScan database for our study. MarketScan is an excellent database as it tracks both inpatient and outpatient medical encounters and pharmacy patient claims, allowing us to longitudinally follow patients' treatment for UTI and recurrence. Uncomplicated UTIs were defined as ICD-9 codes associated with an antibiotic prescription between zero to 14 days after UTI diagnosis. Recurrence was defined as more than three in one year and more than two in six months. Index UTI was defined as the first in a series of recurrence, or the sole UTI in those who did not meet definition for recurrence. We excluded factors that could complicate UTI, as well as history of immunocompromised and any active concomitant infections. ICD-9 codes for medical conditions that could increase risk of UTI were identified. Antibiotics for the Index UTI was considered as the first antibiotic prescribed within the zero to 14 days of less than 30 days duration. IDSA guidelines were used to define first line, second line, and other antibiotics. Adverse events included allergic reaction and C. diff infection. We examined evaluation for UTI through the following laboratory testing and imaging modalities. We identified prescriptions for medications commonly used for UTI prophylaxis, including long-term antibiotics, vaginal estrogen, methamphetamine mandelate, and methamphetamine heparate. Data was used for analysis. Descriptive characteristics were described using percentages. Comparisons were performed between those who did and did not meet criteria for recurrence using the appropriate tests, and matching were used to control for confounding. P-values of less than .05 were considered significant. In this database, 718,000 women aged 45 or older were treated for UTI. Of these, 10.3% met our criteria for recurrence. There were no significant differences between age, region, insurance, provider, or clinical characteristics commonly associated with UTI in those who did and did not meet criteria for recurrence. Of note, race could not be identified through this database. Here, we have a table describing initial antibiotics prescribed for the index UTI, separated into first line, second line, and other antibiotics based on IDSA guidelines. Mean duration of initial antibiotic was seven days, and duration was similar between those who did and did not meet criteria for recurrence. The most commonly prescribed initial antibiotic was ciprofloxacin, followed by trimethopim, sulfamethoxazole, and then nitroferantoin. Antibiotic prescription patterns were similar between those who did and did not meet criteria for recurrence. Coding for adverse events was uncommon, less than 1% for both allergic reaction and C. diff infection. Urine testing was performed in 80% of women with UTI. Out of the 51%, only underwent one testing modality, while 49% went two or more tests. The most commonly performed tests were urine culture without susceptibility, urine dipstick, and urine dipstick with micro-urine analysis. Less than 1% of women with UTI underwent any imaging, the most common being cystoscopy. Those who met criteria for recurrence were more likely to undergo cystoscopy, CT, abdominal X-ray, and IVP than those who did not. Prescriptions for UTI prophylaxis were rare. The most commonly prescribed therapy was vaginal estrogen. The figure on the right shows the start date of prescriptions for UTI prophylaxis. While 52% of women were started on vaginal estrogen prior to the index UTI, the majority of prescriptions for methamphetamine hyperate and mandelate were prescribed after the index UTI. When we examined the proportion of women who met criteria for recurrence based on timing of prescription start date, those who received vaginal estrogen and methamphetamine hyperate prior to the index UTI were less likely to meet criteria for recurrence than those who received prescriptions after the index UTI. This did not meet significance in methamphetamine mandelate. In conclusion, UTIs in recurrence are common in women age 45 and older. Ciprofloxacin unfortunately continues to be the most commonly prescribed initial antibiotic for uncomplicated UTIs in this population, which should be discouraged. 20% of women did not receive testing for UTI. Those who met criteria for recurrence were more likely to receive imaging as part of their workup, but prescriptions for UTI prophylaxis was low in this population. To our knowledge, this is the first study examining antibiotic prescription patterns evaluation with recurrence and use of UTI prophylaxis in a high-risk population using a large longitudinal database. Limitations to this data include use of claims data, capturing only UTIs associated with coding, coded visits, and evaluations. It also includes accuracy of coding, particularly for chronic medical conditions such as obesity and incontinence. Imaging for UTI prophylaxis may have been performed for other reasons other than UTI. For example, vaginal estrogen is commonly prescribed for vaginal atrophy. However, our study does provide further insight into improvements we can make in antibiotic use, identification workup, and use of prophylaxis for recurrence. Thank you, and I welcome your questions. Do you have questions from the audience? Really nice study, Dr. Chu, but it was 2009 to 2015. Do you have any data on whether there was less sepro being prescribed in 2015 than in 2009? That's a good question. That's probably going to be part of what we look at in the manuscript, seeing if there's changes over time and also changes when the IDSA guidelines were established, but I don't have that currently. Brandon Chen from Loyola. This question is for Dr. Jung. Since the majority of the organisms that you cultured were non-E. coli, do you have any information regarding the antibiotic susceptibility profiles of those? So we did not perform antibiotic resistance profiles on the expanded culture, but according to the standard cultures, there was some form of resistance for about almost half of them, and those that did have some form of resistance were mostly the Klebsiella species, and they were all resistant to ampicillin. That was universal. Go ahead. Marcia Manassian, Boston. This question is for Dr. Baird. I enjoyed all presentations. Specifically, the women who were catheterized after surgery, did they receive prophylactic antibiotics, and if not, did they receive an antibiotic when the folio was removed? So all women received the standard antibiotics at time of surgery. Other than that, they didn't receive any additional antibiotics if they remained catheterized. We did record whether or not women were on antibiotics for prophylactic recurrent UTIs, and it was a very small number in the cohort, and similar between the groups. But there was no standard prophylactic antibiotics given. Thank you. Dr. Jung, did you compare your findings to next-generation sequencing identification of DNA, or are you doing parallel studies to do that? We did not. We're just using, currently in this cohort, just the two types of cultures. Because that's really what we want to know, right? What's really there. And then I just have a quick question for Dr. Chu. So are we able, with treatment, to capture the patient who gets antibiotics on the phone, where you call in a prescription and they're not getting cultures? Because this looks to me like a really good capturing of infections, which seems not what I see in practice. So in fact, it's a very good database to examine patients who get antibiotics on the phone, and also to identify anyone who actually, at least, picks up the prescription for the antibiotics, because that's what the database tracks. So this concludes the question. Thank you very much to our presenters. Thank you. Thank you. Thank you. Thank you. OK.

microscopic hematuria

evaluation

management

women

urological malignancy

risk factors

cost-effectiveness

bladder injuries