Transcript Slides

Objectives
 Categorize urinary tract infections by group
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Asymptomatic bacteriuria
Cystitis
Pyelonephritis
Complicated urinary tract infection/Catheter-associated UTI
 Recognize how to distinguish “Infection” from “Bacteriuria” and
when to NOT given antibiotics for “UTI”
 Discuss the approach to cystitis
 Define pyelonephritis and identify evidence-based therapies
 Consider complicated pyelonephritis, catheter-associated UTI
(CA-UTI) and treatment of highly-resistant organisms
IDSA guidelines
 Asymptomatic bacteriuria1
 Catheter-associated UTI2
 Cystitis and pyelonephritis3
Asymptomatic bacteriuria
1
(ASB)
 Presence of bacteria in urine in the absence of symptoms
 Women: 2 consecutive voided urine specimens with SAME
bacterial strain ≥105 cfu/mL
 Men: Single clean-catch urine with 1 species ≥105 cfu/mL
 Men and women: Single catheterized urine with 1 species
≥102
 Pyuria without symptoms is NOT an indication for
antimicrobial treatment
1
Asymptomatic bacteriuria
Asymptomatic bacteriuria
 DO NOT TREAT ASYMPTOMATIC PATIENTS!!
 Not in non-pregnant women, diabetics, old people, institutionalized
people, spinal cord injury, or in patients with catheters. Treating even
in renal transplant patients is controversial.
UNLESS!!!!!
1.
Pregnant women should be screened in early pregnancy
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2.
Prior to TURP
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3.
Treat 3 – 7 days if positive
Start night before or immediately pre-procedure, stop postprocedure
Prior to urologic procedure where mucosal bleeding is anticipated
Why is asymptomatic
bacteriuria over-treated?
 20 – 80% of ASB is inappropriately treated
 Survey of 95 resident physicians who managed
bacteriuria10
 32% of ASB inappropriately treated with antibiotics
 Presented with 7 vignettes
 37% correct
 Reasons cited for improperly treating ASB in survey:
 Concern for post-op infection
 Elevated inflammatory markers
 Abnormal urinalysis
Lee et al. BMC Infectious Diseases (2015) 15:289
Do not screen or treat ASB prior
to surgical procedures
 No benefit prior to CT or spine surgery11,13
 ASB not associated with post-operative joint replacement
infections12
Clin Infect Dis 2014;59(1):41–7
Cystitis3
 Common in otherwise healthy women
 NO FEVER, NO FLANK PAIN
 Nitrofurantoin 100mg bid x5d
 Cephalexin 500mg bid x 3-7 days4
 AVOID:
 Trimethoprim/sulfa: most sites >20% E. coli resistance
 Fluoroquinolones: unnecessarily broad, more C. diff, antipseudomonal/pneumococcal spectrum not needed
 Amoxicillin/clavulanate: poor empiric E. coli activity
Pyelonephritis3
 Fever, flank pain, and/or nausea and vomiting
 Get a urine culture first!!
 Option 1:
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Oral fluoroquinolone (if local E. coli sensitivity ≥90%)
 Higher cure rates than 14 days of trimethoprim/sulfa5
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Ciprofloxacin 500mg po bid x7 days5, or
Levofloxacin 750mg po daily x5 days6
If baseline resistance >10%, can consider ceftriaxone 1g x1 then PO quinolone
while sensitivities pending if follow-up can be assured
 Option 2:
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Beta-lactam7 or TMP/SMX5 as follows:
Ceftriaxone 1g IV or IM x1, then cephalexin8 1g PO TID x 10-14 days total, OR
Ceftriaxone 1g x1 then TMP/SMX DS 1 po bid x14 days
Bacteremia and pyelonephritis
 If bacteremic and not improving, repeat blood cx and
consider imaging to rule-out complicated pyelonephritis
 Good data with quinolones and tmp/smx
 Caution with oral beta lactam regimen
 We give several days IV until clinically improved then finish
with high dose oral beta lactam or swap to quinolone to
finish
“Complicated” UTI
 Historical, messy term
 Cystitis or pyelonephritis accompanied by abnormality of the urinary
tract9
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Obstruction: strictures, stones, prostatic hypertrophy, congenital
Instrumentation: catheters, tubes, stents, procedures
Poor voiding: reflux, neurogenic bladder, cystocele
Transplant
 Infections are harder to eradicate in these patients
 If there is hydronephrosis suggesting obstruction, in the presence of
infection this is a medical emergency; infected kidneys must be
decompressed emergently!
 Indwelling catheters are most common cause of complicated UTI
Catheter-associated UTI (CA-UTI)
 IDSA guideline 20092
 SYMPTOMS of UTI plus ≥103 cfu/mL ≥1 organism from
catheter specimen or midstream void <48h after catheter
removal
 Fever, rigors, AMS, malaise, or lethargy with NO other cause
 Flank pain, CVA tenderness, acute hematuria, pelvic pain
 IF NO SYMPTOMS IT IS CA-ASB!!!!
 Smelly or cloudy urine is NOT a symptom!
 Massive pyuria is NOT a symptom!
 Do NOT screen for ASB prior to or immediately after
catheter placement
Culturing catheterized patients
 Catheters rapidly become colonized at a rate of 3 – 8%
each day14
 Can’t get CA-UTI without a catheter! When in doubt get it
out!!!
 If catheter in place 2 weeks or more, replace and send
culture from NEW catheter before starting antibiotics
 We replace prior to cultures if >72h catheter duration
 Do not treat yeast in the urine15
 Only 3% treated in large cohort, no complications
 29% had catheter changed
Preventing CA-UTI and CA-ASB
 Minimize catheter use!
 Create guideline for post-op removal
 Nurse-driven protocol to remove when indication no longer
met
 Keep system closed
 Minimize breaks, bag changes
 Do not flush junk into bladder! Do not flush at all… if
plugged up, replace
 No dependent loops; use securing device
 Good perineal care daily
CA-UTI treatment2
 Tailor to culture results
 7 days for prompt response
 10-14 days for delayed response
 5 days levofloxacin is an option that decreases duration6
 3 days if cystitis, female <65, and catheter removed
ESBL E. coli and UTI
 3% of isolates in Anchorage
 Limited drug options
 Gentamicin 3mg/kg IV or IM q24h
 Ertapenem 1g IV q24h
 Nitrofurantoin 100mg po bid x5 days (if no allergy, susceptible,
and preserved renal function)
 Amoxicillin/clavulanate 500/125mg BID x5-7d16
 Use ONLY for cystitis and ONLY if MIC ≤8
 Cure rate 93% for MIC 8 or less, 54% for MIC 16 or higher
 Possible role for amoxicillin/clavulanate PLUS oral 3rd
generation cephalosporin but NOT YET DEFINED17
ESBL E. coli UTI and Fosfomycin
 Broad coverage of GNR and gram positives
 Long urinary excretion from single 3g PO dose
 Highly active against ESBL E. coli (96%)18
 Lower efficacy vs. Klebsiella ESBL (54%)
 Poorer microbiologic cure but similar clinical efficacy of
~90%3,19
 For cystitis in patients with highly resistant E. coli or with
allergies precluding other agents, fosfomycin 3g PO x1 is a
feasible option19 that we use in Anchorage once or
twice/month
References
1.
Clinical Infectious Diseases 2005; 40:643–54
11.
Interactive CardioVascular and Thoracic
Surgery 0 (2016) 1–7
2.
Clinical Infectious Diseases 2010; 50:625–663
12.
Clin Infect Dis 2014;59(1):41–7
3.
Clinical Infectious Diseases 2011;52(5):e103–
e120
13.
J Korean Neurosurg Soc 47 : 265-270, 2010
4.
JAMA. 1995 Jan 4;273(1):41-5.
14.
N Engl J Med 1974; 291:215–219
5.
JAMA 2000; 283:1583–90.
15.
American Journal of Infection Control 43
(2015) e19-e22
6.
Urology 2008; 71:17–22.
16.
Arch Intern Med. 2008;168(17):1897-1902
7.
Emerg Med J 2002; 19:19–22.
17.
Antimicrob Agents Chemother 60:424 –430.
8.
Obstet Gynecol 1990;76:28–32.
18.
Antimicrob Agents Chemother 60:1134 –1136.
9.
Can J Infect Dis Med Microbiol. 2005 16(6):
349-360
19.
Antimicrob Agents Chemother 59:7355–7361
10.
Lee et al. BMC Infectious Diseases (2015)
15:289