Chair Infectious Disease Division Summa Health System Akron Ohio Professor of Internal Medicine Chair ID Section Northeast Ohio Medical University Rootstown Ohio Asymptomatic Bacteriuria ID: 775181
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Thomas M File Jr. MD, MSc, MACP, FIDSA, FCCPChair, Infectious Disease DivisionSumma Health System, Akron, Ohio;Professor of Internal Medicine, Chair ID SectionNortheast Ohio Medical UniversityRootstown, Ohio
Asymptomatic Bacteriuria
(
Frequently occurs; Frequently mistreated):
Approach to reducing unnecessary antimicrobial therapy and thereby reducing Harm
Slide2List why treatment of asymptomatic bacteriuria can be harmfulList strategies to reduce unnecessary antibiotics for asymptomatic bacteriuria
Learning Objectives
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Slide384 yof resides at home. PMH includes: hypertension, osteoarthritis, diabetes, neuropathy, and dementia. Her daughter (primary caretaker) calls in your office and requests a prescription for trimethoprim-sulfamethoxazole for her mother’s worsening mentation as this helped her last time. Pt denies any fever, pain, or changes with urination habits. A urinalysis and urine culture are collected by the home care nurse via bed pan. UA reveals 5-10 WBC/HPF and moderate bacteria. Urine culture is pending. What is the most appropriate next step?Prescribe trimethoprim-sulfamethoxazole 1 DS twice daily for 5 daysPrescribe ciprofloxacin 250 mg twice daily for 3 daysDo not treat until culture and sensitivity results are availableDo not treat, search for alternate causes of altered mentation
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Height: 5’5”Weight: 140 lbsCrCl = 64 ml/min
Slide4Antimicrobial Stewardship Worksheet
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Slide5UTIs and Older Adults
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Detweiler K,et al.
Urol Clin N Am
2015; 42: 561–568.
Jump RLP, et al.
J Am Geriatr Soc
2018; 66: 789-803.
Crnich CJ,et al.
J Am Geriatr Soc
2017; 65: 1661-3.
Rowe TA, et al
. Inf Dis Clin North Am Am
2014; 28: 75-89.
Slide6Treatment of ASB in Nursing Home Patients Leads to Multi-drug Resistant Organisms
Cohort from 5 Nursing Homes in ConnecticutFindings: Increasing episodes of observed bacteriuria among nursing home residents in this cohort are not associated with hospitalization for UTI or change in mental status, but are associated with antibiotic utilization and occurrence of multi-drug resistant gram negative rods. Restricting antibiotic prescriptions for bacteriuria should continue to be a guiding principleContinued inappropriate utilization may increase hospital transfers and transmission of resistant organisms to the inpatient setting
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Das R, et al.
Infect Control Hosp Epidemiol
2011 Jan; 32(1): 84–86.
Slide7“No evidence beyond anecdote suggests that delirious patients who have asymptomatic bacteriuria do better with antibiotic treatment. For these patients, we believe clinicians should not ask whether there is a “real urinary tract infection,” but whether the patient is safer with antibiotic treatment or without it. Accepting asymptomatic bacteriuria as the cause of delirium, dubbing it “urinary tract infection,” and then giving antibiotics is dangerously complacent.
Bacteriuria in Individuals Who Become Delirious
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McKenzie R et al. Am J Med. 2014
Slide8Asymptomatic Bacteriuria
Patient with bacteria in the urine, but without clinical signs of a UTIWomen – two consecutive voided urine specimens with isolation of the same organism in counts of ≥ 105 cfu/mL Men – a single voided urine specimen with isolation of a single organism in counts of ≥ 105 cfu/mLCatheterized – a single catheterized specimen with isolation of a single organism in counts of ≥ 105 cfu/mLPresence of pyuria (≥10 leukocytes/mm3 in UA) NOT SUFFICIENT/SPECIFIC for diagnosis of bacteriuria (or UTI)Indications to treat: Pregnancy; Urological Procedures
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Boscia JA.
Ann Intern Med
1989;110(5):404
.
Nicolle LE.
Infect Dis Clin North Am
2012; 26(1): 13-27.
Slide9Treatment of Asymptomatic Bacteriuria (ASB) in Young Women
Randomized Control Trial of women ages 18-40 with ASBNo therapy vs. antimicrobial therapy (based on culture results)Result:Recurrence: No therapy 13.1%Recurrence: Therapy 46.8% (p < 0.0001)Conclusion:No benefit to treat ASBASB may play a protective role in preventing symptomatic recurrenceDon’t treat ASB
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Cai T, et al.
Clin Infect Dis
2012 Sep;55(6):771
-7.
Slide102015 Cochrane Review: Antibiotics vs. No Treatment or Placebo for ASB
Randomized controlled trials or Quasi RCTs ( 9 studies with 1614 pts )Treatment vs. No Treatment, or Treatment vs. PlaceboConclusion: No difference in outcomes of development of symptomatic UTI, complications or deathSignificantly higher adverse events in treatment groupNo clinical benefit from treating ASB
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Trestioreanu ZA, et al. Cochrane Database Syst Rev. 2015 Apr 8;4:CD009534
.
Slide11Summary: UTI vs. ASB
UTIASB+ PyuriaYesPossible+ CultureYesYesSymptomsdysuria, frequency, urgency, hematuria, incontinence, suprapubic pain, fever, chills, nausea, vomiting, costovertebral angle (CVA) tenderness, flank painNoneAntibiotics Benefit YesNoneAntibiotics Cause HarmPossibleYesAltered Mental Status AssociatedPossibleVery unlikely (other cause almost always present)
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Slide12Importance of Normal Microbiome
Gut microbiome plays a role DigestionMetabolismImmunityBalanced, diverse microbiome contributes to better overall healthSpecific biochemical functions of normal bacteria effect immune responseAntimicrobials cause Disruption of microbiomeResults in less diversity Diminished Immunity
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Belkaid and Hand. Role of the microbiome in immunity and inflammation. Cell 2014; 157: 121
TIME Health Spring 2018
Slide13EducationED algorithm and auditGeriatrics and Home Nurses GrantRemove UA and Cultures from order sets (delirium, falls)UA reflex culturesNew IDSA Guidelines
Reducing Unnecessary Antimicrobials: Approaches
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Slide14Asymptomatic Bacteriuria: Fact or Fiction?
FictionFactAn abnormal urinalysis (UA) indicates a UTIUA specimens are often contaminated in the elderly if not received by straight catheterEven when done by catheter and culture is positive, most cases are ASBUA should be ordered as a screening testOrder UA only when patient has UTI symptomsAn abnormal UA explains weakness, fatigue, change in mental statusPrevalence of ASB high in elderly patientsSeek other causes (dehydration, medication changes, constipation, sleep changes, signs of other infection)Pyuria can differentiate ASB from UTIPatients with ASB often have WBC in their urineCloudy or foul smelling urine is diagnostic of a UTIThese changes are also seen in ASBOther causes include dehydration, certain medications, diet
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Adapted from: Massachusetts Coalition for the Prevention of Medical Errors
http://www.macoalition.org/evaluation-and-treatment-uti-in-elderly.shtml
Slide15Other Causes of Delirium
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JAMA
. 2016;316:1775-1785. Crit Care Med 2014; 42:1899–1909. Crit Care Med 2014; 42:1480–1486.J Crit Care 2008; 23: 372-379.
Crit Care
2008 : 12: S3 (doi:10.1185/cc6149).
Arch Intern Med
2007; 167: 1629-1634.
Circulation
2009; 119: 229-231.
JAMA
1996; 275: 852-857.
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Slide1806.01.2016
Summa Health Sample Preso
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Summa Health System Asymptomatic Bacteriuria vs. UTI Pathway
Slide2020
Slide21From Jenkins TC et al. Clin Infect Dis 2018; 67: 1550-8
Slide22Reflexive Urine Culture based on UA
Effects of Reflexive Urine Cultures on Antibiotic use in Hospitalized patients. Petty et al. (Univ Chicago)IDWeek 2015
Less Ucx being performed.
CA-UTI rates decreased
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Slide23Asymptomatic BacteriuriaFirst do NO HARM
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Slide24Case Question:A nurse from ECF calls about a 84 year old female who fell and appeared more confused. The nurse is requesting an order for an antimicrobial since her urine culture was obtained indicating 100,000 colonies of E. coli. What is best response?A. Prescribe fosfomycin since you are concerned for ESBL organisms B. Prescribe nitrofurantoin since her creatinine clearance is greater than 40 C. Order urinalysis D. If no symptoms of UTI avoid antimicrobial and search for alternative cause of confusion
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Slide25Increase selection of resistant pathogens which are more likely to cause symptomatic infection Unnecessary adverse effects such as CDI Unnecessary Cost Disturbance of normal microbiome All above
Assessment Question #1Which of the following are reasons why antimicrobial treatment of asymptomatic bacteriuria can result in harm to patients?
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Slide26Reserve antimicrobial treatment to patients with asymptomatic bacteriuria who demonstrate a change in mental status Education of patients, family members and healthcare providers as to the negative consequencesScreening of all patients from long term care facilities with voided urine cultureAll of above
Assessment Question #2Which of the following strategies are effective to reduce unnecessary antibiotics for asymptomatic bacteriuria?
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Slide27Thomas M File Jr. MD, MSc, MACP, FIDSA, FCCPChair, Infectious Disease DivisionSumma Health System, Akron, Ohio;Professor of Internal Medicine, Chair ID SectionNortheast Ohio Medical UniversityRootstown, Ohio
Asymptomatic Bacteriuria
(
Frequently occurs; Frequently mistreated):
Approach to reducing unnecessary antimicrobial therapy and thereby reducing Harm