Harika Yalamanchili PGY-2 - PowerPoint Presentation

Slide1

Harika Yalamanchili PGY-2

IDSA guidelines for treatment of UTIs

Slide2

IDSA: Infectious Diseases Society of America

Slide3

Definitions

Acute

cystitis: infection

of the

bladder - lower

urinary

tract

Pyelonephritis: infection

of the kidney

-

the upper urinary

tract

Considered uncomplicated

in

healthy non-pregnant

adult

women

C

omplicated UTI

Diabetes

Pregnancy

Symptoms for 7 or more days before seeking care

Hospital acquired infection

Renal failure

Urinary tract obstruction

Presence of an indwelling urethral catheter, stent, nephrostomy tube or urinary diversion

Recent urinary tract instrumentation

Functional or anatomic abnormality of the urinary tract

History of urinary tract infection in childhood

Renal transplantation

Immunosuppression

U

ropathogen

with broad-spectrum antimicrobial resistance

Slide4

Risk factors for UTIs

R

ecent

sexual

intercourse

R

ecent

spermicide

use

H

istory

of urinary tract

infection

Improper hygiene

Urinary tract structural abnormalities

Immunosuppression

Catheterization

Slide5

Pathogenesis

Begins

with colonization of the vaginal

introitus

by

uropathogens

from the fecal flora, followed by ascension via the urethra into the

bladder

Pyelonephritis develops when pathogens ascend to the kidneys via the ureters

Slide6

Most common uncomplicated UTI uropathogens

Escherichia

coli

 

75-95%

Enterobacteriaceae

Proteus mirabilis

Klebsiella

pneumonia

Staphylococcus

saprophyticus

Among

healthy non-pregnant

women, the isolation of organisms such as lactobacilli, enterococci, Group B streptococci, and coagulase-negative staphylococci

(other

than 

S.

saprophyticus

)

 from voided urine most commonly represents contamination

Slide7

Most common complicated UTI uropathogens

Common pathogens

Pseudomonas

Serratia

Providencia

species

Enterococci

Staphylococci

Fungi

Slide8

Diagnosis

Clinical manifestations of cystitis

consists

of dysuria, frequency, urgency, suprapubic pain, and/or 

hematuria

Clinical manifestations of pyelonephritis

can consist

of the above symptoms

together

with

fever,

chills, flank pain,

CVA tenderness

, and 

nausea/vomiting

Slide9

Diagnosis: Older Populations

For patients >65 years: chronic

urinary

nocturia

, incontinence, and general sense of lack of well-being

are common

and nonspecific for

UTI

 s

hould not

routinely prompt urine

studies

Fever

, acute dysuria

(<1 week),

new or worsening urinary urgency, new incontinence, frequency, gross hematuria, and suprapubic or

CVA pain/tenderness

are more discriminating

symptoms

 s

hould

prompt urine

studies

Cognitively

impaired patient who has persistent change in mental status and change in character of the urine that is not responsive to other interventions such as

hydration

 should prompt urine studies

Slide10

Diagnosis

UA for

evaluation of

pyuria

is the most valuable laboratory diagnostic test for

UTI

Pyuria

is present in almost all women with acute cystitis or

pyelonephritis

Its

absence strongly suggests an alternative

diagnosis

In young non-pregnant women, the probability of cystitis is >50% with any symptom of UTI and >90% with dysuria and frequency without vaginal discharge or irritation

 UA or UC

usually

adds

little and are often not indicated

 can empirically

treat

L

eukocyte esterase: enzyme

released by

leukocytes

 reflects

pyuria

Leukocyte esterase may be used to detect >10 leukocytes per high power field

Nitrite: reflects the

presence of

gram negative bacteria

Convert

urinary nitrate to

nitrite

Lacks

adequate sensitivity for detection of lower colony counts and of other

organisms

 interpret negative results with c

aution

False positive nitrite tests can occur with substances that turn the urine

red (

phenazopyridine

or ingestion of

beets)

Slide11

Diagnosis: Positive urine culture

In asymptomatic women, standard

threshold

on

a midstream voided urine that is reflective of bladder

bacteriuria

as opposed to contamination is ≥10

5

 

CFU/ml

I

n

symptomatic women with

pyuria

, lower midstream urine counts (

ie

, ≥10

2

/mL) have been associated with the presence of bladder

bacteriuria

Findings

of a colony count <10

5 

but

 

≥10

2

/mL may still be indicative of a

UTI

Lower

bacterial counts still representative of infection are also seen in men,

patients

already on antimicrobials, and with organisms other than 

E. coli

 and 

Proteus

 species

Slide12

Differential diagnosis

Vaginitis

Urethritis

Structural

urethral abnormalities

Painful

bladder syndrome

Pelvic

inflammatory disease

Nephrolithiasis

Slide13

Uncomplicated UTI Treatment

Nitrofurantoin

monohydrate/

macrocrystals

100

mg orally

BID x 5 days

Should

be avoided if there is suspicion for early

pyelonephritis

Contraindicated

when creatinine clearance is <60 mL/minute.

Slide14

Uncomplicated UTI Treatment

Trimethoprim-

sulfamethoxazole

One

double strength tablet 

(160/800

 

mg) BID x 3 days

Empiric

tx

should

be avoided if the prevalence of resistance

is >20% or

if

TMP-SMX has been taken for

cystitis in the preceding 3

months

Alternative: Trimethoprim 100

mg

BID x 3 days can be

used in place of TMP-SMX and is considered equivalent

Only for specific countries and regions

Slide15

Uncomplicated UTI Treatment

Fosfomycin

trometamol

3 grams x 1 dose

Should

be avoided if there is suspicion for early

pyelonephritis

Becoming more useful due to increased resistance among

uropathogens

Clinical

outcomes are not

yet reported

from randomized, controlled

studies

Role against MDRO is unknown

Slide16

Uncomplicated UTI Treatment

Pivmecillinam

400

mg

BID x 3-7 days

Minimal

resistance and ecological adverse

effects

An

extended gram-negative spectrum penicillin used only for treatment of

UTI

Availability

limited to some European

countries

Slide17

Uncomplicated UTI alternative treatment options

Fluoroquinolones

(

ofloxacin

, ciprofloxacin,

and levofloxacin)

are highly efficacious in

3 day

regimens

but

have a propensity for collateral

damage

Should be reserved

for important uses other than acute

cystitis

Main

concern

is

the promotion of

fluoroquinolone

resistance, not

only among

uropathogens

but also other

organisms



more serious

and

difficult to treat

infections at other

sites, increased rates of MRSA

Beta-Lactam agents

Amoxicillin-

clavulanate

,

cefdinir

,

cefaclor

, and

cefpodoxime-proxetil

x 3-7 days

Appropriate when other recommended

agents cannot be

used

Generally have

inferior efficacy and more adverse

effects

Concern for propagation of ESBL resistance among gram negative bacteria

Amoxicillin

or ampicillin should not be used

alone for empirical

treatment given the relatively poor

efficacy

and very high prevalence

of antimicrobial

resistance

Slide18

Treatment Options

Choice should be individualized based on patient circumstances (allergy, tolerability, compliance), local community resistance prevalence, availability, cost

Inability to tolerate

po

precludes outpatient treatment

If diagnostically uncertain of cystitis

versus early

pyelonephritis, avoid

nitrofurantoin

,

fosfomycin

,

and

pivmecillinam

because

they do not

achieve adequate

renal tissue

levels

U

se of TMP-SMX in

the preceding 3–6 months

is an

independent

risk factor

for

resistance

Travel

outside the

US in

the preceding 3–6 months i

s

independently associated

with resistance

Collateral

damage: ecological

adverse effects

of antimicrobial therapy

Selection

of

drug-resistant organisms

Colonization

or infection

with MDR organisms

Slide19

Complicated UTI Treatment

Can tolerate

po



oral ciprofloxacin (500 mg BID or 1000 mg extended release daily) or levofloxacin (750 mg daily) x 5-10 days

Moxifloxacin

attains lower urinary levels than other

fluoroquinolones

and is not recommended

Nitrofurantoin

, TMP-SMX,

fosfomycin

and oral beta-lactams are poor choices for empiric oral therapy due to high resistance rates

ESBLs treatment options generally limited to the

Carbapenems

Mild cystitis due to ESBL-producing E. coli and low suspicion for pyelonephritis



nitrofurantoin

and

fosfomycin

are reasonable if susceptible

Gram-positive cocci on Gram stain



suggestive of

enterococcal

UTI

Ampicillin

(1 g q6h) or Amoxicillin (500 mg

po

q8h)

May require further imaging

Duration of treatment: 5-10 days

Slide20

Pyelonephritis

In patients suspected of having pyelonephritis, a

urine culture

and susceptibility test should always be performed

Slide21

Treatment of Outpatient Uncomplicated Pyelonephritis

Oral

ciprofloxacin: 500 mg BID x 7 days +/- initial

400-mg dose of

IV ciprofloxacin

Alternative: Ciprofloxacin 1000

mg extended

release x 7 days or levofloxacin 750

mg

x 5 days

Appropriate for

patients not

requiring hospitalization and prevalence

of resistance

to

fluoroquinolones

is

not >10%

If >10%, will need to add additional IV dosage

Alternative initial IV therapy: long-acting antimicrobial -

1 g

ceftriaxone

or a

consolidated 24-h

dose of an

aminoglycoside (One 5-7 mg/kg

dose of

gentamicin)

Oral

TMP-SMX: 160/800

mg

(1 DS tablet) BID x 14 days

if

the

uropathogen

is

known to

be

susceptible

If susceptibility

is not known, an

initial IV dose

of a long-acting parenteral

antimicrobial-

1 g ceftriaxone or a consolidated 24-h dose of an

aminoglycoside

Oral

Beta-lactam

agents are less effective than

other available agents and lead to higher relapse rates

If an oral beta-lactam

agent is used, an

initial

IV dose of a long-acting parenteral antimicrobial- 1 g ceftriaxone or a consolidated 24-h dose of an

aminoglycoside

Duration:

10–14 days

Slide22

UTIs in Men

Much more rare in men than women

Appx

5-8 UTIs per year per 10,000 young to middle-aged men

Traditionally, all UTIs and asymptomatic

bacteriuria

in men considered complicated

Acute uncomplicated UTIs occur in a small number of men between 15-50

Risk factors:

insertive

anal intercourse and lack of circumcision

Due to longer urethral length, drier

periurethral

environment, and antibacterial substances in prostatic fluid

Clinical manifestations: dysuria, frequency, urgency, suprapubic pain, and/or hematuria

Differential:

Dysuria, urinary frequency and urgency, and

pyuria

can also be seen with acute bacterial prostatitis

May have additional fever, chills, malaise,

myalgias

, pelvic or perineal pain, or obstructive symptoms such as dribbling and hesitancy (due to acute urinary retention)

 DRE 

edematous, tender prostate

Underlying chronic prostatitis should be considered in men with cystitis, particularly in those men who have recurrent UTIs

Urethritis

Diagnosis: UA with UC

Slide23

UTIs in Men

Treatment options

TMP-SMX one DS tab (160/800 mg) BID

Fluoroquinolones

Ciprofloxacin (500 mg BID or 1000 mg extended release daily) or Levofloxacin (500-750 mg daily)

Nitrofurantoin

and beta-lactams should usually not be used in men with cystitis

Do not achieve reliable tissue concentrations

Would be less effective for occult prostatitis

Data for

Fosfomycin

in men is limited

Duration

Not many studies but traditionally 7-14 days

Slide24

Slide25

Catheter Associated UTI (CA-UTI)

CA

infection: infection occurring in

a person whose urinary tract is currently catheterized or

has been

catheterized within the previous 48

h

CA-UTI:

pt

with

indwelling

urethral, indwelling suprapubic

, or intermittent

catheterization with symptoms

or signs compatible with UTI with

no other

identified source of infection

+ ≥10^3 CFU/ml of

1 bacterial species in a single

catheter urine

specimen or in a midstream voided urine

specimen from

a patient whose urethral, suprapubic, or condom

catheter has

been removed within the previous 48

h

Unable to be determined if condom catheter used

Slide26

CA-UTI

Signs and

symptoms: new

onset or worsening of fever, rigors,

AMS, malaise

, or lethargy with no other identified

cause

Flank pain, CVA tenderness, acute hematuria, pelvic discomfort

Removed catheters: dysuria

, urgent or frequent urination, or suprapubic pain

or tenderness

Spinal cord injury: increased

spasticity

, autonomic

dysreflexia

, or sense of

unease

Slide27

Catheter Associated Asymptomatic Bacteriuria (CA-ASB)

Patients

with indwelling urethral,

indwelling suprapubic

, or intermittent catheterization

with the presence

of

≥10^5 CFU/ml of

1 bacterial species in a

single catheter

urine specimen in a patient without symptoms

compatible with UTI

Condom Catheter: Presence

of

≥10^5 CFU/ml

of 1 bacterial species in a

single urine

specimen from a freshly applied condom

catheter

Slide28

CA-Bacteriuria

CA-

bacteriuria

is the most frequent health care–associated infection

worldwide

Accounts

for up to 40% of hospital-acquired infections in US hospitals each

year

Incidence

of

bacteriuria

associated with indwelling

catheterization is 3-8

% per

day

Duration of catheterization

is the most important risk factor for the

development of CA-

bacteriuria

Other risk

factors:

Not

receiving systemic antimicrobial

therapy

Female

Positive

urethral meatal culture

results

Microbial colonization of

the drainage

bag

Catheter

insertion outside the

OR

Catheter

care

violations

Rapidly

fatal

underlying illness

Older age

Diabetes mellitus

Elevated

serum

creatinine at

the time of

catheterization

Approximately 20% of healthcare-associated

bacteremias

arise from the urinary tract

Slide29

CA Urinalyses

Pyuria

is not diagnostic of CA-

bacteriuria

or CA-UTI

Presence, absence, or degree of

pyuria

should not be used to differentiate CA-ASB from CA-UTI

Pyuria

accompanying CA-ASB should not be

interpreted as

an indication for antimicrobial

treatment

Presence

or absence

of odorous

or cloudy urine alone should not be used to

differentiate CA-ASB

from CA-UTI or as an indication for

urine culture

or antimicrobial

therapy

Screening for and treatment of CA-ASB is not recommended to reduce subsequent CA-

bacteriuria

or CA-UTI except in specific populations

Slide30

CA-Pathogens

E.

coli

is the most frequent species

isolated

Other

Enterobacteriaceae

:

Klebsiella

species,

Serratia

species,

Citrobacter

species, and

Enterobacter

species

Pseudomonas aeruginosa

Gram-positive cocci including

coag

-negative staph and

Enterococcus

species

Proteus mirabilis

Morganella

morganii

Providencia

stuartii

Long-term catheterization: usually

polymicrobial

Slide31

CA-Treatment

Prevention

Education

Very limited use

Condom catheters

Intermittent catheterization

Closed

catheter drainage

system

Antimicrobial Coated

Catheters

UC should be obtained prior to

initiating antimicrobial

therapy, replace catheter if >2

wks

, obtain UC from new catheter or if catheter

DCed

obtain

voided midstream urine

specimen

Symptoms

appropriate for obtaining a culture

and initiating

antimicrobial therapy include new

CVA

tenderness

, rigors

, or new onset of

delirium

Consider treating CA-ASB

that persists

48h

after short-term indwelling catheter removal in women

to

reduce the risk of subsequent

CA-UTI

Slide32

CA-UTI Treatment

Based upon the culture results

In seriously ill patients, empiric antimicrobial choice should be tailored to results of past cultures, use of prior antimicrobial therapy, community prevalence of antimicrobial resistance, and allergies

Urine Gram stain

If nothing available, empiric therapy should provide coverage against gram-negative bacilli

If not seriously ill and do not suspect MDRO, 3rd-gen cephalosporin (Ceftriaxone 1 g IV daily or

Cefotaxime

1 g IV q8h) or a

fluoroquinolone

(Ciprofloxacin at 500 mg PO or 400 mg IV BID or Levofloxacin 250-500 mg PO or IV daily)

If seriously ill or suspect MDRO, treat with ciprofloxacin,

ceftazidime

(1 g IV q8) or

cefepime

(1 g IV q12h)

If suspect ESBL (based on prior cultures), treat with

carbapenem

Gram positive cocci on Gram stain



enterococci or staphylococci

 empiric IV

vancomycin

 

Slide33

CA-Treatment

7

days

for patients

who have

prompt resolution

of

symptoms

10–14

days of

treatment for

those with a delayed

response

5-day

regimen of

levofloxacin in patients that are not

severely

ill

3-day antimicrobial regimen may be considered

for women >65

yo

who

develop CA-UTI without

upper urinary

tract symptoms after an indwelling catheter has

been removed

Treatment may need to be extended and a

urologic evaluation

may need to be performed if the patient does

not have

a prompt clinical response with

defervescence

by 72 h

Slide34

Asymptomatic Bacteriuria

Women

Two

consecutive voided urine specimens

with isolation

of the same bacterial strain in

quantitative counts ≥10^5 CFU/mL

Men

Single

, clean-catch voided urine specimen

with 1

bacterial species isolated in a quantitative

count ≥10^5 CFU/mL

Catheters (women or men)

A

single catheterized urine specimen with 1

bacterial species

isolated in a quantitative

count ≥10^2 CFU/mL

Slide35

Asymptomatic Bacteriuria Organisms

E. coli

is the most common

Characterized by

fewer virulence characteristics than are those isolated

from women

with symptomatic

infection

Enterobacteriaceae

Coagulase-negative staphylococci

Enterococcus

species

Group

B

streptococci

Gardnerella

vaginalis

Men:

Coagulase-negative

staphylococci

Gram-negative bacilli

Enterococcus

species

Slide36

Asymptomatic Bacteriuria

Screening for or treatment of asymptomatic

bacteriuria

is

not recommended

for:

Premenopausal

,

nonpregnant

women

Diabetic women

Older

persons living in the

community

Elderly

, institutionalized

subjects

Persons

with spinal cord

injury

Catheterized

patients while the catheter

remains in

situ

Slide37

Asymptomatic Bacteriuria

Pyuria

accompanying asymptomatic

bacteriuria

is not

an indication for antimicrobial

treatment

Pregnant women should be screened for

bacteriuria

by

urine culture at least once in early

pregnancy, and

they should be treated if the results are

positive

Asymptomatic

bacteriuria

in early

pregnancy has

a

20-30 fold

increased risk of developing

pyelonephritis during pregnancy

More

likely

to experience

premature delivery and to have infants of low

birth weight

Duration of treatment is 3-7 days

Periodic screening for recurrent

bacteriuria

should

be undertaken following

therapy

Screening for and treatment of asymptomatic

bacteriuria

before TURP is recommended

Antimicrobial therapy should be initiated

shortly before

the

procedure

Antimicrobial

therapy should not be

continued after

the procedure, unless an indwelling

catheter remains

in

place

Screening for and treatment of asymptomatic

bacteriuria

is

recommended before other urologic

procedures for

which mucosal bleeding is anticipated

Slide38

Resources

Fekete

T, Hooton TM. Approach to the adult with asymptomatic

bacteriuria

. In:

UpToDate

, Post TW (Ed),

UpToDate

, Waltham, MA. (Accessed on December 15, 2014)

Fekete

T. Catheter-associated urinary tract infection in adults. In:

UpToDate

, Post TW (Ed),

UpToDate

, Waltham, MA. (Accessed on December 15, 2014)

Gupta K, Hooton TM,

Naber

KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases.

Clin

Infect Dis 2011; 52:e103.

Hooton, TM. Acute complicated cystitis and pyelonephritis. In:

UpToDate

, Post TW (Ed),

UpToDate

, Waltham, MA. (Accessed on December 15, 2014)

Hooton, TM. Acute uncomplicated cystitis, pyelonephritis, and asymptomatic

bacteriuria

in men. In:

UpToDate

, Post TW (Ed),

UpToDate

, Waltham, MA. (Accessed on December 15, 2014)

Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America.

Clin

Infect Dis 2010; 50:625.

Hooton TM

, Gupta K. Acute uncomplicated cystitis and pyelonephritis in

women. In

:

UpToDate

, Post TW (Ed),

UpToDate

, Waltham, MA. (Accessed on December 15,

2014)

Nicolle

LE, Bradley S,

Colgan

R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic

bacteriuria

in adults.

Clin

Infect Dis 2005; 40:643.

Slide39

Thanks and

G

ig’em