Amy Robertson PharmD PGY1 Pharmacy Resident UAMS NW Disclosure and Conflict of Interest I have no relevant financial or nonfinancial relationships or conflicts of interest to disclose ID: 702891
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Asymptomatic Bacteriuria: To Treat or Not to Treat
Amy Robertson, PharmDPGY-1 Pharmacy Resident – UAMS NWSlide2
Disclosure and Conflict of Interest
I have no relevant financial or nonfinancial relationships or conflicts of interest to disclose.
2Slide3
Objectives
Describe appropriate management of asymptomatic bacteriuria in various patient populationsIdentify risks associated with inappropriate treatment of asymptomatic bacteriuria
Understand the evidence supporting the recommendation not to treat asymptomatic bacteriuria in certain patient populations
3Slide4
Guidelines
“Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of
Asymptomatic Bacteriuria
in
Adults”
Update in
progress
Projected publication in
Spring 2017
4Slide5
Definitions
Asymptomatic bacteriuria (ASB) – isolation
of a specified quantitative count of bacteria
in appropriately
collected urine
specimens
obtained from a person without symptoms or signs referable to urinary infection
Acute uncomplicated urinary tract
infection (UTI)
– symptomatic
bladder infection characterized by frequency, urgency, dysuria, or suprapubic pain in
women
with a normal genitourinary (GU) tract
Complicated urinary tract infection – symptomatic urinary infection in individuals with functional or structural abnormalities of the GU tract; may involve either the bladder or kidneysAcute non-obstructive pyelonephritis – renal infection characterized by costovertebral angle pain and tenderness, often with fever
5Slide6
Definitions Continued
Relapse – recurrent UTI after therapy resulting from persistence of the pre-therapy isolate in the urinary
tract
Reinfection
– recurrent UTI with an organism originating from outside of the urinary tract, either a new bacterial strain or strain previously isolated that persisted in the colonizing
flora
Pyuria
– presence of increased numbers of
polymorphonuclear
leukocytes in the urine; evidence of inflammatory response in the urinary tract
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Why is this topic relevant?
7Slide8
Diagnosis
Asymptomatic WomenTwo consecutive voided urine specimens with:
Isolation of the same bacterial strain
AND
≥10
5
cfu
/mL
Asymptomatic Men
Single
voided urine specimen (clean-catch) with:
Isolation of 1 bacterial species AND ≥105 cfu/mLCatheterized Women or MenSingle voided urine specimen with:
Isolation of 1 bacterial species
AND
≥10
2
cfu
/mL
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ASB versus UTI
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ASB versus UTI
Frequency
Urgency
Dysuria
Suprapubic pain
10Slide11
Appropriate
Criteria for Sending a Urine Culture2
Population
Criteria
Urinary catheter present
(indwelling catheter, condom catheter, or intermittent straight
cathetherization
)
New onset of fever (>38ºC)
or provider report of fever
Rigors
Altered mental status
Acute hematuria
Costovertebral pain or tenderness
Increased spasticity or autonomic
dysreflexia
(spinal cord injury)
Urinary catheter removed
<48 h prior
Any of
the above criteria or
Urgency
Frequency
Dysuria
No history of urinary catheter or removal >48 h prior
to development of symptoms
Fever
>38ºC
Urgency
Frequency
Dysuria
Costovertebral pain or tenderness
Suprapubic pain
Acute hematuriaNew or worsening incontinence
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Prevalence of ASB
WomenIncreases with age, sexual activity, and a diagnosis of diabetes
No difference
observed
between pregnant and
non-pregnant women
Men
Increases with age
Rarely seen in
healthy,
young
men
No difference
seen with diagnosis of diabetes12Slide13
ASB Prevalence in Special Populations
Patient
Population
Prevalence
Short-term indwelling
urethral catheters
2-7% per day
Spinal cord injury
>50%
Hemodialysis
28%
Elderly in long-term care facilities
Women: 25-50%
Men: 14-50%
Long-term indwelling catheter or permanent ureteric stent
100%
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Microbiology
14Slide15
To Treat or Not to Treat?
15Slide16
Treat
Pregnant women Urologic interventions/traumatic genitourinary procedures associated with mucosal bleeding
Do Not Treat
Premenopausal, non-pregnant women
Diabetic women
Older persons in the community
Elderly institutionalized subjects
Spinal cord injury patients
Long-term catheters
*Pyuria
is NOT an indication for antimicrobial
treatment*
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Treatment Populations
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Pregnant Women
Why?20 to 30-fold increased risk of pyelonephritisIncreased risk of premature delivery of infants with low birth weight
Screening
Urine culture at least once in early pregnancy
Must test for cure once treated for ASB
Periodic screening for recurrent bacteriuria following antibiotic therapy
No recommendation on repeated screening of culture-negative women
Treatment
If urine culture is positive
give antibiotics
Optimal antibiotic duration has not been determined
May consider 3-7 days
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Urologic Interventions
Why?Higher rate of post-procedure bacteremia and sepsisAntibiotics prevent complications of bacteriuria
Screening
Prior to transurethral resection of the prostate is recommended
Prior to other urologic procedures for which mucosal bleeding is anticipated
Treatment
Initiate antibiotics shortly before the procedure
Antibiotics should not be continued after the procedure
Exception: indwelling catheter remains in place
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Non-treatment Populations
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Possible Considerations
21Slide22
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Actual Considerations
No
difference
in:
Recurrence of symptomatic UTI
Survival rates
Hospitalizations
Adverse outcomes
Worsening GU symptoms, progression
of
disease
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Evidence
Unnecessary urine culturesAccording to Hartley et al
2
,
76%
(71/94) of
patients with ASB had no guideline-based indication for urine
culture
Inappropriate prescribing of antibiotics
20-83%
of patients with ASB (positive urine culture) receive antibiotics
2,5,7
Hartley et al
2 identified 435 days of unnecessary antibiotic useIncreased antibiotic resistanceCai et al4 revealed E. coli
isolates significantly more resistant to antibiotics in patients repeatedly treated for ASB compared to no treatment
Increased recurrence rate
Cai
et al
4
showed significantly more recurrences in patients treated for ASB
38%
(97/257) in non-treated patients versus
70%
(204/293) in treated patients
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25Slide26
What needs to be done?
“Multimodal interventions are needed to improve antimicrobial use”2
Possible mechanisms
2
for decreasing inappropriate treatment of ASB
include:
Education
Audit
and feedback
Computer-based
reminders
Antibiotic “timeouts”
Multiple studies have shown improvements in prescribing practices after implementation of various interventionsGrigoryan et al3 administered a pre- and post-intervention survey that revealed:Significant increase in knowledge scoresDecreased utilization of inaccurate prescribing cues
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Intervention Results
3
27
0 20 40 60 80 100
Percent of respondents that withheld antibiotics from patients with ASB
ESBL
E. coli
E. Coli
Candida
Mixed GP + enterococcus
Mixed GP
Pre-intervention sample
Post-intervention sampleSlide28
What Pharmacists Can Do…
In-service presentations Notifications
posted in the physician offices, conference rooms, and
mailboxes
P
ocket
cards
with ASB algorithms and
antibiogram
Electronic
memorandums to hospitalists for ASB management
recommendations
Pharmacists alerted daily to positive urine cultures
Pharmacist participation in daily rounds Encourage hospitalists to document indication for ordering urine culture, the category of UTI being treated, and anticipated duration of treatment
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No
Yes
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What Pharmacists Can Do…
Multi-modal pharmacist-driven interventions led to a significant decrease in treatment of ASB
Hartley SE
et al
6
revealed decrease in inappropriate antibiotics from
76.8%
(76/99) to
53.3%
(49/92)
Hartley SE et al
6
revealed decrease in antimicrobial days of therapy per patient from
4.6 (455 days/99 patients) to 3.3 (305 days/92 patients)Kelley et al7 revealed decrease in empiric antibiotics from 62% (66/107) to 26%
(28/107)
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ASB Resource
Nebraska Medicine Antimicrobial StewardshipUrinary Tract Infection and Asymptomatic Bacteriuria Guidance
http://
www.nebraskamed.com/careers/education-programs/asp/plans
31Slide32
Which patient should
not receive antimicrobial treatment?
28-year-old asymptomatic pregnant female with urine culture revealing bacteriuria
72-year-old male with urine culture revealing >100,000
cfu
/mL, new-onset altered mental status, fever, and costovertebral pain
20-year-old female with positive urinalysis, urgency, and dysuria
45-year-old
asymptomatic diabetic female with pyuria and urine culture revealing >100,000
cfu
/mL
65-year-old male with planned transurethral resection of the prostate found to have asymptomatic bacteriuria
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Conclusions
There are select patient populations that warrant treatment of ASBPregnant womenUrologic interventions
Risks of treating ASB outweigh benefits in other patient populations
Interventions are needed to bridge the gap between recommendations in clinical guidelines and prescribing habits
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References
1Nicolle 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;40:643–654
.2
Hartley S, Valley S, Kuhn L, et al. Overtreatment of Asymptomatic Bacteriuria: Identifying Targets for Improvement.
Infect Control
Hosp Epidemiol 2015;36(4):470–473. doi:10.1017/ice.2014.73. 3Grigoryan L, Naik AD, Horwitz D, et al. Survey find improvement in cognitive biases that drive overtreatment of asymptomatic bacteriuria after a successful antimicrobial stewardship intervention. Am J Infect Control
2016
.
4
Cai T,
Nesi
G,
Mazzoli
S, et al. Asymptomatic
Bacteriuria Treatment
Is Associated
With a Higher Prevalence
of Antibiotic
Resistant Strains in Women
With Urinary
Tract
Infections.
Clin
Infect Dis
2015;61(11
):
1655–61.
5Lee MJ, Kim M, Kim NH, et al. Why is asymptomatic bacteriuria overtreated?: A tertiary care institutional survey of resident physicians. BMC Infect Dis 2015;15:289. doi: 10.1186/s12879-015-1044-3.6Hartley SE, Kuhn L, Valley S, Washer LL, Gandhi T, Meddings J, Robida M, Sabnis S, Chenoweth C, Malani AN, Saint S, Flanders SA. Evaluating a Hospitalist-Based Intervention to Decrease Unnecessary Antimicrobial Use in Patients with Asymptomatic Bacteriuria. Infect Control Hosp Epidemiol 2016;37:1044–1051.7Kelley D, Aaronson P, Poon E, McCarter YS, Bato B, Jankowski CA. Evaluation of an Antimicrobial Stewardship Approach to Minimize Overuse of Antibiotics in Patients with Asymptomatic Bacteriuria. Infect Control Hosp
Epidemiol
2014;35(2):
193-195.
8
Trautner BW,
Grigoryan
L, Petersen NJ, et al. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter-Associated Asymptomatic Bacteriuria.
JAMA Intern
Med
2015;175(7):1120-1127.
doi:10.1001/jamainternmed.2015.1878.
9
Irfan
N, Brooks A,
Mithoowani
S,
et al. A Controlled Quasi-Experimental Study of an Educational Intervention to Reduce the Unnecessary Use of Antimicrobials For Asymptomatic Bacteriuria.
PLoS
ONE
10(7
):e0132071
.
doi:10.1371/journal.pone.0132071.
10
Colgan R, Nicolle LE,
McGlone
A, Hooton TM. Asymptomatic Bacteriuria in Adults.
Am
Fam Physician
2006;74:985-90
.
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Questions?
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Asymptomatic Bacteriuria: To Treat or Not to Treat
Amy Robertson, PharmDPGY-1 Pharmacy Resident – UAMS NW