Urinary Tract Infections always uncomplicated

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Urinary Tract Infections always uncomplicated?

• Fiona Robb
• Antimicrobial Pharmacist
• NHS North West Glasgow
• October 2009

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Introduction

• Urinary tract infections (UTI)
• Diagnosis
• Common pathogens
• Resistance patterns
• UTI in non-pregnant adult women
• UTI in pregnant adult women
• UTI in adult men
• UTI in adult patients with catheters
• Inverclyde UTI audit

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Urinary Tract Infections

• 2nd most common clinical indication for empirical
  antimicrobial therapy
• Urine samples constitute the largest single
  category of specimens sent to microbiology
• Hospital acquired UTI account for 23 of all
  infections
• Catheter associated UTI accounts for 8 of
  hospital acquired bacteraemia
• 50 of antibiotic prescriptions are
  inappropriate
• Considerable practice variation
• SIGN 88
• Local Urinary Tract Infection (UTI) guidelines

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Diagnosis
If 3 symptoms or both dysuria frequency,
UTI probability is gt 90

• Lower UTI
• Dysuria
• Frequency
• Urgency
• Mild fever

• Upper UTI
• Loin/ Back pain
• Flank tenderness
• Fever
• Rigor
• Sepsis

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Diagnosis

• Near patient testing
• Appearance of urine urine turbidity
• Urine microscopy likely contamination and
  unqualified personnel to make diagnosis - not
  recommended
• Dipstick tests (leukocytes /- nitrites) guides
  but does not confirm diagnosis
• Dipstick tests should only be used to diagnose
  bacteriuria in women with limited symptoms and
  signs

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Diagnosis

• Urine cultures
• Specimen type MSSU, CSU, needle aspiration of
  urine. Risk of contamination?
• Number of isolates cultured
• Clinical details pregnant, renal failure,
  long-term catheter
• Presence/ absence pyuria
• Number of organisms present
• Empirical treatment if gt 100,000 /ml
• Repeat culture if 10 100,000 /ml

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Risk Factors for Asymptomatic Bacteriuria

• Female ( 25 women, 10 men)
• Sexual activity
• Co-morbid diabetes
• Increasing age gt 70 years 10 20
• Institutionalisation 20 50
• Hospitalisation 30
• Presence of a catheter

NNTH 3 (rash, gastrointestinal symptoms)
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Common Pathogens

• Escherichia Coli
• Staphylococcus saprophyticus
• Proteus mirabilis
• Enterococcus

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Resistance Patterns
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Management of Bacterial UTI in Non-pregnant
Adult Women

• Symptomatic Lower UTI
• Trimethoprim 200mg bd 3 days
• Nitrofurantoin 100mg M/R bd 3 days
• (or 50mg qds)
• Co-trimoxazole 960mg bd 3 days
• SIGN 88 3-6 days as effective as 7-14 days
• N.B. Nitrofurantoin
• Renal Handbook 3rd ed use if CrCl gt 20ml/min
• Avoid alkalising agents reduced antibiotic
  effect

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Management of Bacterial UTI in Non-pregnant
Adult Women

• Symptomatic Upper UTI
• Often accompanied by bacteraemia life
  threatening condition
• If systemic symptoms or no response after 24
  hours then admit to hospital
• Ciprofloxacin 500mg bd 7 days
• Co-trimoxazole 960mg bd 14 days
• Asymptomatic bacteriuria
• No antibiotic treatment recommended
• Increased risk of adverse events (NNTH 3)

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Management of Recurrent Bacterial UTI in
Non-pregnant Adult Women

• Recurrent UTI
• Cranberry products interaction with warfarin,
• not available on the NHS, optimal dose and route
  of administration not addressed.
• (NNT 6.4 to prevent one UTI in 6 months)
• Standby Antibiotics
• Prophylaxis Antibiotics
• Nitrofurantoin 50mg Stat dose post coital
  or OD nocte
• Trimethoprim 100mg Stat dose post coital
  or OD nocte

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Case 1
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Management of Bacterial UTI in Pregnant Women

• Symptomatic bacteriuria can lead to
• Premature rupture of membranes
• Premature labour
• Risks of morbidity
• Mortality to pregnant woman
• Symptomatic bacteriuria occurs in 17 20 of all
  pregnancies
• Perform culture at first antenatal visit in all
• Confirm ve result with 2nd culture and treat
• Repeat at each antenatal visit until delivery if
  initial culture ve

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Management of Bacterial UTI in Pregnant Women

• Symtomatic bacteriuria
• 1st line
• Nitrofurantoin 50 100mg qds 3-7 days
• Trimethoprim 200mg bd 3-7 days
• 2nd line
• Amoxicillin 250mg tds 3-7 days
• Cefalexin 500mg bd 3-7 days
• See BNF, local guidelines, toxbase
  www.toxbase.com

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Management of Bacterial UTI in Pregnant Women

• Symptomatic Upper UTI
• Trimethoprim 200mg bd 14 days
• Co-amoxiclav 625mg tds 14 days
• Cefalexin 500mg tds or bd 14 days
• N.B. Ciprofloxacin is contraindicated in
  pregnancy
• Asymptomatic bacteriuria
• Treat with antibiotic

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Case 2
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Management of Bacterial UTI in Adult Men

• Send urine sample for culture in all men
• Consider prostatitis, chlamydial infection,
  epididymitis
• Symptomatic bacteriuria
• Ciprofloxacin 500mg bd 14 days
• Co-trimoxazole 960mg bd 14 days
• Trimethoprim 200mg bd 14 days
• Asymptomatic bacteriuria
• Men gt 65 years no antibiotic treatment

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Case 3
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Management of Bacterial UTI in Adult Patients
with Catheters

• 2 7 of patients acquire bacteriuria with each
  day of catheterisation
• All patients with long-term indwelling catheters
  have bacteriuria
• Asymptomatic bacteriuria
• No antibiotic treatment recommended
• Antibiotic prophylaxis is not recommended

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Management of Bacterial UTI in Adult Patients
with Catheters

• Symptomatic bacteriuria culture urine
• New onset costo-vertebral tenderness
• Rigor
• New onset delerium
• Fever T gt 37.9C or 1.5C above baseline on 2
  occasions during 12 hours
• Nausea and/ or vomiting
• Nitrofurantoin 50 100mg qds 7 days
• Trimethoprim 200mg bd 7 days
• Co-trimoxazole 960mg bd 7 days

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Management of Bacterial UTI in Adult Patients
with Catheters

• If catheter related sepsis
• Remove/ replace catheter
• Cover with single dose of gentamicin
• Further antibiotic may not be required
• If signs of sepsis (SIRS 2)
• Amoxicillin 1g IV tds Gentamicin
• IVOST to oral antibiotics as soon as appropriate
• Total duration 14 days men, 7 days women

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What are the indicators for sepsis and
infection severity?

• DEFINITION OF SEPSIS AND INFECTION SEVERITY
  INDICATORS
• Sepsis
• Clinical symptoms of infection (pyrexia, sweats,
  chills, rigors)
• PLUS
• 2 or more of the SIRS criteria
• Temperature lt 36 or gt 38oC
• Heart rate gt 90 bpm
• Respiratory rate gt 20 /minute
• WCC lt 4 or gt 12 x 109/L
• Severe sepsis
• Sepsis organ dysfunction / hypoperfusion
• (oliguria, confusion, acidosis, hypotension)
• Note The above features may be masked in
  specific situations eg immunosuppression,
  the elderly and in patients on certain medication
  (ß-blockers, corticosteroids etc)

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When would you choose anIV antimicrobial?

• INDICATIONS FOR IV ROUTE
• Sepsis, severe sepsis or deteriorating clinical
  condition
• Febrile with neutropenia / immunosuppression
• Deep-seated/specific infections bone/joint,
  moderate to severe cellulitis, deep abscess,
  endocarditis, meningitis
• Oral route compromised vomiting, nil by mouth,
  severe diarrhoea, swallowing disorder,
  unconscious, malabsorption, no oral formulation
  available

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When would you switch a patient from IV to oral?
Oral route compromised? Continuing sepsis or
deteriorating condition? Special indication for
IV therapy? Antimicrobial only available in an
IV formulation?
NO
SWITCH TO ORAL THERAPY
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Case 4
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IRH UTI Audit

• Total 25 patients 18 female, 7 male
• 23 patients gt 65 years old
• Sample sent 13 MSSU, 12 CSU

• MSSU (13 patients)
• 3 patients treated according to IMG
• 1 patient discharged before treatment Rxd
• 3 asymptomatic patients prescribed antibiotics
• All 13 micro sensitivity reports released
  Cefalexin

• CSU (12 patients)
• 3 patients treated according to IMG
  (asymptomatic no catheter change and no
  antibiotic therapy)
• 2 patients had catheter changed but no antibiotic
  cover

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IRH UTI Audit

• Only 6/19 patients treated appropriately
  according to guidelines
• Recommendations
• Microbiology to hold back Cefalexin from hospital
  sensitivity reports
• Infection management guidelines updated August
  2009 in line with SIGN 88
• Education and future audit required

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Conclusion

• UTIs are the 2nd most common clinical indication
  for empirical antimicrobial therapy
• Up to 50 of these will be inappropriate
• Inappropriate antibiotic use has adverse patient
  and public health consequences
• SIGN guidelines/ local policies help to promote
  and support prudent antimicrobial use
• YOU have a key role to play in ensuring that
  patients receive appropriate, safe and effective
  antimicrobial therapy