Update in diagnosis and Asymptomatic bacteriuria management of UTIs - PDF document

4/16/2014 Lecture outline Update in diagnosis and • Asymptomatic bacteriuria management of UTIs • Uncomplicated UTI • Complicated UTI/pyelonephritis Brian S. Schwartz, MD • Pathogenesis and management of recurrent UTI UCSF, Division of Infectious Diseases • Urine screening pre ‐ op • Prostatitis Lecture outline Question 1a • Asymptomatic bacteriuria • 65 y/o female w/ DM presents to clinic for routine evaluation. She has been feeling well. • Uncomplicated UTI A urinalysis is sent to look for protein and the lab accidently also sends for culture • Complicated UTI/pyelonephritis • UA: WBC ‐ 0, RBC ‐ 0, Protein ‐ 300 • Pathogenesis and management of recurrent UTI • The next day you are called because the urine • Urine screening pre ‐ op culture has >100,000 Klebsiella pneumoniae • Prostatitis 1

4/16/2014 1a: What do you recommend? Question 1b • 65 y/o female w/ DM presents to clinic for A. No antibiotics indicated routine evaluation. She has been feeling well. A urinalysis is sent to look for protein and when B. Empiric ciprofloxacin and await susceptibilities the leukocyte esterase is positive, the lab reflexively sends for culture C. Repeat culture in 1 week and if bacteria still present then treat • UA: WBC ‐ >100 , RBC ‐ 0, Protein ‐ 300 • The next day you are called because the urine culture has >100,000 Klebsiella pneumoniae 1b: What do you recommend? Question 1c • 65 y/o female w/ DM presents to clinic for A. No antibiotics indicated evaluation. She complains of dysuria and frequency. A urinalysis and urine culture are B. Empiric ciprofloxacin and await susceptibilities sent. C. Repeat culture in 1 week and if bacteria still • UA: WBC ‐ >100 , RBC ‐ 0, Protein ‐ 300 present then treat • The next day you are called because the urine culture has >100,000 Klebsiella pneumoniae 2

4/16/2014 1c: What do you recommend? Answers: Antibiotics? 1a. Asymptomatic bacteriuria, no pyuria A. No antibiotics indicated – no antibiotics indicated B. Empiric ciprofloxacin and await susceptibilities 1b. Asymptomatic bacteriuria, with pyuria C. Repeat culture in 1 week and if bacteria still – no antibiotics indicated present then treat 1c. Cystitis (symptoms and pyuria) – Antibiotics indicated Definition: Asymptomatic Asymptomatic bacteriuria bacteriuria Pre ‐ menopausal women 1 ‐ 5% Pregnant women 2 ‐ 10% • Bacteriuria without symptoms Post ‐ menopausal women, 50 ‐ 70 yrs 3 ‐ 9% – Midstream: ≥ 10 5 CFU/ml Diabetics (women; men) 9 ‐ 27%; 1 ‐ 11% – Cath: ≥ 10 2 CFU/ml Elderly in LTC facilities (women; men) 25 ‐ 50%; 15 ‐ 40% Pts with spinal cord injuries 23 ‐ 89% • Pyuria is present > 50% of patients Pts undergoing HD 28% Pts with indwelling catheters Short ‐ term 9 ‐ 23% Long ‐ term 100% Nicolle. CID. 2005 3

4/16/2014 Who should you treat with Question 2: Which patient(s) should be treated for asymptomatic bacteriuria? asymptomatic bacteriuria? A. Patients with spinal cord injuries • Clear benefit – Pregnant women B. Patients with indwelling catheters – Patients undergoing traumatic urologic interventions with mucosal bleeding (TURP) C. Prior to transurethral resection of prostate • Possible benefit D. Pregnant women – Neutropenic E. C and D Nicolle. CID. 2005 Treatment of asymptomatic Who does not benefit from Rx for asymptomatic bacteriuria? bacteriuria in diabetic women • Premenopausal, nonpregnant women • Placebo controlled, RCT (N=105) • Postmenopausal ambulatory women • Diabetic women w/ asymptomatic bacteriuria • Institituitionalized men and women • Intervention: Antimicrobial vs. placebo x 14d • Patients with spinal cord injuries • 1 ° endpoint: Time to 1 st symptomatic UTI • Patients with urinary catheters • 42% Rx vs. 40% placebo , p=0.42 • Diabetics Asscher AW. BMJ. 1969; Abrutyn E. J Am Soc Ger. 1996; Harding GKM. NEJM 2003 4

4/16/2014 Provider prescribing practice for urine culture + enterococcus? If you have been treating • 339 hospitalized pts urine + Enterococcus asymptomatic bacteriuria – 54% had asymptomatic bacteriuria unnecessarily, you are not the only one… • 1/3 unnecessarily treated with antibiotics • Pyuria was associated with antibiotic use • 2% asymptomatic bacteriuria had UTI Lin E. Arch Int Med. 2012 What about the patient with Inappropriate quinolone use asymptomatic bacteriuria unable to tell you if they have symptoms? • Prospective eval of quinolone use in hospital • Concern for infection? No • Identified 1,773 use days over 6 weeks – No treatment • 690 (39%) use days were “inappropriate” • Concern for infection? Yes • #1 cause of inappropriate use was… 1.Always look for other sources (blood, lungs, etc.) – Asymptomatic bacteriuria/UTIs 2.If no pyuria, do not treat 3.If candiduria, most cases don’t treat 4.If other source identified, stop UTI treatment Werner NL. BMC Infect Dis . 2011 5

4/16/2014 Lecture outline Is asymptomatic bacteriuria protective? • 712 women with asymptomatic bacteriuria • Asymptomatic bacteriuria Symptomatic UTI (%) • Uncomplicated UTI Follow ‐ up No Antibiotics Antibiotics Stats • Complicated UTI/pyelonephritis 3 months 11 (4%) 32 (9%) NS • Pathogenesis and management of recurrent UTI 6 months 23 (8%) 98 (30%) p<0.0001 • Urine screening pre ‐ op 12 months 41 (15%) 169 (73%) p<0.0001 • Prostatitis Cai T. Clin Infect Dis. 2012 Types of symptomatic UTIs Clinical signs and symptoms of UTIs Lower tract Upper tract Uncomplicated vs. Complicated • Dysuria (1.5X) healthy women everyone else • Fever • Frequency (1.8x) cystitis • CVA tenderness • Hematuria (2.0x) • Nausea/vomiting Lower tract vs. Upper tract • Peripheral leukocytosis • Above with absence of cystitis pyelonephritis vaginal discharge or • Symptoms of cystitis irritation ( 28x ) may not be present Bent S. JAMA 2002 6

4/16/2014 Laboratory diagnosis of Microbiologic diagnosis of UTI uncomplicated UTI • Uncomplicated UTI: culture not needed • Urinalysis – Although still done very commonly – Pyuria: Sensitive but not specific – Squamous epithelial cells: suggests contamination • Culture if… – Complicated UTIs • Dipstick Enterobacteriaceae – Recurrent UTIs – Leukocyte esterase – High local rates of resistance – Nitrite nitrate nitrite Fihn SD. NEJM. 2003; Stamm WE. NEJM. 1982 Bent S. JAMA 2002 Utility of the midstream void culture? Utility of the midstream void culture? • E. coli, Klebsiella, S. saprophyticus • > 200 pre ‐ menopausal women with dysuria – Strong correlation midstream (10 2 )  bladder • Midstream void and catheter specimen • Midstream, mixed culture (86%) • Cultures positive – E. coli present  bladder – 99% midstream • Enterococcus and Group B strep (10% cultures) – 74% catheter specimens – Nearly never found in catheter specimens – 61% had E. coli grew from catheter cultures • Midstream cultures going to change treatment? Hooton TM. NEJM. 2013 Hooton TM. NEJM. 2013 7

4/16/2014 Question: According to the updated IDSA updated guidelines for Infectious Diseases Society of America uncomplicated UTI Guidelines ‐ what is the 1 st line treatment for an uncomplicated UTI? Goal: Low resistance, low “ collateral damage ” A. Ciprofloxacin 250mg BID x 3d • Nitrofurantoin 100 mg PO BID x 5 days B. Nitrofurantoin 100mg BID x 5d • TMP ‐ SMX DS PO BID x 3 days – avoid if resistance >20%, recent usage C. TMP ‐ SMX DS BID x 7d • Fosfomycin 3 gm PO x 2 D. Cephalexin 500 mg QID x 7d Gupta K. CID 2011 Lecture outline Treatment of complicated UTI • Asymptomatic bacteriuria • UTI in everyone other than non ‐ diabetic, non ‐ pregnant women not recently treated for a UTI • Uncomplicated UTI • Empiric therapy (7 ‐ 14 days): • Complicated UTI/pyelonephritis – Non ‐ pregnant: ciprofloxacin/levofloxacin – Pregnant women: Nitrofurantoin or cephalexin • Pathogenesis and management of recurrent UTI • Urine screening pre ‐ op 8

4/16/2014 Shorter course of antibiotics many Treatment of UTI in men be OK in men with UTI? • Diagnosis: • 39,149 Veterans with UTI • Antibiotic duration – Obtain culture ≤ 7 days: 35% (median 7 days) – Assess for STDs (urethritis) > 7 days: 65% (median 10 days) • Treatment: • Veterans who received > 7 days: – Quinolone, TMP ‐ SMX favored – No reduction in recurrences – Duration 7 ‐ 14 days – Increased late UTI recurrences – If recurrent consider prostatitis – Increase Clostridium difficile infection Drekonja DM. JAMA Intern Med. 2013 Empiric treatment of pyelonephritis Question 4: Recommended empiric Rx of pyelonephritis in a young woman? • Recommended – Ciprofloxacin 500 mg PO/IV q12 ( Levo ok, not Moxi ) A. Ceftriaxone 1 gm IV q24 – Ceftriaxone 1 gm IV q24 • Not recommended B. Moxifloxacin 400 mg IV/PO q24 – TMP ‐ SMX C. Nitrofurantoin 100 mg PO q12 – Nitrofurantoin – Cefpodoxime D. Cefpodoxime 200 mg PO q12 • Health ‐ care associated pyelonephritis – Use antipseudomonal agent other than fluoroquinolone 9