Urinary tract infections Asymptomatic bacteriuria Uncomplicated UTI - PDF document

2/3/2014 Lecture outline Urinary tract infections • Asymptomatic bacteriuria • 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 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 1

2/3/2014 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 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% • Pyuria is frequently present > 50% of patients Diabetics (women; men) 9 ‐ 27%; 1 ‐ 11% Elderly in LTC facilities (women; men) 25 ‐ 50%; 15 ‐ 40% Pts with spinal cord injuries 23 ‐ 89% Pts undergoing HD 28% Pts with indwelling catheters Short ‐ term 9 ‐ 23% Long ‐ term 100% Nicolle. CID. 2005 2

2/3/2014 Who should you treat with Question 2: Which patient(s) should be asymptomatic bacteriuria? treated for 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 • Postmenopausal ambulatory women • Diabetic women w/ asymptomatic bacteriuria • Institituitionalized men and women • Intervention: Antimicrobial vs. placebo x 14d • Patients with spinal cord injuries – Cipro or TMP ‐ SMX as appropriate • Patients with urinary catheters • 1 ° endpoint: Time to 1 st symptomatic UTI • Diabetics Asscher AW. BMJ. 1969; Abrutyn E. J Am Soc Ger. 1996; Harding GKM. NEJM 2003 Results: treatment of asymptomatic bacteriuria in diabetic women If you have been treating • 105 pts enrolled asymptomatic bacteriuria • Symptomatic UTI unnecessarily, you are not – 42% Rx vs. 40% placebo the only one… – RR 1.19 (0.28–1.81),p=0.42 • Rx group required longer course of Abx when Rx for symptomatic UTI Harding GKM. NEJM 2003 3

2/3/2014 Provider prescribing practice for Inappropriate quinolone use urine culture + enterococcus? • Prospective eval of quinolone use in hospital • 339 hospitalized pts urine + Enterococcus • Identified 1,773 use days over 6 weeks – 54% had asymptomatic bacteriuria • 690 (39%) use days were “inappropriate” • 1/3 unnecessarily treated with antibiotics • #1 cause of inappropriate use was… • Pyuria was associated with antibiotic use – Asymptomatic bacteriuria/UTIs • 2% asymptomatic bacteriuria had UTI Lin E. Arch Int Med. 2012 Werner NL. BMC Infect Dis . 2011 What about the patient with Is asymptomatic bacteriuria protective? asymptomatic bacteriuria unable to tell you if they have symptoms? • 712 women with asymptomatic bacteriuria Symptomatic UTI (%) • Concern for infection? No Follow ‐ up No Antibiotics Antibiotics – No treatment Stats • Concern for infection? Yes 3 months 11 (4%) 32 (9%) NS 1.Always look for other sources (blood, lungs, etc.) 6 months 23 (8%) 98 (30%) p<0.0001 2.If no pyuria, do not treat 3.If candiduria, most cases don’t treat 12 months 41 (15%) 169 (73%) p<0.0001 4.If other source identified, stop UTI treatment Cai T. Clin Infect Dis. 2012 Lecture outline Types of symptomatic UTIs • Asymptomatic bacteriuria Uncomplicated vs. Complicated healthy women everyone else • Uncomplicated UTI cystitis • Complicated UTI/pyelonephritis Lower tract vs. Upper tract • Pathogenesis and management of recurrent UTI cystitis pyelonephritis • Urine screening pre ‐ op • Prostatitis 4

2/3/2014 Laboratory diagnosis of Clinical signs and symptoms of UTIs uncomplicated UTI Lower tract Upper tract • Urinalysis • Dysuria (1.5X) • Fever – Pyuria: 95% sensitive; 71% specific • Frequency (1.8x) • CVA tenderness – Bacteria visible: 40 ‐ 70% sensitive • Hematuria (2.0x) – Squamous epithelial cells: suggests contamination • Nausea/vomiting • Peripheral leukocytosis • Above with absence of • Dipstick Enterobacteriaceae vaginal discharge or • Symptoms of cystitis – Leukocyte esterase irritation ( 28x ) may not be present – Nitrite nitrate nitrite Bent S. JAMA 2002 Bent S. JAMA 2002 Pathogens causing UTIs Microbiologic diagnosis of UTI • Uncomplicated UTI • E. coli – culture not needed • Staphylococcus saprophyticus • What is a positive • Culture if… • Other Gram negative rods urine culture? – Complicated UTIs – Proteus spp – Recurrent UTIs – Klebsiella spp – High local rates of – Pseudomonas spp resistance • Enterococci spp Fihn SD. NEJM. 2003; Stamm WE. NEJM. 1982 Czaja CJ. CID 2006 Question: According to the updated IDSA updated guidelines for Infectious Diseases Society of America uncomplicated UTI ‐ March 2011 Guidelines ‐ what is the 1 st line treatment for an uncomplicated UTI? Goal: Low resistance and 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 C. TMP ‐ SMX DS BID x 7d – avoid if resistance >20%, recent usage D. Cephalexin 500 mg QID x 7d • Fosfomycin 3 gm PO x 2 Gupta K. CID 2011 5

2/3/2014 Lecture outline Treatment of complicated UTI • “ Complicated UTI ” – UTI in everyone other • Asymptomatic bacteriuria than non ‐ diabetic, non ‐ pregnant women not • Uncomplicated UTI recently treated for a UTI • Complicated UTI/pyelonephritis • Empiric therapy (7 ‐ 14 days): • Pathogenesis and management of recurrent UTI – Non ‐ pregnant: ciprofloxacin/levofloxacin • Urine screening pre ‐ op – Pregnant women: Nitrofurantoin or cephalexin 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 – Assess for STDs (urethritis) ≤ 7 days: 35% (median 7 days) > 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 6