Burning Issues with UTIs

Meghan Brett, MDDivision of ID

Hospital EpidemiologistMedical Director, Antimicrobial Stewardship

Objectives• Distinguish between asymptomatic bacteriuria (ASB) and different

types of active UTIs (complicated vs. uncomplicated)

• Describe in which patients ASB should be treated

• Learn how to diagnose a catheter-associated UTIs (CAUTIs)

• Describe how to determine empiric treatment and how long uncomplicated UTIs should be treated

• Know how to access and use various antibiograms and other resources

What’s the Burden of UTIs?

• 50% of women will have a UTI in their lifetime– Up to 25% may have a second UTI within 6 months

• Visits related to UTI– 3 million ED visits in 2010– Most common primary diagnosis for U.S. women visiting EDs– 100,000 hospitalizations in U.S.– 0.9% of all ambulatory visits

• Half of all UTIs were among patients age 18 to 44 years• Pts visiting the ED have higher acuity than those pts

presenting to primary care– 400,000 (13%) were for pyelo (13 visits/10,000 people)– In general population: 1 case/28 cases of cystitis

Who is Most Affected by UTIs?

• Annual Incidence of UTIs– Young, sexually active women: 2 – 4%– Women > 70 yrs: 5 – 10%– Women > 80 yrs: 50%– Institutionalized Women: 40%– Adult men (childhood through middle age): < 1%– Men > 65 yrs: 1 – 3%– Men > 80 yrs: 10%– Institutionalized Men: 25%

• CAUTIs: ~1 million/year

What Are Take Home Points?

• Assemble the whole clinical picture (i.e., limiting reflexive Rx of positive Urine Cx)

• Determine the syndrome• Distinguish between complicated vs.

uncomplicated UTIs• Choose appropriate empiric antibiotics based on

likely bacterial etiologies and their resistance• Adjust antibiotics based on culture results• Decide about length of therapy

Questions (1st Set)• How do you define asymptomatic bacteriuria ASB?

• How do you differentiate between asymptomatic bacteriuria and UTI?

• Which groups need to be treated for ASB?

• What criteria do you use to define uncomplicated vs. complicated UTIs?

• Why does distinguishing uncomplicated vs. complicated help?

• What kinds of questions would you ask to distinguish between uncomplicated and complicated?

Asymptomatic Bacteriuria

• Asx women: 2 consecutive voided urine specimens with isolation of same bacterial strain in quantitative counts ≥ 105 cfu/mL

• Men: single, clean-catch voided specimen with 1 bacterial species isolated in quantitative counts ≥ 105 cfu/mL

• Women or men: single catheterized specimen with 1 bacterial species isolated in quantitative count ≥ 102 cfu/mL

Infectious Diseases Society of America (IDSA), ASB guidelines 2005

ASB

• Evidence that screening and treatment does not lead to improved clinical outcomes

• More likely, unnecessary antibiotics may cause harm– Adverse effects– C difficile infection– Antibiotic resistance– Wasted expense

UTI Signs/Sx

Clinical Presentation – Distinguishing ASB vx. UTI

• Lower tract signs– Dysuria– Frequent urination– Urgent urination

• DDX:– STIs– Vaginitis– Exposure to chemical or allergic irritants

Clinical Presentation – Distinguishing ASB vx. UTI

• Upper tract:– Fevers, chills– Nausea– Flank pain– Often also with dysuria/frequency/urgency

Which Groups Require Rx for ASB?

• Definitive:– Pregnant Women– Anyone undergoing TURP or Urologic procedures

during which mucosal bleeding is anticipated• Maybe:– Renal transplant patients– Neutropenic patients

Infectious Diseases Society of America (IDSA), ASB guidelines 2005

Uncomplicated vs. Complicated

• Uncomplicated – premenopausal women– No structural or functional abnormalities in urinary

tract– Not pregnant

• Complicated – – Structural abnormalities (e.g., nephrolithiasis)– Functional abnormalities (e.g., ureteral reflux)– Compromised hosts (e.g., pregnant, diabetic)– UTIs in boys/men: until structural/functional ruled

outIDSA, Uncomplicated UTI Guidelines 2011Dielubanza EJ. ID Clin N Am 2014.

Why Distinguish Between Uncomplicated vs. Complicated?

• Guidelines for uncomplicated but none for complicated UTIs

• More important than upper tract/lower tract• Complicated – May need further evaluation (diagnostics, urology consult)– Increased morbidity and mortality– May encounter more drug resistance (IV ABX)– Duration of therapy will likely be longer

• Assess conversion from uncomplicated to complicated (may indicated underlying issues)

Questions to Distinguish Uncomplicated from Complicated

• Pregnancy status• History of kidney stones• Structural/functional GU abnormalities• Pelvic surgery• DM• Neurologic disorders• Recent ABX use• Recent hospitalization• Recent GU instrumentation

Questions (2nd Set)

• What’s the best way to obtain a urine sample for diagnosing a UTI?

• What are indications for having a Foley catheter?

• What tests do you review on a urinalysis to make you consider a UTI? ASB?

• How do you diagnose a CAUTI?

Key Issue – Urine Sample Collection

• Clean-catch, mid-stream = best• In/Out catheterization• DO NOT insert Foley catheters for sake of

urine collection (unless otherwise indicated)

Indications for Foley Catheters

• Patients with hemodynamic instability (e.g., on pressors) who require urine output monitoring

• Urinary obstruction/retention • Sacral or perineal wounds in patients with

incontinence • Genitourinary surgery/Placed by a Urologist • Requires prolonged immobilization (unstable

spine) • End of life care

CDC (HICPAC) CAUTI Prevention Guidelines, 2009http://www.cdc.gov/HAI/ca_uti/uti.html

Review of UA for Evidence of Infection

• Check squamous cells first… if > 20, likely a contaminated sample

• Nitrites– Produced by many Gram-negatives– Requires hours for conversion of nitrate nitrite– Not by Gram-positives, candida species

• WBCs– > 10 per high powered field

• Leukocyte esterase– Enzyme found in neutrophils– If present, indicates neutrophil activity

Caveats

• Pyuria in ASB does not need to be treated• Urine samples that sit will have alterations in

UA results– Samples analyzed within 2 hours or refrigerated to

limit false positive and false negative results

Questions (3rd Set)• How do you select an antibiotic for empiric treatment

treatment?

• When do you change from empiric to directed antibiotic therapy?

• How long do you treat uncomplicated cystitis? Uncomplicated pyelonephritis?

• How do you treat CAUTIs? For how long?

• Do you test urine for cure? Why?

Treatment of UTIs – What Bugs?

• Enteric flora colonizing perineum and urethra• E. coli

– 80% of first infection in women, men, children– 50% of nosocomial UTIs– Most common for acute uncomplicated cystitis– Many episodes of complicated UTIs and pyelo

• Staphylococcus saprophyticus– 11% of UTIs (sexually active, younger women)

• Remaining– GNRs (Klebiella, Proteus mirabilis) increasingly MDROs– Gram-positive cocci (entercoccus and GBS)

What’s First Line Therapy (Empiric Treatment)? – Uncomplicated Only!

• Antimicrobial Stewardship Clinical Pathway (with a focus on inpatients)

Change from Empiric to Directed?

• When you have culture results• Look at susceptibility interpretations• Determine what has good urine/kidney

penetration• Lowest MIC ≠ Best ABX selection• Questions? Call Antimicrobial Stewardship!

(on amion.com)

How Long to Treat?

• It depends!• Uncomplicated UTIs– Cystitis

• Nitrofurantoin or Bactrim 3 days• 20% resistance in isolates is an indication not to use this for

empiric coverage• Note: nitrofurantoin should not be used in patients with

Creatinine clearance < 50 (does not reach bladder)– Pyelonephritis

• FQ 5 – 7 days• Beta-lactams 10 – 14 days• Bactrim 14 days

How Long to Treat CAUTIs?

• 7 days of treatment for patients with CAUTI who have prompt resolution of symptoms

• 10 – 14 days in patients with delayed response to treatment

• 3 day regimen may be considered for women ≤ 65 yrs who develop CAUTI without upper tract sx after a catheter has been removed

Test of Cure?

• Nope (please don’t)

Other Notes

• Complicated including CAUTIs– Polymicrobial for longer-term (>30d) indwelling

catheters– More drug resistant (ESBLs, P. aeruginosa, or

enterococcus faecium)• S. aureus – what to do?

Treatment of CAUTIs

• Algorithm to be developed

Greatest Overuse of Antibiotics

It’s ASBpatient’s positive urine cx

Unintended Consequences of ABX

• Drug reactions• C difficile infections• Selection for drug resistance

• Stay tuned… impact to the microbiome

Resources

• https://hospitals.health.unm.edu/intranet/Index.cfm

• https://hospitals.health.unm.edu/intranet/antimicrobial/pathways.shtml

• http://www.tricore.org/Healthcare-Professionals/Test-Information/Antibiograms

ASP – Inpt Antibiograms and Clinical Pathways

Tricore – Outpatient Antibiograms