CLASSIFICATION OF URINARY TRACT INFECTIONS AND SURGICAL ... ESU AMU Apr 2016... · INFECTIONS AND SURGICAL FIELD CONTAMINATION CATEGORIES AS A BASIS FOR TREATMENT AND PROPHLAXIS Magnus

CLASSIFICATION OF URINARY TRACT

INFECTIONS AND SURGICAL FIELD

CONTAMINATION CATEGORIES AS A BASIS

FOR TREATMENT AND PROPHLAXIS

Magnus Grabe, M.D., Ph.D.

Associate Professor of Urology

University of Lund

Sweden

[email protected]

ESU AMU UTI Apr 2016/MG

University of Lund – since 1666


University hospital - Malmö 2013


Scania: South Swedish Province


Winter


Layout

• The European Association of Urology (EAU)

Guidelines on Urological Infections (versions

2015 and 2016)

• Principle of classification of Urinary tract

infections

• Surgical field contamination categories as a

model for peri-operative antimicrobial prophylaxis

• Antimicrobial (= antibiotic) stewardship

• Conclusions and take home message


EAU Guidelines 2015


www.uroweb.org/guidelines

Non-oncology/urological infections/archive: 2015

http://www.uroweb.org/guidelines

Main types of infections associated with

urological care


Wound infections

Surgical site

infeciton (SSI)

Urinary tract

infection

Male accesory

gland infection

(MAGI)

Systemic and

Other organ

infection

Female

resproductive

organ infection

Classification of Urogenital infections

Urinary tract infection

(UTI)

Male accessory gland

infection (MAGI)

Uro-Genital infections (UGI)

Female

reproductive

organs

infection

EAU guidelines

Grabe et al. EAU guidelines 2012-2015 ESU AMU UTI Apr 2016/MG

PRINCIPLES OF A MODERN

CLASSIFICATION OF UTI

European Section of Infection in Urology

ESIU

European Association of Urology

EAU


What we have

ICD 10

N30.9 Cystitis

N10

N11.9

Pyelonephritis

N39 UTI unspecified

A41.9 Sepsis, unspecified

N41.9 Prostatitis

• CDC 1988

• CDC update 2008

• IDSA 1992

• ESCMID 1993



European Association

of Urology and

International

Consultation on

Urological Diseases

• 16 sections, divided in several chapters

• 991 pages

• Each section chaired by one expert coordinating an international effort

• Evidence based review of the literature

• Totally 3628 references

T N M like

classification

A UTI severity

score

What we would like to have


What is important for a UTI in Urology?

• Clinical criteria

• Presentation - localisation

• Severity

• Risk factors

• Endogenous

• Exogenous

• Urological circumstances

• Pathogens

• Pathogen (type, virulence)

• Antibiotic sensitivity

• Circumstances of UTI

acquisition

• Community

• Hospital environment

• Long term residential

• Therapeutic options


STEP ONE (1) The Localisation

Symptoms

Presentation


Localisation of infection of the UT

Localisation Symptoms giving the localisation Acronym

Urine (only) No

Source level unknown

ABU

Bladder Lower Urinary Tract symptoms

Cystitis

CY

Kidney Upper Urinary tract symptoms

Pyelonephritis, Pyonephrosis

“Febrile” UTI (Avoid “pyelitis”)

PN

Systemic Sepsis

“Urosepsis”

US

Male genital

infection

Prostatitis

Epididymitis


Classification of clinical presentation

Clinical

diagnosis

Clinical symptoms

Grade of

severity

Acronym

Cystitis Dysuria, frequency, urgency,

suprapubic pain, etc… 1 CY-1

Mild,moderate

pyelonephritis

“Febrile UTI”

Fever (>38oC), abdominal or flank pain

Unspecific febrile symptoms with or

without symptoms of CY

2 PN-2

Severe

pyelonephritis

“Febrile UTI”

As PN-2 with nausea and vomiting 3 PN-3

UroSepsis

SIRS

Any signs of Systemic Inflammatory

Response Syndrome (SIRS) +/- PN/CY 4 US-4*

Severe Sepsis US-4 + hypo-tension and -perfusion 5 US-5*

Sepsis with

organ failure

US-5 + organ failure not responding

supportive therapy 6 US-6*

Adapted from Bjerklund Johansen, 2010


* Sepsis – 2/2001

New classification of Sepsis (Sepsis-3/2016)


JAMA, 2016:315(8)

Feb 23

New classification of Sepsis (Sepsis-3/2016)


JAMA, 2016:315 (8);Feb 23

New classification of Sepsis (Sepsis-3): SOFA score


JAMA, 2016:315 (8);Feb 23

Local symptoms Dysuria, frequency,

urgency, pain or

bladder tenderness

General symptoms Fever, Flank pain

Nausea, vomiting

Systemic response SIRS Fever, shivering

Circulatory failure

US-6 ABU CY-1 PN-2 PN-3

Febrile UTI

US-5

Symptoms

Clinical

diagnosis

Treatment

Medical

and

Surgical

US-4

+

Organ failure Single-, multiple-

Organ failure

No

symp

toms

Severity

Investigat-

ions

Risk factors

* Two exceptions: pregnancy and prior to urological procedure


STEP TWO (2)

The degree of severity

A continuum



urgency, pain or

bladder tenderness


Nausea, vomiting


Circulatory failure


Febrile UTI

US-5

Symptoms

Clinical

diagnosis

Treatment

Medical

and

Surgical

US-4

Gradient of severity

+


Organ failure

No

symp

toms

Severity

Investigat-

ions

Risk factors



STEP THREE (3)

Risk Factor assessment

Grouping the Risk Factors



urgency, pain or

bladder tenderness


Nausea, vomiting

Dipstick

(MSU Culture + S

as required)

Dipstick

MSU Culture + S

Renal US or I.V. Pyelogram /renal CT


Circulatory failure

Dipstick

MSU Culture + S and Blood culture

Renal US and/or Renal and abdominal CT


Febrile UTI

US-5

Symptoms

Clinical

diagnosis

Treatment

Medical

and

Surgical

US-4

Risk factor assessment according to ORENUC (Table 2.1)


+


Organ failure

No

symp

toms

Severity

Investigat-

ions

Risk factors


Uncomplicated UTI Complicated UTI


ORENUC Risk Factors

O R E N U C

No RF of

recur-

rence

Extra-

genital

Nephro-

pathic

Urolog-

ical

Cathe-

ter

related


Host Risk Factors in UTI (EAU Guidelines 2011-2015)

Type Category of risk factor Examples of risk factors

O No known/associated RF Healthy premenopausal women

R RF of recurrent UTI, but no risk of severe

outcome

Sexual behaviour and contraceptive devices

Hormonal deficiency in post menopause

Secretory type of certain blood groups

Controlled diabetes mellitus

E Extra-urogenital RF, with risk of more severe

outcome

Pregnancy

Male gender

Badly controlled diabetes mellitus

Relevant immunosuppression*

Connective tissue diseases*

Prematurity, new-born

N Nephropathic disease, with risk of more

severe outcome

Relevant renal insufficiency*

Polycystic nephropathy

U Urological RF, with risk of more severe

outcome, which can be resolved during

therapy

Ureteral obstruction (i.e. stone, stricture)

Transient short-term urinary tract catheter

Asymptomatic Bacteriuria**

Controlled neurogenic bladder dysfunction

Urological surgery

C Permanent urinary Catheter and non

resolvable urological RF, with risk of more

severe outcome

Long-term urinary tract catheter treatment

Non resolvable urinary obstruction

Badly controlled neurogenic bladder dysfunction


Bjerklund-Johansen et al. Urological infections. EAU-ICDU, 2010 * Not well defined

STEP FOUR (4)

Pathogen and its sensitivity


Theurapeutic options

Microorganism Sensitivity


Susceptibility Level

Susceptible a

Reduced

susceptibility

b

Multiresistant c

THE FINAL CODE Clinical presentation

Severity

Risk factors

Pathogen and sensitivity

Therapeutic options


Additive factors for UTI severity assessment

Clinical presentation

UR: Urethritis

CY: Cystitis

PN: Pyelonephritis

US: Urosepsis

MA: Male genital glands

Grade of severity

1: Low, cystitis

2: PN, moderate

3: PN, severe, established

4: US: SIRS

5: US: Organ dysfunction

6: US: Organ failure

Risk factors ORENUC

O: No RF

R: Recurrent UTI RF

E: Extra urogenital RF

N: Nephropathic RF

U: Urological RF

C: Catheter RF

Pathogens

Species

Susceptibility grade

• Susceptible

• Reduced susceptibility

• Multi-resistant

ESIU, MG, 2010


Grabe et al. EAU Guidelines on

Urological infections 2011-2015

Treatment:

Medical

Surgical?

PN-3,U:E.COLI (S)

US-5,E:PROTEUS (A)

CY-1,O:E.coli (s)

CY-1,R:E.coli (s)


Not validated but a

practical tool


urgency, pain or

bladder tenderness


Nausea, vomiting

Dipstick

(MSU Culture + S

as required)

Empirical

3-5 days

Dipstick

MSU Culture + S


Empirical + directed

7-14 days


Circulatory failure

Dipstick



US-6


7-14 days Consider combine 2 antibiotics

ABU CY-1 PN-2 PN-3

Febrile UTI

US-5

Symptoms

Clinical

diagnosis

Treatment

Medical

and

Surgical

NO* Empirical + directed

10-14 days Combine 2 antibiotics

US-4



+


Organ failure

No

symp

toms

Severity

Investigat-

ions

Risk factors





urgency, pain or

bladder tenderness


Nausea, vomiting

Dipstick

(MSU Culture + S

as required)

Empirical

3-5 days

Dipstick

MSU Culture + S



7-14 days


Circulatory failure

Dipstick



US-6


7-14 days Consider combine 2 antibiotics

ABU CY-1 PN-2 PN-3

Febrile UTI

US-5

Symptoms

Clinical

diagnosis

Treatment

Medical

and

Surgical

NO* Empirical + directed

10-14 days Combine 2 antibiotics

US-4



+


Organ failure

No

symp

toms

Drainage/surgery as required

Severity

Investigat-

ions

Risk factors




SURGICAL FIELD

CONTAMINATION LEVEL


CLASSIFICATION OF UROLOGICAL

PROCEDURES IN RELATION TO

LEVEL OF CONTAMINATION

Based on CDC Guidelines on prevention of SSI Mangram et al. Infect Control Hosp Epidemiol 1999;20:250-78

Adapted for urological procedures by EAU

Section on infections in Urology (ESIU)

Urological Infections 2011-2015


Grabe et al. World J Urol 2011

Surgical field contamination: General

Surgical

contamination

Description Principle of

antimicrobial

prophylaxis

Clean (I)

Clean-contaminated

(II)

Contaminated

(III)

Dirty (IV)


Mangram et al, 1999

Surgical field contamination: General

Surgical

contamination


antimicrobial

prophylaxis

Clean (I) Urinary, genital or alimentary tracts not entered

Uninfected operative wound and no evidence of

inflammation. No break in technique.

Blunt trauma.

Clean-contaminated

(II)

Urinary, alimentary, pulmonary or genital

tracts entered with no or little (controlled)

spillage. No break in technique

Contaminated

(III)

Urinary, alimentary, pulmonary or genital

tracts entered, spillage of GI content;

inflammatory tissue; major break in technique;

Open, fresh accidental wounds

Dirty (IV) Pre-existing infection; viscera perforation

Old traumatic wound


Mangram et al, 1999

Surgical field contamination: Urology

Surgical

contamination


antimicrobial

prophylaxis




Blunt trauma.

Clean-contaminated

(UT) (IIA)

Urinary or genital tracts entered with no or little

(controlled ) spillage. No break in technique

Clean-contaminated

(bowel) (IIB)

Gastrointestinal tract entered, no or little

(controlled) spillage. No break in technique

Contaminated

(III)

UT or GI tracts entered, spillage of GI content;



Bacterial growth in urine


Old traumatic wound


Grabe et al, WJU 2011

Mangram et al, 1999

Clean but entering the lower UT

Surgical field contamination: Urology

Surgical

contamination


antimicrobial

prophylaxis




Blunt trauma.

No

Clean-contaminated

(UT) (IIA)

Urinary or genital tracts entered with no or little

(controlled ) spillage. No break in technique Yes

Single dose If prolonged =

treatment Clean-contaminated

(bowel) (IIB)

Gastrointestinal tract entered, no or little

(controlled) spillage. No break in technique

Contaminated

(III)

UT or GI tracts entered, spillage of GI content;



Bacterial growth in urine

Pre-operative

control


Old traumatic wound Treatment


Grabe et al, WJU 2011

Mangram et al, 1999

Clean but entering the lower UT

Other criteria?

Event Example Decision

Breach of

protecting mucosal

layer

Cystoscopy

Endourological procedures

(e.g. URS)

Does it change?

Small rift, no change

Larger rift?

Perforation of organ Bladder wall

Ureter perforation during

stone management

Kidney pelvic wall perforation

during PCNL

Change from

prophylaxis to

treatment?

Necrotic tissue or

purulent liquide

Resection of prostate or

bladder tumour

Infected environment


Lack of evidence for such decisions

Antimicrobial Stewardship (1)

• Optimise

• The outcome of prevention and treatment of infection

• Curbing overuse and misuse of antimicrobial agents

• Measure of success:

• Regulating antibiotic prescription

• Healthcare associated infection = HAI (reporting, feed-back)

• Emergence of resistant organisms, e.g. Clostridium difficile

• In urology

• Urinary tract infections (UTI)

• Male accessory glands infection (MAGI)


Antimicrobial Stewardship (2)

• The most important components

• Regular training of staff in best use of antimicrobial agents

• Adherence to local, national and international guidelines

• Regular ward visits and consultation with infectious disease physicians

• Treatment outcome evaluation

• Monitoring and regular feedback to prescribers of their antimicrobial prescribing performance and local pathogen resistance profile, by

• Clinic and Ward audits


Conclusions – message to take home

• Urological care is accompainied by several different forms of infections and infectious complications

• A stepwise assessment of each patient is essential for a correct management • Localisation of infection

• Careful risk factor evaluation

• Expected microorganism and resistance pattern

• Need for surgical management in addition to medical

• The surgical field contamination level is a tool to prevent infectious complications in conjunction with urological surgery

• Antibiotic stewardship programme is a tool for improving the rational and reasonable use of antibiotics


Documents

CLASSIFICATION OF URINARY TRACT INFECTIONS AND SURGICAL ... ESU AMU Apr 2016... · INFECTIONS AND SURGICAL FIELD CONTAMINATION CATEGORIES AS A BASIS FOR TREATMENT AND PROPHLAXIS Magnus