PSMID Urosurgical Infections

Urosurgical Infections

Arthur Dessi Roman, MD, MTM, FPCP,

DPSMID

27 November 2014, Crowne Plaza

Philippine Society for Microbiology and Infectious Diseases36th Annual Convention

Relationship Between Urosurgical Conditions and

Infection1. GU abnormalities predispose to infection

Provide nidus for infections

Obstruction urine stasis.

As little as ___ mL of residual urine has been calculated to be significant.

O'Grady & Cattell, 1966; O'Grady et ai, 1973


Infection1. GU abnormalities predispose to infection

Provide nidus for infections

Obstruction urine stasis.


Infection

Urease splits urea to ammonia and carbonic acid

Ammonia raises urinary pH

Growth of struvite stones (carbonate apatite, Mg ammonium phosphate

2. Growth of urinary tract calculi and proliferation of bacteria are synergistic

Uy NT, Lapitan MCM, Gatchalian ER. The epidemiology of urinary stones in a tertiary government hospital. Phil J Urol 2008; 18(2): 31-37.


Infection3. Instrumentation and manipulation (e.g.

catheterization)

1 out 5 admissions are catheterized

70% develop bacteremia at the rate of 3-10%/day

Bacteremia is universal by 30 days


Infection

4. Infection predisposes to post-operative complications

Plaza and Lapitan. Predictors of Postoperative Complications of Transurethral Resection of the Prostate in a Resource-Poor Setting* . Philippine Journal of Urology December 2012; 22: 2

Pre-operative UTI

4XPost-operative complications


Infection

5. Surgery is the modality of choice in certain infection (e.g. renal abscess >5 cm)


Infection


Survey says…What is the most common urologic diagnosis that

warrants surgical intervention?

PyonephritisAbscess, all forms


Infection


Survey says…What is the most common surgery done for which

infection is the indication?

Urinary diversion (e.g. nephrostomy)

Scope of

Urosurgical infections

Antimicrobial prophylaxis

Screening for asymptomatic bacteriuria

Infections in the pre-, peri- and post-kidney transplant patients and donor organ infections

Management of complicated UTIs secondary to the Presence of

structural abnormalities causing urinary stasis and obstruction of the

genitourinary tract

Management of complicated UTIs secondary to Functional abnormalities that affect normal urine outflow

Management of complicated UTIs associated with Iatrogenic

urosurgical conditions

Infections for which urosurgery is indicated

Strength of Recommendation and Quality of Evidence

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schunemann HJ, GRADE Working Group. GRADE: an emerging consensuson rating quality of evidence and strength of recommendations. BMJ 2008;336: 924-926Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, Schünemann HJ and for the GRADE Working Group. Going from evidence torecommendations. BMJ 2008; 336: 1049-51

Scope of the Lecture

• Renal abscess

• Recommendations for Empiric Antimicrobial Treatment

• Screening for asymptomatic bacteriuria

• Antimicrobial pre-operative antimicrobial prophylaxis in urology


• Renal abscess




What is a renal abscess?

• collection of pus within the kidney that may extend into the retroperitoneum.

What is a renal abscess?

• Tissue necrosis of the lobules walled off inside a cavity

• Incidence density among diabetics: 1.1 to 4 cases per 10,000 person years

• Case fatality rate: 39-50% 3-6%

– better imaging modalities and better antibiotics

Lin HS 2008, Meng MV 2002, Coelho 2007, Lee 2008, Ko M-C 2011

S/Sx of renal abscess similar with other cUTI syndromes

• Fever (75-93% )

• CVA tenderness (75%)

• Lumbar pain (36-64.5%)

• Nausea and vomiting (30%)

• Dysuria (8.9-12%)

• Anorexia (6-37%)

Deyoe 1990, Coelho 2007, Lee 2008, Lim 2011, Rai 2007

When to suspect renal abscess?

Diabetic patients presenting with hypotension and renal impairment

Strong level of recommendation, low quality of evidence

Patients suspected to have upper UTI who remain febrile and hypotensive 72 hours after initial intravenous antibiotic

administration.



DM is the most common predisposing factor

DM (p=0.016, OR 5.8)Hypotension (p=0.044, OR 4.7)

renal impairment (P = 0.001, OR 13.4) and

Lee BE 2008, Coelho 2007, Rai RS 2007, Lee SH 2010, Lin HS 2008Lim SK and Ng FC. Acute pyelonephritis and renal abscesses in adults--correlating clinical parameters with radiological (computer tomography) severity. Ann Acad Med Singapore 2011; 40:407-13.Mowat AG 1971, Bybee JD 1964 , Repine JE 1980

defective chemotaxis, phagocytosisand bactericidal activity of phagocytes in DM patients



Strong level of recommendation, low quality of evidence


administration.



administration.

Only 13% of cUTI patients will have fever beyond 72 hours post treatment

Behr MA, Drummond R, Libman MD, Delaney JS, Dylewski JS. Fever duration in hospitalized acute pyelonephritis patients. Am J Med. 1996 Sep; 101(3):277-80.Yen DH, Hu SC, Tsai J, Kao WF, et al. Renal abscess: early diagnosis and treatment. Am J Emerg Med. 1999 Mar;17(2):192-7

A protracted UTI course despite initiation of antibiotic was associated with renal abscess

Recommendations: Renal abscess diagnostics

• Imaging: UTZ or CT-scan (higher sensitivity)

• Cultures

– Urine (41-43% positivity rate)

– blood culture (31-40%)

– Abscess aspirate (59%)- if drainage performed

• blood or urine culture may parallel the bacteriology of the abscess

Strong level of recommendation, Low quality of evidence

Capitan Manjon C, Tejido Sanchez A, Piedra Lara JD, Martinez Silva V, Cruceyra Betriu G, Rosino Sanchez A, Garcia Penalver C, LeivaGalvis O. Retroperitoneal abscesses: analysis of a series of 65 cases. Scand J Urol Nephrol. 2003;37:139–144.Yen DH, Hu SC, Tsai J, Kao WF, et al. Renal abscess: early diagnosis and treatment. Am J Emerg Med. 1999 Mar;17(2):192-7.

Renal abscess: Management Algorithm

Do Imaging: CT scan (preferable) or

ultrasound

YES

Continue antibiotics

NO

Pt suspected with upper UTI PLUS:

DM + Hypotension/ Renal impairment

OR Failure to respond to IV

antibiotics with 72 hours

Renal abscess: Management Algorithm

Renal abscess >

5 cms?

If UTZ is negative consider doing a CT scan.

If CT scan is negative, renal abscess is unlikely.

Continue antibiotics for a minimum of 4weeks, antibiotics can be discontinued upon resolution of abscess on repeat CT scan

Refer to Urology for drainage of abscess, antibiotics is continued for a minimum of 4 weeks in a setting of

proper drainage

YES

NORenal abscess present?

NO

What empiric antibiotic to start?

Microbiology of Renal Abscess

• E. coli, Klebsiella sp., and Proteus spp.

• Similar with complicated UTI pathogens, may include drug-resistant pathogens (e.g. ESBL, Pseudomonas, Staphylococcus aureus)

• Recommendations for empiric antibiotics the same for renal abscess and severe complicated UTIs

Yen 1999, Lee 2008, Deyoe 1990, Lin 2008, Saiki 1982


• Renal abscess




Reasons for Antibiotic RecommendationAntimicrobial Agent ARSP 2013* ARSP2012** cUTI study 2013+

N %R N %R

All cultures,

N=178

(n, %R)

ESBL-producing,

N=48

(n, %R)

Amikacin

Ampicillin

Ceftazidime

Ceftriaxone

Cefuroxime axetil

Ciprofloxacin

Co-amoxiclav

Ertapenem

Gentamicin

Imipenem

Levofloxacin

Meropenem

Nitrofurantoin

Piperacillin-tazobactam

Tigecycline

TMP-SMX

1,835

1,670

-

1,683

871

1,635

1,974

1,059

-

-

-

-

1,622

1,835

-

1,465

6%

85%

-

36%

40%

46%

23%

2%

-

-

-

-

6%

6%

-

69%

1,253

-

-

1,326

443

1,362

1,397

1.452

-

-

-

-

1,264

-

-

1,239

5.2%

-

-

30.8%

34.2%

42.1%

27.1%

2%

-

-

-

-

8.3%

-

-

68.9%

3 (2.1%)

125 (80.7%)

51 (31.7%)

49 (32.2%)

62 (41.6%)++

-

63 (42.6%)

0

47 (29.2%)

3 (2.1%)

80 (48.2%)

1 (0.7%)

32 (24.2%)

30 (24.2%)

5 (4.6%)

95 (59.4%)

0

48 (100%)

44 (91.7%)

47 (97.9%)

48 (100%)++

-

38 (79.2)

0

24 (50.0%)

0

43 (93.8)

0

12 (34.3%)

16 (45.7%)

5 (15.2%)

40 (83.3%)

Antimicrobial Resistance Surveillance Reference Laboratory, Antimicrobial Resistance Surveillance Program Annual Report, 2013: Manila, Philippines.Henson, K.R., et al., Prevalence and risk factors for extended-spectrum beta-lactamase-producing organisms among patients with complicated urinary tract infections in a developing country, in 53rd Interscience Conference on Antimicrobial Agents and Chemotherapy2013: Denver, CO, USA.

The global phenomenon of rising antimicrobial resistance has been

observed in the region

ESBL (extended spectrum beta-lactamase)

- ESBL-rate in the Asia-Pacific region: 28.2%

- Tertiary hospital in Manila in 2007: 37%

- Private tertiary hospital in Pasig in 2011: 29%

KPC (K. pneumoniae carbapenemase) production

Fluoroquinolone and TMP-SMX resistance

Multidrug-resistance Henson, K.R., et al., Prevalence and risk factors for extended-spectrum beta-lactamase-producing organisms among patients with complicated urinary tract infections in a developing country, in 53rd Interscience Conference on Antimicrobial Agents and Chemotherapy2013: Denver, CO, USA.Zamora, R.P., et al., Clinical and molecular profile, risk factors and outcome of beta-lactamase-producing Enterobacteriaceae infections in a government university hospital, in 2013 ID Week2013 October 2-6: San Francisco, CA, USA

Risks for Antibiotic Resistance

ESBL-producing organisms

Prolonged stay in a hospital or healthcare facility

Recent use of antibiotics* (fluoroquinolones, cephalosporins, B-lactams)

Recent hospitalization (past 3 months)

Recent travel to ESBL-highly endemic areas (Asia, The Middle East or Africa) in the past 6 weeks

Presence of Diabetes mellitus and/or other co-morbidities (e.g. neutropenia)

Urinary catheterization, surgery or instrumentation and use of other invasive devices

Recent episode of UTI, recurrent UTI

Structural or anatomical abnormality of the genitourinary tract, including prostatic disease

Mechanical ventilation

Pseudomonas (including multi-drug resistant Pseudomonas)

Use of antibiotics in the past 2 months* (ciprofloxacin, BLICs)

Recent episode of UTI

Previous urinary tract surgery, catheterization

Underlying urinary tract pathology (e.g. pathological VCUG results)

Recent stay in another healthcare unit/facility

Empiric antibiotic options for complicated UTI

ANTIBIOTICRecommended Dose

and DurationComments

Amikacin (First line) 15 mg/kg q24h Be cautious in giving aminoglycosides in patients with

renal insufficiency

Ertapenem 1g IV q24h1 For patients with no risk for Pseudomonas or

Enterococcus

Anti-Pseudomonal carbapenems For patients with risk for Pseudomonas infection

For ESBL-producing EnterobacteriaceaeDoripenem2

Imipenem-cilastin3

Meropenem4

500 mg q8h

500 mg q6h

1 g q8h

Vancomycin 1g IV q 12 For suspected staphylococcal infections5

Colistin (Colistimethate sodium) For multidrug-resistant Enterobacteriaceae, Klebsiella

pneumonia carbapenemase-producing (KPC) bacteria,

Multi-drug resistant (MDR) Pseudomonas sp. or MDR

Acinetobacter sp.

Colomycin6 31,250–62,500 IU/kg per

day, divided in 2-4 equal

doses

(240-480 mg/kg/day)

Coly-Mycin Double the dose of

colomycin (400-800

mg/kg/day)

Empiric antibiotic options for complicated UTI

ANTIBIOTICRecommended Dose

and DurationComments

Tigecycline 100 mg IV loading dose then

50 mg IV q12

For vancomycin-resistant Enterococci

For ESBL-producing Enterobacteriaceae (except

Pseudomonas sp.

Ampicillin 1-2 g IV q6-8h For susceptible enterococcal infections

Cefepime 1-2 g IV q8-12h For Pseudomonas or Acinetobacter sp. infections

Ceftazidime 1-2 g IV q8h+

Piperacillin-

Tazobactam

4.5 g IV q24

Levofloxacin 750 mg q24h For mild infections with no history of previous third

generation cephalosporin or fluoroquinolone use

Fluconazole For fungal infections (see Section on Urinary

Candidiasis and Candida Urinary Tract Infections for

dosing regimens)

Amphotericin B ±

5-flucytosine

Duration of Treatment

• In general, at least 7-14 days of therapy is recommended. Treatment duration may be extended depending on the clinical situation.

Strong recommendation, Moderate quality of evidence

• Antibiotics are modified according to the results of the urine culture and sensitivity tests. Patients started with parenteral regimen may be switched to oral therapy upon clinical improvement.

Strong recommendation, Moderate quality of evidence


• Renal abscess




Recommendation

Screening and treatment for ASB is recommended in patients who will undergo

genitourinary manipulation or instrumentation.

Strong recommendation, Grade of evidence vary per procedure

Philippine Society for Microbiology and Infectious Diseases36th Annual Convention

Definitions: Asymptomatic Bacteriuria

Significant bacteriuria without symptoms

Pyuria ≠ symptomatic infection

Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis 2005; 40:643-54

Definitions: Significant Bacteriuria

Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis 2005; 40:643-54

Men Women Both

Specimen Single, clean-catch voided urine

specimen

Two (2) consecutive , clean catch voided urine specimens

taken > 24 h apart

Single catheterized urine specimen with

Microbiologic criteria

Isolation of 1 bacterial species

Isolation of the same bacterial strain

Isolation of 1 bacterial species

Quantitativecount

≥105 cfu/mL 105 cfu/mL. ≥ 100 cfu/mL

GRADE Strong recommendationLow quality of evidence

Strong recommendationHigh quality of evidence

Strong recommendationHigh quality of evidence

Rationale

Grabe M. Antimicrobial agents in transurethral prostatic resection. J Urol 1987; 138:245–52.Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis 2005; 40:643-54.

• Bacteremia occurs in up to 60% of bacteriuricpatients who undergo TURP

– sepsis in 6%–10% of patients

• 1 Retrospective and 4 RCT: antibiotics prevent complications in bacteriuric men undergoing TURP

Recommendation

Grabe M. Antimicrobial agents in transurethral prostatic resection. J Urol 1987; 138:245–52.Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis 2005; 40:643-54.

Take cultures 72 hours prior to the procedure.

Initiate antibiotics the night before or immediately before the procedure

Catheter removed:Stop antibiotics after

procedure

Catheter remains:Continue antibiotics until

catheter is removed

Strong recommendation, Low quality of evidence

Urine culture beyond reach?

Norman DC, Yamamura R. Yoshikawa TT. Pyuria: Its predictive value of asymptomatic bacteriuria in ambulatory elderly men. J Urol 1996; 135:520-2

significant pyuria (>10 wbc/hpf)

OR

positive gram stain of unspun urine (>2 microorganisms/oif)

Strong Recommendation, Low quality of evidence

Two consecutive unspun midstream urine samples

Urine culture and sensitivity testing are not necessary when urinalysis is negative for pyuria or urine gram stain

Strong Recommendation, Moderate quality of evidence

Digressing a bit…

Spot QuizIn what other condition is screening and

treatment for ASB recommended?


• Renal abscess




Who should receive antimicrobial prophylaxis?

Patient group Strength of

Recommendation

Quality of evidence

Trans-rectal or trans-perineal prostate biopsy Strong High

TURP Strong High

Clean, contaminated, open or laparoscopic urological surgeries• Pelvio-ureteric junction repair• Nephron- sparing tumor resection• Total prostatectomy, bladder surgery, partial cystectomy• Urine diversion, orthotopic bladder replacement• Ileal conduit

Strong Low

Complicated endourological surgery, nephrostomy tube

insertion, ureteroscopy of proximal or impacted stone,

percutaneous stone extraction

Strong Low

Risk Factors for Infectious Complications

• Old age

• Nutritional deficiency

• Impaired immune response

• DM

• Smoking

• Extreme weight

• Co-existing infection at a remote site

• Long pre-operative hospital stay or recent hospitalization

• History of recurrent urogenital infections

• Surgery involving bowel segment

• Long term drainage

• Urinary obstruction and urinary stone










Duration of treatment

• The duration of peri-operative prophylaxis should be kept to a minimum.

• The decision to continue and/or to shift antibiotics and the duration after the procedure will depend on the best clinical judgement of the physician.

Strong recommendation, low quality of evidence

In summary…

• Suspect renal abscess in patients with a protracted course of UTI especially diabetics. Treatment is antibiotics and surgery (for size >5 cms).

• Amikacin and ertapenem are good empiric antibiotic options.

• Always assess for the presence of risk factors for antimicrobial-resistant organisms when deciding for empiric antibiotic.

• Screen and treat for ASB in patient who will undergo urologic surgery.

• Initiate antibiotic prophylaxis in high-risk urologic procedures and if risk factors for infectious complications are present.

UTI Task ForceChair: Mediadora C. Saniel, MD

Co Chair: Marissa M. Alejandria, MD

Cluster Heads, Complicated UTI

Arthur Dessi E. Roman, MD

Allan Raymond S. Tenorio , MD

Members:

Rufino T. Agudera, MD

Anne Margaret J. Ang, MD

Regina P. Berba, MD

Jill R. Itable, MD

Marie Carmela M. Lapitan. MD

Maria Nicolette M. Mariano, MD

Katha W. Ngo-Sanchez. MD

Oliver S. Sanchez, MD

Thank you!

Health & Medicine

PSMID Urosurgical Infections