“When I woke up just after dawn on September28, 1928, I certainly didnt plan to revolutionize allmedicine by discovering the worlds first antibiotic, orbacteria killer. But I suppose that was exactly what Idid.” –Alexander Fleming
“URINARY TRACT INFECTIONS: SPECTRUM OF ORGANISMS ALONGWITH THEIR ANTIBIOTIC SENSITIVITY IN INPATIENT AND OUTPATIENTSET-UPS” Total Number of Cases Studied(n) = 200 INCLUSION CRITERIA: This study will include all those patients in whom UrinaryTract Infections are suspected and their Urine Culture andAntibiotic sensitivity pattern have been sent. Both pediatric and adults of both sexes included . Both Inpatients and Outpatients Included. EXCLUSION CRITERIA: Patients in whom Urine Culture and/or Antibiotic SensitivityPattern have not been done.
MATERIALS AND METHODS This study will be a cross-sectional study of all patients of suspected Urinary Tract Infections in whom Urine Culture and Antibiotic Sensitivity patterns have been done. All patients who are diagnosed to have urinary tract infections will be thoroughly studied regarding the organism isolated from urine culture as well as their sensitivity pattern to antibiotics. All the study subjects will be evaluated using the proforma attached along with their Urine Culture reports and Antibiotic sensitivity pattern.
URINARY TRACT INFECTIONS Leadingcause of morbidity and health care expenditures in persons of all ages. An estimated 50 % of women report having had a UTI at some point in their lives. 8.3million office visits and more than 1 million hospitalizations, for an overall annual cost > $1 billion in USA (2010)
ACUTE UNCOMPLICATED CYSTITIS Sexually active young women. Causes: anatomy and certain behavioral factors, including delays in micturition, sexual activity, and the use of diaphragms and spermicides tract. Aggressive diagnostic work- ups are unwarranted in young women presenting with an uncomplicated episode of cystitis.
ACUTE UNCOMPLICATED CYSTITIS The microbiology is limited to a few pathogens. 70%- 85% are caused by Escherichia coli 5-20%are caused by coagulase-negative Staphylococcus saprophyticus 5-12% are caused by other Enterobacteriaceae such as Klebsiella and Proteus.
ACUTE UNCOMPLICATED CYSTITIS Diagnosis: direct history and PE PE: Temperature, abdominal exam, assessment of CVA tenderness, pelvic exam. H/o STD’s, new sexual partner, partner with urethral symptoms, gradual onset.
ACUTE UNCOMPLICATED CYSTITIS Guidelines for tx of acute cystitis recommend empiric antibiotic tx. Unnecessary antibiotic use?? Clinical criteria for Dx: Dysuria, presence of > trace urine leukocytes, and presence of nitrites or... Dysuria and frequency in the absence of vaginal discharge.
ACUTE UNCOMPLICATED CYSTITIS UA:Evaluation of midstream urine for pyuria. White blood cell casts in the urine are Dx of upper tract infection. Urine Culture: Not necessary Warranted in: Suspected complicated infection, persistent symptoms following tx, symptoms recur < 1 mo after tx.
ACUTE UNCOMPLICATED CYSTITIS Urine dipsticks: Leukocyte esterase (pyuria), sensitivity 75- 90%, specificity 95% Nitrite (Enterobacteriacea), sensitivity 35- 85%, specificity 95%, false positive with phenazopyridine, beets. Microscopic evaluation for pyuria or a culture is indicated in pt with negative leukocyte esterase that have urinary symptoms.
ACUTE UNCOMPLICATED CYSTITIS Susceptibility: E.coli 30% isolates resistance to ampicillin and sulfonamides Increasing of resistance to TMP-SMX Resistance to nitrofurantoin is <5% Resistance to fluoroquinolones <5% S.saprophyticus 3% resistant to TMP-SMX 0% resistant to nitrofurantoin 0.4% resistant to ciprofloxacin
ACUTE UNCOMPLICATED CYSTITIS Treatment: Short course vs. prolonged tx Short course preferred except with beta-lactam agents TMP-SMX (160/800mg BID x 3) first-line tx if: no allergy to the drug, no antibiotics in the past 3 mo, no recent hospitalization. Nitrofurantoin (100mg BID x 5 days) Analgesia: Phenazopyridine 200mg TIDx2
ACUTE COMPLICATED CYSTITIS UTI when/with structural, functional or metabolic abnormalities (polycystic, solitary, transplant kidney;DM, CRF, indwelling cath, neurogenic bladder) or elderly, male, child, pregnant or h/o recurrent UTI) E.coli accounts for fewer than one third of complicated cases. Clinically, the spectrum of complicated UTIs may range from cystitis to urosepsis with septic shock.
ACUTE COMPLICATED CYSTITIS Urine culture and susceptibility are necessary. These infections are usually associated with high- count bacteriuria (> 10(5) CFU/mL). MO: Proteus, Klebsiella, Pseudomonas, Serratia, and Providencia, enterococci, staphylococci and fungi AND E.coli
ACUTE COMPLICATED CYSTITIS Empiric therapy for these patients should include an agent with a broad spectrum of activity against the expected uropathogens: fluoroquinolone, ceftazidime, cefepime, aztreon am, imipenem-cilastatin. (Obtain Ucx prior to Tx) Tx x 7-14 days Follow-up urine culture should be performed within 14 days after treatment???
RECURRENT CYSTITIS Up to 27% of young women with acute cystitis develop recurrent UTIs. The causative organism should be identified by urine culture. Relapse: infection with the same organism (multiple relapses = complicated UTIs). Recurrence: infection with different organisms.
RECURRENT CYSTITIS >3 UTI recurrences documented by urine Cx within one year can be managed using one of three preventive strategies:1. Acute self-treatment with a three-day course of standard therapy.2. Postcoital prophylaxis with one-half of a TMP- SMX double-strength tablet (80/400 mg).3. Continuous daily prophylaxis TMP-SMX one-half tablet per day (40/200 mg); nitrofurantoin 50 to 100 mg per day; norfloxacin 200 mg per day.
UNCOMPLICATED PYELONEPHRITIS Suspect if: Cystitis-like illness and accompanying flank pain Severe illness with fever, chills, nausea, vomiting, abdominal pain Gram-negative bacteremia.
UNCOMPLICATED PYELONEPHRITIS DX: Clinical, confirm with: UA: pyuria and/or WBC casts UCx with > 10 (5) CFU/mL (80%) Tx: 14 days total Oral: TMP/SMX, fluoroquinolones IV: 3rd gen cephalosporin, aztreonam, quinolones, aminoglycoside
UNCOMPLICATED PYELONEPHRITIS Pt with symptoms after 3 days of appropriate antimicrobial tx should be evaluated by renal US or CT for obstruction or abscess.
UTI IN MEN At risk: Older men with prostatic disease, UT instrumentation, anal sex, or partner colonized with uropathogens. UCx: 10 (3) CFU/mL sensitivity and specificity 97%. Additional studies? Not necessary in young healthy men who have a single episode.
UTI IN MEN Tx: Uncomplicated cystitis: TMP/SMX or fluoroquinolones x 7 days Complicated cystitis: Fluoroquinolones x 7-14 days Bacterial prostatitis: Fluoroquinolone x 6-12 weeks
CATHETER-ASSOCIATED UTI Risk of bacteriuria is ~ 5%/day (long term catheter bacteriuria is inevitable). 40% of nosocomial infections Most common source of gram-negative bacteremia. Dx: Ucx 10 (2) CFU/mL MO: E.coli, Proteus, Enterococcus, Pseudomona, Enterobacter, Serratia, Candida
CATHETER-ASSOCIATED UTI Mild to mod: oral quinolones10-14days Severe infection: IV/oral 14-21days Asymptomatic bacteriuria in pt with an indwelling Foley should not be Tx unless they are immunosuppressed, have risk of bacterial endocarditis or pt who are about to undergo urinary tract instrumentation.
ASYMPTOMATIC BACTERIURIA UCx: > 10(5)CFU/mL with no symptoms Three groups of pt with asymptomatic bacteruria have been shown to benefit from tx: Pregnant Renal transplant Pt who are about to undergo urinary tract procedures.
PREGNANT PATIENTS Asymptomatic bacteriuria: two consecutive voided urine specimens with isolation of the same bacterial strain >10(5) or a single cath urine specimen. Nitrofurantoin 100mg BID x 5-7 days Amoxi/Clav 500mg BID or 250 TID x 7days Fosfomycin 3g PO x 1
URINARY CATHETER• Developed in the 1920s by Dr. Frederick Foley• The urinary catheter was originally an open system with the urethral tube draining into an open container.• In the 1950s, a closed system was developed in which the urine flowed through a catheter into a closed bag. 40
Urinary Catheter Utilization• About 25% of patients during their hospitalization• Almost all of them are placed the same admission• A large number is placed in ED• Intensive care medical-surgical units 41
Urinary catheters are not harmless…• Urinary tract infection• Mechanical trauma to urethra and bladder• Immobility (restraining patient)* Prolonged stay?Pressure Ulcers? Falls? *Saint S, Ann Intern Med 2002; 137: 125-7 42
HOSPITAL-ACQUIRED UTI:PREVALENCE• 600,000 patients develop hospital-acquired UTI’s per year• Catheter-associated infections (CAUTI) comprise 80% of these cases• UTIs account for 40% of all hospital-acquired infections 43
CATHETER ASSOCIATED UTI (CAUTI) Catheter-risk of bacteriuria increases each day of use: • Per day: 5% • 1 week: 25% • 1 month: 100% 44
BIOFILM: EXTRACELLULAR POLYMERS(DONLAN, CID 2001; 33:1387–92, LIEDL, CURR OPINION UROL 2001;11:75-9) Organisms attach to and grow on a surface and produce extracellular polymers Intraluminal ascent (48hours) of bacteria faster than extraluminal (72-168 hours) Most catheters used >1 week have biofilms Staphylococcus aureus biofilm on an indwelling catheter. Extraluminal more CDC Public Health Image Library important in women 45
Usually females Usually males 46 Maki, Emerg Infect Dis 2001; 7: 1-6
BACTERIOLOGIC MONITORING• Not recommended for asymptomatic patients.• Only culture the urine if the patient has symptoms of an UTI such as fever, chills, and abdominal pain• Cloudy urine ≠infection• Sediment in urine ≠infection 48
ASYMPTOMATIC BACTERIURIA No benefit from treatment Increased risk of resistance and C. difficile disease with treating asymptomatic bacteriuria Pyuria does not equate infection when catheter present Avoid urine cultures unless patient is symptomatic or if it is a part of sepsis workup in a catheterized patient 49
ACCEPTABLE INDICATIONS FOR URINARY CATHETER PLACEMENT Acute urinary retention or obstruction Perioperative use in selected surgeries Assist healing of perineal and sacral wounds in incontinent patients Hospice/comfort/ palliative care Required immobilization for trauma or surgery Chronic indwelling on admission 50 50
ACUTE URINARY RETENTION OROBSTRUCTION Outflow obstruction: examples include prostatic hypertrophy with obstruction, urethral obstruction related to severe anasarca, urinary blood clots with obstruction Acute urinary retention: this may be medication induced, medical (neurogenic bladder) or trauma to spinal cord. 51 51
PERIOPERATIVE USE IN SELECTED SURGERIES Urologic surgery or other surgery on contiguous structures of the genitourinary tract Anticipated prolonged duration of surgery, large volume infusions during surgery, or need for intraoperative urinary output monitoring Spinalor epidural anesthesia may lead to urinary retention; prompt discontinuation of this type of anesthesia should prevent need for urinary catheter placement 52 52
ASSIST HEALING OF PERINEAL AND SACRAL WOUNDS IN INCONTINENT PATIENTS Thisis a relative indication when there is concern that incontinence is leading to worsening skin integrity in areas where there is skin breakdown 53 53
HOSPICE/ COMFORT CARE/ PALLIATIVE CARE Thisis a relative indication. In end-of-life situations, it is reasonable to accommodate the patient’s wishes on what provides them with the best comfort 54 54
REQUIRED IMMOBILIZATION FOR TRAUMA OR SURGERY This includes:1. unstable thoracic or lumbar spine2. multiple traumatic injuries such as pelvic fractures3. Acute hip fracture is risk for dislocation 55 55
CHRONIC INDWELLING URINARY CATHETER UPON ADMISSION Patientsfrom home or extended care facility with a chronic urinary catheter 56 56
URINE OUTPUT MONITORING OUTSIDEINTENSIVE CARE This includes: 1. Close urinary output monitoring by nephrology in patients with renal failure 2. Monitoring of urine output in patients with congestive heart failure on diuretics Potential solutions:1. Use urinals for men and hats for women (to monitor output)2. Accurate daily weights. 58 58
URINE OUTPUT MONITORING OUTSIDEINTENSIVE CARE For patients with congestive heart failure, consider involving the patient Provide patients with information regarding how to document their output and daily weights (consider pamphlets) This will also help the patient learn to accurately measure their output. 59
INCONTINENCE Incontinence should not be a reason for urinary catheter placement. Patients admitted from home or from extended care facilities with incontinence managed their incontinence without problems prior to admission. Mechanisms to keep the skin intact need to be in place and avoid urinary catheter placement in that population. 60 60
INCONTINENCE: POTENTIALSOLUTIONS Use Skin Barrier Creams for protection Start Toilet Training: Offer use of bedpan or assist patient up to commode regularly Evaluate for any wet bed linen and change if wet at the time patient is being turned in bed 61 61
PATIENTS TRANSFERRED FROMINTENSIVE CARE TO FLOOR The intensive care is an area where high prevalence of urinary catheter utilization is present. Evaluating those who are transferred to non- intensive care units for need of urinary catheter and discontinuation of those not needed may significantly reduce unnecessary utilization 62 62
MORBID OBESITY AND IMMOBILITY Morbid obesity should not be a trigger for urinary catheter placement. Patients that are morbidly obese have functioned without a urinary catheter prior to admission. The association of immobility and morbid obesity may lead to more inappropriate catheter placement. This may result in more immobility with the urinary catheter being a “one point restraint” 63 63
IMMOBILITY: POTENTIAL SOLUTIONS Start toilet training every 2 hours Offer bedpan, urinal or assist patient out of bed Of 145 hospitalized patients with a high risk for pressure ulcers, urinary catheter presence was associated with 1.8 times risk of pressure ulcer compared to those without urinary catheter (p=0.03). The most significant association was between urinary catheter catheter use and stage 2 pressure ulcer. 64 64
CONFUSION OR DEMENTIA Patients with confusion or dementia should not have a urinary catheter placed unless there is an indication for placement 65 65
THE VERY ELDERLY PATIENTS Disproportionate use inappropriately in the very elderly. It may be a marker of immobility, incontinence, and dementia? 66
PATIENT REQUEST Although healthcare workers may report that patients want the urinary catheter in, this is infrequently documented. The only exception is in patients that are end of life or palliative care. Patient’s Convenience: - Example: patient on diuretics and does not want to move out of bed multiple times - Education is key! Provide reasons to patient of increased risk of urinary catheter : urine infection, skin breakdown, deep venous thrombosis and/or pneumonia due to immobility 67 67
INCREASED WORK LOAD FOR HEALTHCARE WORKERS (HCW) Increased acuity of patients or reduction of the nurse to patient ratio e.g., patient is incontinent and immobile and requires multiple changes of sheets Potential solution: link it to other initiatives (eg. pressure ulcer prevention requires frequent repositioning of patients), evaluate the nurse to patient ratio, shift resources to support the HCW that has more responsibilities 68
WHAT NEEDS TO BE DONE Both nurses and physicians should evaluate the indications for urinary catheter utilization. Physicians should promptly discontinue catheters that are no longer needed. Nurses evaluating catheters and finding no indication should contact physician to promptly discontinue catheter. 69