Urinary tract infections
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WHO Italian CME course an antibiotic stewardship • Understand the frequent occurrence and implications of contaminated urine cultures and of asymptomatic bacteriuria • Illustrate the complexity of using urinalysis and urine culture to support the diagnosis of urinary tract infections • Demonstrate the use of local evidence-based guidelines based upon local antimicrobial resistance data in managing urinary tract infections
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Urinary tract infections
- 2. Course content Courseroadmap Basic concepts Common infections 2
- 3. "The thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with the penicillin-resistant organism.” Sir Alexander Fleming Nobel prize winner for the discovery of penicillin, 1945 3
- 4. Core competencies for antimicrobial prescribing C1: Understands the patient and the patient’s clinical needs C2: Understands treatment options and how they support the patient’s clinical needs C3: Works in partnership with the patient and other healthcare professionals to develop and implement a treatment plan C4: Communicates the treatment plan and its rationale clearly to the patient and other health professionals C5: Monitors and reviews the patient’s response to treatment 4 Core Competencies
- 5. Objectives • Understand the frequent occurrence and implications of contaminated urine cultures and of asymptomatic bacteriuria • Illustrate the complexity of using urinalysis and urine culture to support the diagnosis of urinary tract infections • Demonstrate the use of local evidence-based guidelines based upon local antimicrobial resistance data in managing urinary tract infections 5
- 6. Positive urine cultures could be due to: Contaminated culture Asymptomatic bacteriuria Urinary tract infection (UTI) 6 WHO/A. Kristensen
- 7. Antimicrobial resistance Antimicrobial use 7 Antibiotics commonly inappropriately prescribed for asymptomatic bacteriuria
- 8. 8
- 9. WHO/A. Kristensen 9 PART 1: Asymptomatic bacteriuria Core Competencies 1, 2, 3 & 4
- 10. Clinical case 1 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 10
- 11. 45 year-old female with: a positive urine culture 3 weeks ago urine culture performed because of dysuria & urinary frequency now asymptomatic normal physical exam 11
- 12. Clinical case 1 12 Should she submit another sample for urine culture? WHO/O. Karatuna
- 13. Obtain urine culture only when you suspect UTI • Contaminated urine cultures and asymptomatic bacteriuria (ASB) are common 13 WHO/O. Karatuna
- 14. Urinalysis interpretation • high numbers of squamous epithelial cells suggests specimen contamination • absence of pyuria provides reassurance against a UTI 14 WHO/O. Karatuna
- 15. Asymptomatic bacteriuria (ASB) • Limited indications for ASB treatment – Pregnancy – Invasive urologic procedure • Test of cure cultures should NOT be performed 15
- 16. Clinical case 1 16 Should she submit another sample for urine culture? WHO/O. Karatuna
- 17. Review the microbiologic data • The presence of 3 organisms suggests a contaminated specimen. • Was it necessary? 17 WHO/O. Karatuna
- 18. Clinical case 1 Should she submit another sample for urine culture? • She is asymptomatic. • No indication for culture. • Provide patient education NO! 18 Core Competencies 1, 2, 3 & 4
- 19. WHO/A. Kristensen 19 PART 2: Using guidelines to manage cystitis Core Competencies 1, 2, 3, 4 & 5
- 20. Clinical case 2 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 20
- 21. 45 year-old female with: Dysuria, urinary frequency Denies vaginal discharge Subjective fevers Physical exam normal Received trimethoprim-sulfamethoxazole 2 months ago 21
- 22. An informed choice Severity Source Drug resistance Patient factors Cultures Core Competencies 1 & 2 Optimal antibiotics 22
- 23. Severity Source Drug resistance Patient factors Cultures Stable outpatient How severe is the patient’s condition? 23
- 24. What is the likely source? Severity Source Drug resistance Patient factors Cultures • Cystitis • Most common uropathogen: E. coli 24
- 25. What is the likely source? Severity Source Drug resistance Patient factors Cultures • Consider reasons for recurrent cystitis and/or alternative diagnoses 25
- 26. Severity Source Drug resistance Patient factors Cultures • Recent antimicrobial use? YES • Local cumulative susceptibility data? How likely is resistance? 26
- 27. Example: annual cumulative antibiogram of E. coli isolated from urine 27 No.isolates Ampicillin Cefazolin Ceftriaxone Cefepime Ertapenem Gentamicin Amikacin Ciprofloxacin Nitrofurantoin Trimethoprim- sulfamethoxazole 4792 56 72 86 90 99 86 92 69 92 70 Percentsusceptible togivendrug
- 28. 28
- 29. Empiric regimen per guidelines 2010 IDSA/ESCMID Guidelines Uncomplicated Cystitis in Women • Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily • Trimethoprim-sulfamethoxazole 160/800 mg twice daily • Fosfomycin trometamol 3 gm single dose • Pivmecillinam 400 mg twice daily Core Competency 2 29
- 30. Empiric regimen per guidelines 2016 Public Health England Uncomplicated Cystitis in Women First line: • Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily Alternatives: • Trimethoprim 200 mg twice daily • Pivmecillinam 200 mg three times daily Core Competency 2 30
- 31. Adapting guidelines 2010 IDSA/ESCMID Guidelines 2016 PHE Guidance • Adapt based upon local drug availability and resistance patterns. Core Competency 2 31
- 32. Adapting guidelines 2010 IDSA/ESCMID Guidelines 2016 PHE Guidance • Adapt based upon local drug availability and resistance patterns. • Avoid fluoroquinolones for uncomplicated UTI when alternative antibiotics are possible. Core Competency 2 32
- 33. Clinical case 2 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment Local guidelines • E. coli urine isolates susceptibility pattern: • 85% trimethoprim- sulfamethoxazole • 92% nitrofurantoin 33
- 34. Other considerations? Severity Source Drug resistance Patient factors Cultures • Allergies? NO • Renal or liver dysfunction? NO • Pregnant? NO 34
- 35. Severity Source Drug resistance Patient factors Cultures Urine culture Do I need cultures? 35
- 36. An appropriate urine sample for culture • Clean the skin • Collect midstream • Use sterile container • Transportation delays impact accuracy • Contribute data for local surveillance 36 WHO/O. Karatuna
- 37. Return to case Severity Source Drug resistance Patient factors Cultures 37
- 38. Duration per guidelines 2010 IDSA/ESCMID Guidelines Uncomplicated Cystitis in Women • Nitrofurantoin monohydrate/macrocrystals 100 mg bid • Trimethoprim-sulfamethoxazole 160/800 mg bid • Fosfomycin trometamol 3 gm • Pivmecillinam 400 mg bid 5 days 3 days 1 dose 5 days Core Competency 2 38
- 39. Duration per guidelines Public Health England Uncomplicated Cystitis First line: • Nitrofurantoin 100 mg BID Alternatives: • Trimethoprim 200 mg BID • Pivmecillinam 200 mg TDS Women: 3 days Men: 7 days Core Competency 2 39
- 40. Clinical case 2 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 40 Core Competencies 1, 2, 3, 4 & 5
- 41. Clinical case 2 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 41 Core Competencies 1, 2, 3, 4 & 5
- 42. Review: Urinary Tract Infections Drug Dose Duration Route prescription ............. ............. ............. 42
- 43. Review: Urinary Tract Infections Drug Dose Duration Route prescription ............. ............. ............. Obtain urine culture ONLY when you clinically suspect a UTI. 43
- 44. Review: Urinary Tract Infections Drug Dose Duration Route prescription ............. ............. ............. Obtain urine culture ONLY when you clinically suspect a UTI. Obtain an appropriate urine sample for culture. 44
- 45. Review: Urinary Tract Infections Drug Dose Duration Route prescription ............. ............. ............. Obtain urine culture ONLY when you clinically suspect a UTI. Obtain an appropriate urine sample for culture. Use local guidelines to guide empiric antimicrobial choice and duration. 45
- 46. Quiz time! Please click “Next” to proceed.