Update in diagnosis I have no disclosures and management of UTIs - PDF document

3/15/2017 Update in diagnosis • I have no disclosures and management of UTIs Brian S. Schwartz, MD UCSF, Division of Infectious Diseases Lecture outline Lecture outline • Challenges in cystitis • Challenges in cystitis • Complicated UTI/pyelonephritis • Complicated UTI/pyelonephritis • Asymptomatic bacteriuria • Asymptomatic bacteriuria • Recurrent UTIs • Recurrent UTIs • Pre-op urine screening • Pre-op urine screening 1

3/15/2017 Do you obtain a urine culture? Case A.Yes • 27 year-old female with no significant past medical history presents to your clinic with B.No 4 days of dysuria and frequency. Denies vaginal discharge or pelvic pain. Urinalysis reveals: – 3+ Leukocyte esterase – 1+ Heme – 2+ Nitrite • What do you do next? When should you get a urine Do you give empiric antibiotics? culture for uncomplicated cystitis? A. No • Uncomplicated UTI: culture not needed B. Nitrofurantoin x 5 days – Will likely be susceptible E coli • Culture if… C. TMP-SMX x 5 days – Complicated UTIs (pyelo) D. Ciprofloxacin x 3 days – Recurrent UTIs – High local rates of resistance E. Cefazolin x 7 days Hooton TM. NEJM. 2012 2

3/15/2017 IDSA updated guidelines for Efficacy of nitrofurantoin uncomplicated UTI in elderly? • Study of older women (mean age 79 years) Goal: Low resistance, low “ collateral damage ” – Mean GFR was 38 mL/min •Nitrofurantoin 100 mg PO BID x 5 days • Evaluated for Rx failure on different abx •TMP-SMX DS PO BID x 3 days – Other vs. nitrofurantoin – avoid if resistance >20%, recent usage – 130/1989 ( 6.5% ) vs. 516/3739 ( 13.8% ), CI 0.36-0.53 •Fosfomycin 3 gm PO x 1 • However, higher Rx failure in high GFR group too • Cipro more effective than nitrofurantoin in all • Failure rate same for nitrofurantoin vs. TMP-SMX Gupta K. CID 2011 Singh N. CMAJ. 2015 Take home on nitrofurantoin and Safety of nitrofurantoin elderly? in elderly? • May be less efficacious • Age > 65 years with Dx cystitis • Unlikely dangerous for Rx • N=13,421 (2007-12) • Danger increase for chronic suppression • Evaluated for nitrofurantoin use ≈ lung injury • Nitrofurantoin exposure ≠ lung injury • Chronic use ≈ lung injury (aRR 1.53 [1.04-2.24]) Santos JM. JAGS. 2016 3

3/15/2017 You start patient on TMP-SMX, culture Utility of the midstream void culture? reveals > 100K CFU/ml of enterococcus (Susceptible to amox, resistant to TMP-SMX) • > 200 pre-menopausal women w/ dysuria A.Change to amoxicillin • Midstream void and catheter specimen B.Continue present Rx • Cultures positive C.Stop all antibiotics –99% midstream –74% catheter specimens Hooton TM. NEJM. 2013 You start patient on TMP-SMX, culture Utility of the midstream void culture? reveals > 100K CFU/ml of enterococcus • E. coli, Klebsiella, S. saprophyticus (Susceptible to amox, resistant to TMP-SMX) – Strong correlation (10 2 ) with catheter specimen A.Change to amoxicillin • Mixed culture (86%) – E. coli often in catheter specimen B.Continue present Rx • Enterococcus and Group B strep (10% cultures) – Nearly never found in catheter specimens C.Stop all antibiotics – 61% had E. coli grew from catheter cultures • Midstream cultures going to change treatment? Hooton TM. NEJM. 2013 4

3/15/2017 Ciprofloxacin How is guideline compliance? Grigoryan. Open Forum Infect Dis. 2015 Quinolones Nitrofurantoin TMP-SMX other Grigoryan. Open Forum Infect Dis. 2015 TMP-SMX Nitrofurantoin Grigoryan. Open Forum Infect Dis. 2015 Grigoryan. Open Forum Infect Dis. 2015 5

3/15/2017 Lecture outline Treatment of complicated UTI • Challenges in cystitis • Complicated – Anyone other than a • Complicated UTI/pyelonephritis healthy woman without • Asymptomatic bacteriuria recurrent infections • Recurrent UTIs • Empiric therapy (7-14 days): • Pre-op urine screening – Non-pregnant: ciprofloxacin/levofloxacin – Pregnant women: Nitrofurantoin or cephalexin Shorter course of antibiotics Treatment of UTI in men many be OK in men with UTI? • Diagnosis: • 39,149 Veterans with UTI –Obtain culture • Antibiotic duration –Assess for STDs (urethritis) ≤ 7 days: 35% (median 7 days) • Treatment: > 7 days: 65% (median 10 days) –Quinolone, TMP-SMX favored • Veterans who received > 7 days: –Duration 7-14 days – No reduction in recurrences –If recurrent consider prostatitis – Increase Clostridium difficile infection Drekonja DM. JAMA Intern Med. 2013 6

3/15/2017 Oral antibiotics active against ESBL ESBL trends at UCSF Gram negative pathogens 100 % isolates susceptible 90 n=46 80 70 60 50 40 30 20 10 0 2013 2014 2015 Fosfomycin Nitrofurantoin Doxycycline Cipro Amox-clav Prakash V. AAC 2009 Catheter-associated UTI Fosfomycin (Monurol) • Hard to Dx: – Bacteriuria common • Activity against Gram pos and neg – Often unable to give symptoms • FDA approved for Rx of uncomplicated UTI • Pathogens – More resistant GNRs • Treatment for complicated infections : – Candiduria common, most cases don’t treat – 3 gm (mixed in 4 oz H 2 O) Q2 days for 7-14 d • Treatment – Change Foley, reduces duration of symptoms, relapse – Antibiotics 7-14d Hooton TM. Clin Infect Dis. 2010 7

3/15/2017 Empiric treatment of pyelonephritis Recommended empiric Rx of pyelonephritis in a young woman? • Recommended – Cipro 500 mg PO/IV q12 ( Levo ok, not Moxi ) A.Ceftriaxone 1 gm IV q24 – Ceftriaxone 1 gm IV q24 • Not recommended B.Moxifloxacin 400 mg IV/PO q24 – TMP-SMX C.Nitrofurantoin 100 mg PO q12 – Nitrofurantoin – Cefpodoxime D.Cefpodoxime 200 mg PO q12 • Health-care associated pyelonephritis – Use antipseudomonal agent other than fluoroquinolone Lecture outline Case • 65 y/o female w/ DM presents to clinic for routine • Challenges in cystitis evaluation. She has been feeling well. A urinalysis • Complicated UTI/pyelonephritis is sent to look for proteinuria and the lab processes for culture because bacteria are seen • Asymptomatic bacteriuria • UA: WBC-0, RBC-0, Protein-300 • Recurrent UTIs • The next day you are called because the urine culture has >100,000 Klebsiella pneumoniae • Pre-op urine screening 8

3/15/2017 What do you recommend? Case • 65 y/o female w/ DM presents to clinic for routine A. No antibiotics indicated evaluation. She has been feeling well. A urinalysis is sent to look for proteinuria and when B. Empiric ciprofloxacin and await the leukocyte esterase is positive, the lab reflexively sends for culture susceptibilities • UA: WBC->50 , RBC-0, Protein-300 C. Repeat culture in 1 week and if bacteria • The next day you are called because the urine still present then treat culture has >100,000 Klebsiella pneumoniae What do you recommend? Case • 65 y/o female w/ DM presents to clinic for A. No antibiotics indicated evaluation. She complains of dysuria B. Empiric ciprofloxacin and await and frequency. A urinalysis and urine culture are sent. susceptibilities • UA: WBC->50 , RBC-0, Protein-300 C. Repeat culture in 1 week and if bacteria • The next day you are called because the still present then treat urine culture has >100,000 Klebsiella pneumoniae 9

3/15/2017 1c: What do you recommend? Answers: Antibiotics? 1a. Asymptomatic bacteriuria, no pyuria A. No antibiotics indicated – no antibiotics indicated B. Empiric ciprofloxacin and await susceptibilities 1b. Asymptomatic bacteriuria, with pyuria C. Repeat culture in 1 week and if bacteria still – no antibiotics indicated present then treat 1c. Cystitis (symptoms and pyuria) – Antibiotics indicated Definition: Asymptomatic Asymptomatic bacteriuria bacteriuria Pre-menopausal women 1-5% Pregnant women 2-10% • Bacteriuria without symptoms Post-menopausal women, 50-70 yrs 3-9% –Midstream: ≥ 10 5 CFU/ml Diabetics 9-27% –Cath: ≥ 10 2 CFU/ml Elderly in LTC facilities (women; men) 15-50% Pts with spinal cord injuries 23-89% • Pyuria is present > 50% of patients Pts undergoing HD 28% Pts with indwelling catheters 25-100% Nicolle. CID. 2005 10

3/15/2017 Who should you treat with Which patient(s) should be treated for asymptomatic bacteriuria? asymptomatic bacteriuria? A. Patients with spinal cord injuries • Clear benefit –Pregnant women B. Patients with indwelling catheters –Patients undergoing traumatic urologic C. Prior to transurethral resection of prostate interventions with mucosal bleeding (TURP) D. Pregnant women • Possible benefit E. C and D –Neutropenic Nicolle. CID. 2005 Who does not benefit from Rx of Treatment of asymptomatic asymptomatic bacteriuria? bacteriuria in diabetic women • Premenopausal (non-pregnant) women • Placebo controlled, RCT (N=105) • Postmenopausal women • Diabetic women w/ asymptomatic bacteriuria • Institutionalized men and women • Intervention: Antimicrobial vs. placebo x 14d • Patients with spinal cord injuries • 1 ° endpoint: Time to 1 st symptomatic UTI • Patients with urinary catheters • 42% Rx vs. 40% placebo , p=0.42 • Diabetics Asscher AW. BMJ. 1969; Abrutyn E. J Am Soc Ger. 1996; Harding GKM. NEJM 2003; Cai T. Clin Infect Dis. 2015 11