Urinary Tract Infection clinical practice guideline.pptx

Philippines clinical practice guideline for urinary tract infection.

1. URINARY TRACT INFECTION Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults (2015)

2. Acute Uncomplicated Cystitis in Women Diagnosis: suspected in pre-menopausal non-pregnant women presenting with acute onset if dysuria, frequency, urgency and gross hematuria and without vaginal discharge. Urinalysis is not necessary to confirm the diagnosis of AUC in women presenting with one or more of the above symptoms of UTI in the absence of vaginal discharge and complicating conditions,

3. Risk factors for complicated UTI Hospital acquired infection Indwelling urinary catheter Recent urinary tract infection Recent urinary tract instrumentation (in the past 2 weeks) Functional or anatomic abnormality of the urinary tract Recent antimicrobial use (in the past 2 weeks) Symptoms for > 7 days at presentation Diabetes mellitus Immunosuppression

4. Approach to Management Primary Nitrofurantoin monohydrate 100mg BID x 5 days Fosfomycin trometamol 3 g SD PO Alternative Ofloxacin 200mg BID x 3 days PO Ciprofloxacin 200mg BID x 3 days PO Ciprofloxacin extended release 500mg OD x 3 days PO Levofloxacin 250mg OD x 3 days Norfloxacin 400mg BID x 3 days Amoxicillin-clavulanate 625mg BID x 7 days PO Cefuroxime axetil 250mg BID x 7 days Cefpodoxime proxetil 100 mg BID x 7 days PO

5. Acute Uncomplicated Pyelonephritis: - suspected in otherwise healthy women with no clinical or historical evidence of anatomic or functional urologic abnormalities, who present with the classic syndrome of fever (T > 38C), chills, flank pain, costovertebral angle tenderness, nausea and vomiting , with or without signs and symptoms of lower urinary tract infection. - laboratory findings include pyuria (>5 WBC/ hpf ) on urinalysis and bacteriuria with counts of >10,000 CFU of uropathogen /mL on urine culture .

6. Pre-treatment diagnostic tests: Urinalysis and Gram stain are recommended. Urine culture and sensitivity test should also be performed routinely to facilitate cost-effective use of antimicrobial agents. Blood cultures are NOT routinely recommended except patients with signs of sepsis.

7. Signs of Sepsis: Any two of the following: > Temperature >38C or <36C > Leukopenia (WBC <4000) or leucocytocis (WBC >12000) > Tachycardia (HR>90 beats/min) > Tachypnea (RR >20mins or PaCO2 <32mmHg) > Hypotension (SBP <90mmHg or >40mmHg drop from baseline)

8. Biomarkers Biomarkers (procalcitonin, mid-regional pro-atrial natriuretic peptide and C-reactive protein) are not recommended since they are not clinically useful in determining the need for admission of in predicting adverse outcomes such as recurrence and prolonged hospitalization. INDICATIONS FOR ADMISSION: Inability to maintain oral hydration or take medications Concern about compliance Presence of possible complicating conditions Severe illness with high fever, severe pain, marked debility and signs of sepsis

9. Antibiotic Treatment: ORAL Dose, Frequency and Duration Primary Ciprofloxacin 500mg BID for 7-10days Ciprofloxacin ER 1000 mg OD for 7 days Levofloxacin 250 mg OD for 7-10 days 750 mg OD for 5 days Ofloxacin 400 mg BID for 14 days Alternative Cefixime 400mg OD for 14 days Cefuroxime axetil 500 mg BID for 14 days Co-amoxiclav 625mg TID x 14 days

10. Parenteral Dose, frequency and Duration Primary Ceftriaxone 1-2 g q 24H Ciprofloxacin 400mg q 12h Levofloxacin 250-750mg q 24h Ofloxacin 200-400 mg q 12h Amikacin 15mg/kg BW q 24h Gentamicin +/- ampicillin 3-5mg/kg BW q 24h Alternative Ampicillin-sulbactam (when GS shows gram pos orgs) 1.5 g q 6h

11. Role of Radiologic Imaging Routine urologic evaluation and routine use of imagine procedures are not recommended Consider early radiologic evaluation if the patient has a history or urolithiasis, urine pH >7.0 or renal insufficiency Consider radiologic evaluation if the patient remains febrile within 72 hours of treatment or if symptoms recur to rule out the presence of nephrolithiasis, urinary tract obstruction, renal or perinephric abscesses or other complications of pyelonephritis. Obtain urologic consultation if radiologic workup shows abnormalities.

12. Follow-up laboratory tests In patients who are clinically responding to therapy, a follow-up urine culture is not necessary Routine post-treatment cultures in patients who are clinically improved are also not recommended In women whose symptoms do not improve during therapy and in those whose symptoms recure after treatment, a repeat urine culture and sensitivity test should be performed.

13. Asymptomatic Bacteriuria All diagnosis of asymptomatic bacteriuria (ASB) should be based on results of urine culture specimens that are collected aseptically and with no evidence of contamination. For asymptomatic women, bacteriuria is defined as two consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts ≥ 100,000 cfu / mL. In men, a single, clean-catch voided urine specimen with one bacterial species isolated in a quantitative count ≥ 100,000 cfu /mL identifies bacteriuria. In both men and women, a single catheterized urine specimen with one bacterial species isolated in a quantitative count ≥ 100 cfu /mL identifies bacteriuria.

14. Indications for screening and treatment of asymptomatic bacteriuria? Patients who will undergo genitourinary manipulation or instrumentation All pregnant women The choice of antibiotic depends on culture results. A seven-day regimen is recommended.

15. Who should NOT be screened and treated for asymptomatic bacteriuria? Patients with Diabetes Mellitus Elderly patients Patients with indwelling catheters Solid organ transplant patients People living with HIV Patients with urologic abnormalities Spinal cord injury patients

16. What is the optimal screening test for asymptomatic bacteriuria? Screening by urine culture is recommended In the absence of facilities for urine culture, significant pyuria (>10wbc/ hpf ) or a positive gram stain of unspun urine (>2 microorganisms/ oif ) in two consecutive midstream urine samples can be used. To screen for asymptomatic bacteriuria. Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment among patients for whom screening and treatment is not recommended,

17. Complicated Urinary Tract Infections Significant bacteriuria plus clinical syndromes which occurs in the setting of Functional or anatomic abnormalities of the Urinary tract or kidneys The presence of an underlying disease that interferes with host defense mechanisms Any condition that increases the risk of acquiring infection and/or treatment failure

18. Diagnostics Urine sample for gram stain, and culture and sensitivity testing must always be obtained before the initiation of any treatment Imaging of the urinary tract is warranted whenever anatomic or structural abnormalities are suspected as contributing to a UTI Pyelonephritis that is not responding to usual treatment Severe pyelonephritis in certain high risk groups (e.g. DM) Recurrent UTI in man CT-scan is generally preferred over KUB ultrasound – but it depend on local availability

19. Approach to treatment

20. How long should antibiotics be given in complicated UTI? In general, at least 7-14 days of therapy is recommended. Treatment duration may be extended depending on the clinical situation. 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.

21. Do patients with complicated UTI need to be hospitalized? Patients with marked debility and signs of sepsis Patients in whom there is uncertainty in diagnosis Patients in whom there is concern about adherence to treatment Patients who are unable to maintain oral hydration or take oral medications

22. URINARY TRACT INFECTION IN MEN Urinary tract infection in men is generally considered complicated However, the first episode of symptomatic lower urinary tract infection occurring in a young (15-40 years old) otherwise healthy sexually active men with no clinical or historical evidence of a structural or functional urologic abnormality is considered as uncomplicated UTI. Significant pyuria in men is defined as > 10 wbc /mm3 or > 5 wbc / hpf in a clean catch midstream urine specimen. Fluoroquinolones may be used depending on prevailing susceptibility patterns in the community or institution Seven-day antibiotic regimens are recommended

23. Recurrent UTI Diagnosed when a healthy non-pregnant with no known urinary tract abnormalities has 3 or more episodes of acute uncomplicated cystitis documented by urine culture during a 12 month period or 2 or more episodes in a 6-month period Recurrent UTI may either be a relapse or a reinfection. Relapse – initial organism persists within the urinary tract and re-emerges despite adequate treatment usually occurring 1-2 weeks after stopping treatment Reinfection – recurrent UTI is caused by a different bacterial isolate, or by the previously isolated bacteria after a negative intervening culture or an adequate period (> 2 weeks) between infections.

24. Screening Routine screening for urologic abnormalities is not recommended for the general population Only recommended in the following situations: a. No response to appropriate anti-microbial therapy or rapid relapse after such therapy b. Gross hematuria during UTI episode or persistent microscopic hematuria c. Obstructive symptoms d. Clinical impression of persistent infection e. Infection with urea-splitting bacteria (Proteus, Morganella , Provicencia )

25. f. History of Pyelonephritis g. History of or symptoms suggestive of urolithiasis h. History of childhood UTI i . Elevated serum creatinine All women with recurrent UTI should undergo a complete history and physical examination to evaluate urogenital anatomy and estrogenization of vaginal tissues and to detect prolapse. Post-void residual urine should be measured.

26. Diagnostics: Radiologic or imaging studies and cystoscopy – not routinely indicated Renal ultrasound or CT-scan/ stonogram – urologic abnormalities Patients with anatomical abnormalities should be referred to a specialist for further evaluation.

27. Prophylaxis Recommended in women whose frequency of recurrence is not acceptable to the patient in terms of level of discomfort or interference with activities of daily living. The following factors should guide the physician in determining the patient’s risk-benefit profile in deciding which prophylactic strategies will be used: Frequency and pattern of recurrences Patient’s lifestyle, compliance and willingness to commit to a specific regimen Plans for a pregnancy Antimicrobial resistance and susceptibility pattern of the organisms causing the patient’s previous UTI Risk of adverse events and drug allergies

28. Antibiotic Prophylaxis Continuous prophylaxis – defined as the daily intake of a low-dose of antibiotic for 6-12 months Post-coital prophylaxis – intake of a single dose of antibiotic immediately after sexual intercourse Intermittent prophylaxis – self-treatment with a single antibiotic dose based on patient’s perceived need (weak recommendation)

29. Hormonal interventions for post-menopausal women Application of intravaginal estriol cream once each night for 2 weeks followed by twice-weekly applications for at least 8 months OR use of an estradiol-releasing silicone vaginal ring for 3 months is recommended for the prevention of recurrent UTI in post menopausal women.

30. Non-Pharmacologic: Post-defecation and anal cleansing antero-posteriorly always in women to avoid contaminating the periurethral area with fecal flora Post coital urination or washing perennial area after contact Liberal fluid intake especially after intercourse Avoidance of tight-fitting underwear Use of alternative form of contraception for women - condom

31. Thank you.