Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2014 Update

Size: px

Start display at page:

Download "Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2014 Update"

Lucas Lambert
6 years ago
Views:

1 -. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2014 Update Asymptomatic Bacteriuria and Recurrent Urinary Tract Infection &40 5 & , 0 8 3&' - ( & &/ / &( ) + +/ ), + * + )!!!"#$%& ' (!!! /. / '

2 Asymptomatic Bacteriuria in Adults - Screening and Treatment Definition ¾ 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. ¾ In men, a single, clean-catch voided urine specimen with one bacterial species isolated in a quantitative count 100,000 cfu/ml identifies bacteriuria. ¾ In both men and women, a single catheterized urine specimen with one bacterial species isolated in a quantitative count 100 cfu/ml identifiesbacteriuria. All diagnosis of asymptomatic bacteriuria should be based on results of urine culture specimens that are collected aseptically and with no evidence of contamination. Indications for screening and treatment: ¾ Screening and treatment for asymptomatic bacteriuria is recommended in the following: (a) (b) All pregnant women. Patients who will undergo genitourinary manipulation or instrumentation. Cases where screening and treatment for asymptomatic bacteriuria is NOT indicated ¾ Routine screening and treatment for asymptomatic bacteriuria is not recommended for healthy adults. ¾ Likewise, periodic screening and treatment for asymptomatic bacteriuria is not recommended in the following: (a) Patients with diabetes mellitus (b) Elderly patients

3 (c) Patients with indwelling catheters Except in the following special populations (1) Pregnant patients (2) Those who will undergo urologic procedures (3) Those whose bacterial agents cause high incidence of bacteremia in their institution (4) Neutropenic patients (5) Those that may be part of an infection control plan to manage cluster infections in a unit (d) Solid organ transplant patients, unless an indwelling catheter is present (e) HIV patients (f) Spinal cord injury patients (g) Patients with urologic abnormalities Screening tests ¾ Screening by urine culture is recommended. ¾ In the absence of facilities for urine culture, significant pyuria (>10 wbc/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. ¾ Urine culture and sensitivity testing are not necessary when urinalysis is negative for pyuria or urine gram stain is negative for organisms. ¾ Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment among patients for whom screening and treatment is not recommended.

4 Treatment of Asymptomatic Bacteriuria ¾ The choice of antibiotic depends on culture results. A seven-day regimen is recommended. ¾ For specific recommendations on pregnant women, refer to Table 1 and the section on UTI in Pregnancy. Table 1. Antibiotics that can be used for asymptomatic bacteriuria Table 1. Antibiotics in pregnancy that can be used for asymptomatic bacteriuria in pregnancy Antibiotics Recommended dose FDA Risk Category and duration Cephalexin 500 mg BID for 7 days B Cefuroxime axetil 500 mg BID for 7 days B Trimethoprimsulfamethoxazole Fosfomycin trometamol Amoxicillinclavulanate Nitrofurantoin macrocrystal 3 g single dose B 625 mg BID for 7 days B 100 mg QID for 7 days;100 mg BID for 7 days for monohydrate macrocrystal formulation (not available locally) B May cause hemolytic anemia, nophthalmia, hypoplastic left heart syndrome, ASD, cleft lip and palate. May be given on the second trimester of pregnancy until 32 weeks AOG. Use in the first trimester of pregnancy is appropriate when no other suitable alternative antibiotics are available) 160/800 mg BID for 7 days C (avoid in 1 st and 3 rd trimester)

5 Algorithm 1: Screening and Treatment of Asympomatic Bacteriuria Patient with NO signs or symptoms of urinary tract infection Is the patient Pregnant? About to undergo genitourinary manipulation/ instrumentation? NO No need for screening and treatment YES Screen for ASB with urine culture NEGATIVE No need for treatment POSITIVE a Treat based on culture results

6 Recurrent UTI - Diagnosis Definition ¾ Recurrent UTI is diagnosed when a healthy non-pregnant woman 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. ¾ Recurrent UTI may either be a relapse or a reinfection. Screening o Relapse occurs when the initial organism persists within the urinary tract and re-emerges despite adequate treatment usually occurring 1-2 weeks after stopping treatment. o Reinfection occurs when 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. ¾ Routine screening for urologic abnormalities is not recommended for the general patient population. ¾ Screening for urologic abnormalities is recommended in the following situations: (a) No response to appropriate antimicrobial therapy or rapid relapse after such therapy (b) Gross hematuria during a UTI episode or persistent microscopic hematuria (c) Obstructive symptoms (d) Clinical impression of persistent infection (e) Infection with urea-splitting bacteria (Proteus, Morganella, Providencia) (f) History of pyelonephritis (g) History of or symptoms suggestive of urolithiasis (h) History of childhood UTI (i) Elevated serum creatinine

7 Diagnostics ¾ Radiologic or imaging studies and cystoscopy are not routinely indicated in patients with recurrent UTI. ¾ Renal ultrasound or CT scan/stonogram may be done to screen for urologic abnormalities ¾ Patients with anatomical abnormalities should be referred to a specialist (nephrologist or urologist) for further evaluation.

8 Recurrent UTI - Prevention Prophylaxis ¾ Prophylaxis is 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. ¾ Prophylaxis may be withheld according to patient preference if the frequency of recurrence is tolerable to the patient. ¾ The following factors should guide the physician in determining the patient s risk-benefit profile and in deciding which prophylactic strategies will be used: (a) (b) (c) (d) (e) 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 Antibiotic prophylaxis ¾ Antibiotic prophylaxis should only be initiated after counseling and behavior modification have been attempted in order to minimize antibiotic exposure and possible adverse effects. ¾ Antibiotic prophylaxis should be limited to women with recurrent UTI in whom non-antimicrobial strategies have not been effective and who prefer prophylactic antimicrobial therapy. ¾ If a decision is made to give antibiotic prophylaxis, any of the following is recommended: (a) (b) (c) Continuous prophylaxis, defined as the daily intake of a lowdose of antibiotic for 6-12 months Post-coital prophylaxis, defined as the intake of a single dose of antibiotic immediately after sexual intercourse Intermittent prophylaxis, defined as self-treatment with a single antibiotic dose based on patient s perceived need.

9 Any of the antibiotics in Table 2 given either continuously for 6 to 12 months or as post-coital prophylaxis can reduce the clinical and microbiologic recurrence of UTI episodes. Table 2. Antibiotics proven effective in reducing the number of recurrences of UTI Antibiotics Recommended doses Nitrofurantoin Continuous prophylaxis mg at bedtime Post-coital prophylaxis mg 50 mg Intermittent prophylaxis Trimethoprim 100 mg at bedtime 100 mg Trimethoprim - sulfamethoxazole Trimethoprim - sulfamethoxazole Ciprofloxacin Norfloxacin Ofloxacin Pefloxacin Cefalexin 40 mg/200 mg at bedtime 40 mg/200 mg 3x/week 125 mg at bedtime 200 mg at bedtime 400 mg weekly mg at bedtime 40 mg/200 mg 40 mg/200 mg 80 mg/400 mg 125 mg 125 mg 200 mg 200 mg 100 mg mg Cefaclor 250 mg at bedtime Fosfomycin 3 g every 10 days Amoxicillin Cefuroxime 250 mg 500 mg 250 mg

10 Recurrent UTI - Prevention Methenamine salts Methenamine hippurate may be used as an alternative to antibiotics for short-term prophylaxis (one week) to prevent UTI in patients without urinary tract abnormalities. Behavioral measures to prevent recurrent UTI ¾ Behavioral measures can be useful antimicrobial-sparing measures in the prevention of recurrent UTI. ¾ These behavioral measures include the following: (a) (b) (c) (d) (e) Post-defecation and anal cleansing antero-posteriorly in women to avoid contaminating the periurethral area with fecal flora Post-coital douche or post-coital urination Liberal fluid intake especially after intercourse Avoidance of tight-fitting underwear Use of alternative form of contraception for women using spermicide-containing contraceptives Biologic mediators A. Lactobacilli Lactobacilli both in oral form and vaginal suppositories are not recommended in the prevention of UTI. B. Cranberry products Cranberry juice and cranberry products can be used among patients wherein long-term antibiotic prophylaxis for recurrent UTI is deemed necessary to avoid emergence of resistance of fecal and urine isolates of E. coli to trimethoprim, amoxicillin and ciprofloxacin. The recommended dose for UTI prevention is daily consumption of 300 ml of cranberry juice cocktail or 500 mg capsules containing 36 mg PACs) taken twice a day as the anti-adhesion activity decreases over time.

11 Table 3. Available cranberry products in the Philippines Cranberry Products Cranbiotics (Futurebiotics) Components PAC component Price per bottle Cranberry extract Lactobacillus sporogenes 120 mg (standardized for 30% PACs) P615/60 caps CranRx (Natures way) Cranberry concentrate (NOW foods) Cranberry GNC Cranberry extract Cranberry concentrate Vitamin C Sugar Cranberry Fruit Powder 500 mg (3X more Standardized PACs) 5,600 mg (700 mg - 8:1 extract) whole cranberries P400/30 caps P410/90 caps 500 mg P1,160 Fontana cranberry juice Cranberry Vitamin C NS P84/1L 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 However, evidence is insufficient to recommend vaginal estrogens over antibiotics for the prevention of recurrent UTI. Low-dose oral estrogen is not recommended for the prevention of recurrent UTI. Oral estrogens were associated with coronary heart disease, venous thromboembolism, stroke and breast cancer.

12 Recurrent UTI - Prevention Immunoprophylaxis Immunoprophylaxis, using immune-active E. coli fractions (Urovaxom), is recommended for the prevention of recurrent UTI. The dosing regimen is once daily PO for 3 months. A longer/extended dosing regimen (once daily for 3 months, rest for 3 months, 10 days per month for 3 months, and rest for 3 months) may be associated with a better control of recurrence in the longer term. Weak recommendation, Moderate quality of evidence Acupuncture Acupuncture on the lower abdomen, back or lower extremities may be used as an alternative for prevention of recurrent UTI among women when antibiotic prophylaxis is contraindicated. Oral hydration Oral water hydration (2 to 2.5 L/day) may be done to prevent UTI.

13 Recurrent UTI - Treatment Consider intermittent self-administered therapy in highly educated, well-informed, motivated patients, wherein the patients are able to recognize the characteristic signs and symptoms of UTI, are compliant with medical instructions and have a good relationship with a medical provider. Individual episodes of UTI in women with recurrent UTI or breakthrough infections during prophylaxis can be treated empirically with any of the antibiotics recommended for acute uncomplicated cystitis (Table 4) other than the antibiotic being given for prophylaxis. Always request for a urine culture and modify the treatment accordingly. Non pharmacologic interventions Cranberry juice and cranberry products are not recommended for the treatment of urinary tract infection. There is no available evidence to recommend coconut juice in the prevention or treatment of UTI. Table 4. Antibiotics for acute uncomplicated cystitis Primary Alternative Antibiotics Nitrofurantoin monohydrate macrocrystals (not sold locally) Nitrofurantoin macrocrystals Fosfomycin trometamol Pivmecillinam (not sold locally) Ofloxacin Ciprofloxacin Ciprofloxacin extended release Levofloxacin Recommended dose and duration 100 mg BID for 5 days PO 100 mg QID for 5 days PO 3 g single dose PO 400 mg BID for 3 7 days PO 200 mg BID for 3 days PO 250 mg BID for 3 days PO 500 mg OD for 3 days PO 250 mg OD for 3 days PO

14 Norfloxacin Amoxicillin clavulanate Cefuroxime axetil Cefaclor Cefixime Cefpodoxime proxetil Ceftibuten 400 mg BID for 3 days PO 625 mg BID for 7 days PO 250 mg BID for 7 days PO 500 mg TID for 7 days PO 200 mg BID for 7 days PO 100 mg BID for 7 days PO 200 mg BID for 7 days PO

15 ONLY if with proven susceptibility Trimethoprimsulfamethoxazole (TMP-SMX) 160/800 mg BID for 3 days PO Table 5. Strength of recommendation and Quality of Evidence Category/Grade Definition Strength of Recommendation Strong Clear desirable or undesirable effects Weak Desirable and undesirable effects closely balanced or uncertain Quality of Evidence High Consistent evidence from well-performed RCTs or exceptionally strong evidence from unbiased observational studies Moderate Evidence from RCTs with important limitations or moderately strong evidence from unbiased observational studies Low Evidence from one critical outcome from observational studies, from RCTs with serious flaws or from indirect evidence Very Low Evidence for one critical outcome from unsystematic clinical observation or very indirect evidence Sources: Task Force on Urinary Tract Infections, Philippine Practice Guideline Group Infectious Disease. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update. Quezon City, Philippines: PPGG-ID Philippine Society for Microbiology and Infectious Disease; 2013 Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schunemann HJ, GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.

16 BMJ 2008; 336: Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, Schünemann HJ and for the GRADE Working Group. Going from evidence to recommendations. BMJ 2008; 336: UTI Task Force Chair: Mediadora C. Saniel, MD Co Chair: Marissa M. Alejandria, MD ASB in Adults Cluster Ricardo M. Manalastas Jr., MD (Head) Louella P. Aquino, MD Shahreza L. Baquiran, MD Sybil Lizzane R. Bravo, MD Jennifer Co, MD Maria Meden P. Cortero, MD Lorina Q. Esteban, MD Analyn F. Fallarme, MD May Gabaldon, MD Jill R. Itable, MD Alfredo M. Lopez, Jr, MD Helen V. Madamba, MD Josefa Dawn V. Martin, MD Erwin R. de Mesa, MD Sharon Faith B. Pagunsan, MD Oliver S. Sanchez, MD Katha W. Ngo-Sanchez, MD Recurrent UTI Cluster Marissa M. Alejandria, MD Coralie Therese Dimacali, MD Leilanie Apostol-Nicodemus, MD Maria Carmela Lapitan, MD Rommel Bataclan, MD Tennille Tan, MD Mark Brian Tan, MD

EMPIRICAL TREATMENT OF SELECT INFECTIONS ADULT GUIDELINES. Refer to VIHA Algorithm for the empiric treatment of Urinary Tract Infection

EMPIRICAL TREATMENT OF SELECT INFECTIONS ADULT GUIDELINES. Refer to VIHA Algorithm for the empiric treatment of Urinary Tract Infection URINARY TRACT Refer to VIHA Algorithm for the empiric treatment of Urinary Tract Infection and Asymptomatic Bacteriuria on the VIHA Intranet: https://intranet.viha.ca/departments/pharmacy/clinical_pharmacy/pages/infec