OHSU URGE OVERKILL - UTIS GRAEME FORREST, MBBS, FIDSA ASSOCIATE PROFESSOR OF MEDICINE VA PORTLAND HEALTHCARE SYSTEM AND OHSU

Transcription

1 URGE OVERKILL - UTIS GRAEME FORREST, MBBS, FIDSA ASSOCIATE PROFESSOR OF MEDICINE VA PORTLAND HEALTHCARE SYSTEM AND

2 DISCLOSURES NOTHING TO DISCLOSE THE INFORMATION PRESENTED IS MY MINE AND NOT A RECOMMENDATION OF THE VA

3 CASE 1 70 YO WOMAN, WITH DIABETES, HBA1C OF 8, HTN ON LISINOPRIL AND METFORMIN ROUTINE HEALTH CHECK NO COMPLAINTS, BUT SOME URINARY FREQUENCY GIVEN PREVNAR AND SHINGLES VACCINE AT VISIT NEXT DAY UA, > 10 5 BACTERIA E COLI

4 WHAT ARE SYMPTOMS OF UTI? Symptoms No catheter Indwelling catheter dysuria and frequency yes no flank pain yes no fever and chills yes no cloudy urine no no smelly urine no no

5 URINARY TRACT INFECTIONS: THE BIG QUESTION HOW DO WE DISCERN A SYMPTOMATIC UTI FROM ASYMPTOMATIC BACTERIURIA/PYURIA? THIS IS A HUGE ISSUE ELDERLY PATIENTS WITH INDWELLING CATHETERS PATIENTS WITH ILEAL-LOOP CONDUITS

6 PREVALENCE OF ASYMPTOMATIC BACTERIURIA AGE (YEARS) WOMEN MEN_ 20 1% 1% 70 20% 15% >70 + LONG-TERM CARE 50% 40% SPINAL CORD 50% 50% (WITH INTERMITTENT CATHETERIZATION) CHRONIC URINARY CATHETER 100% 100% ILEAL LOOP CONDUIT 100% 100% Nicolle LE. Int J Antimicrob Agents Aug;28 Suppl 1:S42-8.

7 TENET 1: TREAT BACTERIAL INFECTION, NOT COLONIZATION EXAMPLE: ASYMPTOMATIC BACTERIURIA 10 5 COLONY FORMING UNITS IS OFTEN USED AS A DIAGNOSTIC CRITERIA FOR A POSITIVE URINE CULTURE IT DOES NOT PROVE INFECTION; IT IS JUST A NUMBER TO STATE THAT THE CULTURE IS UNLIKELY DUE TO CONTAMINATION PYURIA ALSO IS NOT PREDICTIVE ON ITS OWN IT IS THE PRESENCE OF SYMPTOMS AND PYURIA AND BACTERIURIA THAT DENOTES INFECTION

8 DIAGNOSIS OF UNCOMPLICATED CYSTITIS SYMPTOMS ONLY: +DYSURIA, +FREQUENCY, NO DISCHARGE OR IRRITATION:***90% CHANCE OF CYSTITIS*** DIPSTICK: LEUKOCYTE ESTERASE + AND/OR NITRITE + ONLY 75% SENSITIVE, SO SYMPTOMS MORE IMPORTANT EVEN IF DIP IS NEGATIVE CULTURE:10⁵ (100,000) BACTERIAL CFU- TRADITIONAL CRITERION OF UTI- 50% SENSITIVE -WILL MISS UP TO HALF OF CASES OF UTI COUNTS OF 100 TO 10,000 COLONIES ALL AT LEVELS THAT MAY BE CALLED AS NO GROWTH BY MICRO LAB. LEAST SENSITIVE DIAGNOSTIC TEST

9 WHY TREAT ACUTE CYSTITIS? **RARELY PROGRESSES TO SEVERE DISEASE EVEN IF UNTREATED: GOAL IS TO AMELIORATE SYMPTOMS IN SELECTING THERAPY, EFFICACY AS WELL AS ECOLOGIC COLLATERAL DAMAGE (SELECTING FOR ANTIBIOTIC RESISTANT BACTERIA, C. DIFFICILE COLITIS) SHOULD BE CONSIDERED EQUALLY- FLUOROQUINOLONES SHOULD BE AVOIDED, EXCEPT IN PYELONEPHRITIS NITROFURANTOIN, SEPTRA, FOSFOMYCIN ARE THEREFORE FIRST LINE AGENTS NEW STUDY- STILL >50% OF RXS ARE FOR CIPRO, MOST OF THE TIME FOR > THAN 3 DAYS. SEPTRA #2, NITRO #3, FOSFOMYCIN-NO RX

10 EVOLVING CONCEPTS IN THE BENEFICIAL ROLE OF ASYMPTOMATIC BACTERURIA: THE IMPORTANCE OF TREATING CYSTITIS TO RELIEVE SYMPTOMS, BUT NOT TREATING ASYMPTOMATIC BACTERURIA

11 NEW APPROACH TO ASYMPTOMATIC BACTERIURIA (ABU) DEFINITION: PRESENCE OF BACTERIA >100,000 CFU/ML IN URINE OF AN INDIVIDUAL WITHOUT SIGNS OR SYMPTOMS OF UTI. THIS DEFINITION IS INDEPENDENT OF THE PRESENCE OR ABSENCE OF PYURIA, ODOR, CLOUDY URINE

12 ABU IN YOUNG WOMEN WITH HISTORY OF RECURRENT UTI IS THIS A PRECURSOR TO SYMPTOMATIC INFECTION? GET FOLLOW-UP URINE STUDIES AND RE-TREATMENT AFTER INITIAL THERAPY FOR UTI. 673 HEALTHY NON-PREGNANT WOMAN FOLLOWED AFTER FIRST UTI FOR ONE 3 TO 5% OF YOUNG WOMEN HAVE ABU WHAT ROLE DOES THIS HAVE IN RECURRENT UTI S? MANY WOMEN STUDY IN CLINICAL INF. DISEASE -9/15/2012: YEAR.- ALL WERE TREATED AGAIN AT ANY TIME IF HAD SYMPTOMATIC UTIS. URINE CULTURES WERE ALSO OBTAINED AT 3, 6 AND 12 MONTHS-IF POSITIVE BUT IF PATIENT ASYMPTOMATIC ONLY HALF WERE TREATED, OTHER HALF WERE NOT

13 STUDY RESULTS OF ASYMPTOMATIC BACTERIURIA (ABU) IN YOUNG HEALTHY WOMEN RESULTS AFTER ONE YEAR OF OBSERVATION: THOSE TREATED FOR ABU- 46.8% HAD A SYMPTOMATIC UTI LATER DURING THE YEAR THOSE NOT TREATED FOR ABU- ONLY 13.1% HAD ANOTHER UTI! CONCLUSION: THE PARADOXICAL RESULT WAS INCREASED INCIDENCE OF SYMPTOMATIC UTIS IN PATIENTS GIVEN ANTIMICROBIALS FOR ASYMPTOMATIC BACTERURIA!

14 WHY THIS SURPRISING RESULT? BACTERIAL INTERFERENCE- THE INABILITY OF PATHOGENIC BACTERIA TO SET UP A BLADDER INFECTION DUE TO BLOCKAGE BY COMMENSAL BACTERIA COLONIZING THE BLADDER- WAS DISRUPTED BY THE TREATMENT OF ABU. CONCLUSION :THE HUMAN MICROBIOME IS A POTENT DEFENSE MECHANISM AGAINST SUPERINFECTING PATHOGENIC BACTERIA. APPLIES TO THE BLADDER, AS WELL AS THE GI TRACT AND OTHER SITES.

15 RECENT STUDY ON ASB TREATMENT RANDOMIZED 550 WOMEN TO EITHER TREAT OF NOT-TREAT ASB NO ROUTINE MICROBIOLOGIC ANALYSIS URINE ONLY COLLECTED IF SYMPTOMATIC OUTCOMES WERE RATES OF RECURRENT UTI S IN UNTREATED VS TREATED GROUPS AFTER 12 MONTHS Cai et al, CID 2015:61;

16 RESULTS RECURRENT SYMPTOMATIC UTI OCCURRED IN 37% UNTREATED GROUP VS 70% TREATED GROUP (P<0.001) RISK OF RECURRENT UTI 4X GREATER IN TREATED GROUP RESISTANCE IN E COLI INCREASED QUINOLONES, TRIMETHOPRIM-SULPHA

17

18 STUDY CONCLUSION TREATMENT OF ASB IN WOMEN WITH RECURRENT UTI S DOES NOT PREVENT INFECTIONS, ONLY INCREASES RESISTANCE INCREASES RISK OF TOXICITY OR OTHER AE PROBLEM NO BASELINE URINE TO DETERMINE IF RESISTANCE HIGHER IN TREATMENT GROUP PRE-ENROLLMENT

19 WHEN TO TREAT ASB? PREGNANCY SCREEN EVERY VISIT AMOXICILLIN, CEFALEXIN AND BACTRIM (EXCEPT 3 RD TRIMESTER) RECOMMENDED DURATION OF THERAPY IS UNKNOWN! UROLOGIC PROCEDURES ANTIBIOTICS PRIOR TO PROCEDURE DO NOT NEED TO CONTINUE AFTER

20 CASE 2 50 YO MAN WITH PARAPLEGIA LONG TERM FOLEY CATHETER IN PLACE PRESENTS WITH COUGH, FEVER FOLEY CULTURE UA 10 WCC, +VE LE, + NITRITES > 10 5 YEAST 10 3 PSEUDOMONAS 10 3 ENTEROCOCCUS

21 URINARY CATHETERS SIMILAR INCIDENCE OF FEVERS AND INFECTIONS IN TREATED AND UNTREATED GROUPS 40% INCREASE IN RESISTANT BACTERIA IN TREATED GROUP YEAST AND ENTEROCOCCI OFTEN COLONIZERS ONE OF LEADING CAUSES OF ANTIBIOTIC RESISTANCE DUE TO BIOFILM ROLE OF CATHETER REMOVAL, EXCHANGE UNKNOWN

22 CATHETER BIOFILMS WITHIN 1-3 DAYS OF PLACEMENT, BACTERIA WILL COLONIZE URINARY CATHETERS AND COAT THE PLASTIC WITH A BIOFILM. A BIOFILM IS A LAYER OF STICKY SLIME (POLYSACCHARIDES) SECRETED BY BACTERIA THAT PROTECTS THEM FROM ANTIBIOTICS, DRYING OUT AND OTHER THREATS. THE PICTURE SHOWS A BIOFILM (GREY SHEETS) ON A CATHETER AS WELL AS THE BACTERIA THAT SECRETED IT (ROUND WHITE GLOBES). THE BIOFILM PROTECTS THE BACTERIA. A POSITIVE URINE CULTURE OBTAINED FROM AN INDWELLING URINARY CATHETER MAY GROW BACTERIA THAT CAME FROM THE BIOFILM. BACTERIA FROM THE BIOFILM USUALLY DO NOT CAUSE PROBLEMS FOR THE RESIDENT. Photograph obtained from the Public Health Image Library ( Content Providers: CDC/ Rodney M. Donlan, Ph.D.; Janice Carr. Photo Credit Janice Carr.

23 KEY POINTS FOR URINE SAMPLE COLLECTION For people with indwelling urinary catheters, avoid collecting urine from the collection bag. Instead, place a new catheter (preferred method) or use the collection port. In general, if the urinary catheter is <1 week old, it does not need to be changed prior to collection of a urine sample for urinalysis and culture, provided you use the collection port. In men who are unable to get a clean catch urine sample, try placing a condom catheter and check the collection bag every 30 minutes. Because this is clean plastic (newly placed) this is an exception to the above rule. It is acceptable to collect the sample from a collection bag that has held urine for only 1-2 hours. For women unable to obtain a clean catch urine sample, unfortunately an in/out catheterization may be needed.

24 CASE 3 92 YO WOMAN, DEMENTIA, MOSTLY STAYS IN BED INCREASING CONFUSION STAFF NOTE SMELLY, STRONG URINE AND INCONTINENCE NO FEVERS LESS ROUSABLE SENT TO NEAREST HOSPITAL BP 95/50, HR 85, T 36.8 PERKS UP AFTER 1LITER OF FLUID UA WITH > 180 WCC, FEW RBC, CAST AND GPC AND GNR STARTED ON ANTIBIOTICS ON FLOOR IMPROVES NEXT DAY 2 WEEKS LATER GETS C DIFFICILE, DIES FROM C DIFFICILE COLITIS

25

26

27

28 ROLE OF PROPHYLACTIC ANTIBIOTICS IN ASB After 6 months, return of organisms occurs, usually resistant IDSA UTI Guidelines 2005

29 UNTOWARD EFFECTS OF ANTIBIOTICS ANTIBIOTIC RESISTANCE ADVERSE DRUG EVENTS (ADES) HYPERSENSITIVITY/ALLERGY DRUG SIDE EFFECTS CLOSTRIDIUM DIFFICILE INFECTION ANTIBIOTIC ASSOCIATED DIARRHEA/COLITIS INCREASED HEALTH-CARE COSTS Ohl CA, Luther VP. J. Hosp. Med. 2011;6:S4

30 CLOSTRIDIUM DIFFICILE INFECTION (CDI) A POTENTIALLY DEADLY COLITIS ANTIBIOTICS ARE THE 90 SINGLE MOST IMPORTANT 80 RISK FACTOR FOR CDI INCIDENCE AND MORTALITY 50 INCREASING 40 A MORE VIRULENT NAP1/BI 30 STRAIN ALSO SEEN WITH 20 INCREASING FREQUENCY # of CDI Cases per 100,000 Discharges Redelings, et al. EID, 2007;13:1417 CDC. Get Smart for health care. Access at Principal Diagnosis All Diagnoses Annual Mortality Rate per Million Population

31 ANTIMICROBIAL STEWARDSHIP AND ASB 1) TRAUTNER ET AL: VA MULTIFACETED TEACHING IMPLEMENTATION 1) ALGORITHM, FEEDBACK, NP, MD, PA, NURSING, MORNING REPORT 2) DECREASED URINE CULTURE ORDERING BY 50% 3) OVERTREATMENT ASB DECREASED BY 60% 2) ASP AT LTCF ID PHYSICIAN, PHARMACIST 1) 140 CULTURES ORDERED, ONLY 8 TREATED BY GUIDELINES 2) REDUCED ADVERSE EVENTS 1. Trautner, JAMA Int med Doernberg, Antimic Resist IC 2015

32 ASB A CALL TO ARMS! A GAINST R OUTINE M IDSTREAM OR CATHETERIZED URINE TESTING!!!!! DO NOT TEST UNLESS ASK IF SYMPTOMS DEHYDRATION MOST COMMON CAUSE OF CONFUSION IN ELDERLY.

33 SUMMARY OF ASYMPTOMATIC BACTERIURIA TREATMENT TREAT SYMPTOMATIC PATIENTS WITH PYURIA AND BACTERIURIA DON T TREAT ASYMPTOMATIC PATIENTS WITH PYURIA AND/OR BACTERIURIA DEFINE THE SYMPTOMATIC INFECTION ANATOMICALLY DYSURIA AND FREQUENCY WITHOUT FEVER EQUALS CYSTITIS DYSURIA AND FREQUENCY WITH FEVER, FLANK PAIN, AND/OR NAUSEA AND VOMITING EQUALS PYELONEPHRITIS REMEMBER PROSTATITIS IN THE MALE WITH CYSTITIS SYMPTOMS