CLASSIFICATION OF URINARY TRACT INFECTIONS AND SURGICAL FIELD CONTAMINATION CATEGORIES AS A BASIS FOR TREATMENT AND PROPHLAXIS

Transcription

1 CLASSIFICATION OF URINARY TRACT INFECTIONS AND SURGICAL FIELD CONTAMINATION CATEGORIES AS A BASIS FOR TREATMENT AND PROPHLAXIS Magnus Grabe, M.D., Ph.D. Associate Professor of Urology University of Lund Sweden Magnus.grabe@med.lu.se

2 University of Lund since 1666

3 University hospital - Malmö 2013

4 Scania: South Swedish Province

5 Winter

6 Layout The European Association of Urology (EAU) Guidelines on Urological Infections (versions 2015 and 2016) Principle of classification of Urinary tract infections Surgical field contamination categories as a model for peri-operative antimicrobial prophylaxis Antimicrobial (= antibiotic) stewardship Conclusions and take home message

7 EAU Guidelines Non-oncology/urological infections/archive: 2015

8 Main types of infections associated with urological care Urinary tract infection Male accesory gland infection (MAGI) Wound infections Surgical site infeciton (SSI) Female resproductive organ infection Systemic and Other organ infection

9 Classification of Urogenital infections EAU guidelines Female reproductive organs infection Male accessory gland infection (MAGI) Urinary tract infection (UTI) Uro-Genital infections (UGI) Grabe et al. EAU guidelines

10 PRINCIPLES OF A MODERN CLASSIFICATION OF UTI European Section of Infection in Urology ESIU European Association of Urology EAU

11 What we have ICD 10 N30.9 Cystitis N10 N11.9 Pyelonephritis N39 UTI unspecified A41.9 Sepsis, unspecified N41.9 Prostatitis CDC 1988 CDC update 2008 IDSA 1992 ESCMID 1993

12 European Association of Urology and International Consultation on Urological Diseases 16 sections, divided in several chapters 991 pages Each section chaired by one expert coordinating an international effort Evidence based review of the literature Totally 3628 references

13 What we would like to have T N M like classification A UTI severity score

14 What is important for a UTI in Urology? Clinical criteria Presentation - localisation Severity Circumstances of UTI Risk factors Endogenous Exogenous Urological circumstances Hospital environment Pathogens Pathogen (type, virulence) Antibiotic sensitivity acquisition Community Long term residential Therapeutic options

15 STEP ONE (1) The Localisation Symptoms Presentation

16 Localisation of infection of the UT Localisation Symptoms giving the localisation Acronym Urine (only) No Source level unknown ABU Bladder Lower Urinary Tract symptoms Cystitis CY Kidney Upper Urinary tract symptoms Pyelonephritis, Pyonephrosis Febrile UTI (Avoid pyelitis ) PN Systemic Sepsis Urosepsis Male genital infection Prostatitis Epididymitis US

17 Classification of clinical presentation Clinical diagnosis Clinical symptoms Cystitis Dysuria, frequency, urgency, suprapubic pain, etc Grade of Acronym severity 1 CY-1 Mild,moderate Fever (>38oC), abdominal or flank pain pyelonephritis Unspecific febrile symptoms with or without symptoms of CY Febrile UTI 2 PN-2 Severe pyelonephritis Febrile UTI As PN-2 with nausea and vomiting 3 PN-3 UroSepsis SIRS Any signs of Systemic Inflammatory Response Syndrome (SIRS) +/- PN/CY 4 US-4* Severe Sepsis US-4 + hypo-tension and -perfusion 5 US-5* Sepsis with organ failure 6 US-6* * Sepsis 2/2001 US-5 + organ failure not responding supportive therapy Adapted from Bjerklund Johansen, 2010

18 New classification of Sepsis (Sepsis-3/2016) JAMA, 2016:315(8) Feb 23

19 New classification of Sepsis (Sepsis-3/2016) JAMA, 2016:315 (8);Feb 23

20 New classification of Sepsis (Sepsis-3): SOFA score JAMA, 2016:315 (8);Feb 23

21 Severity Symptoms No symp toms Clinical diagnosis ABU Local symptoms General symptoms Systemic response SIRS Organ failure Dysuria, frequency, urgency, pain or bladder tenderness Fever, Flank pain Nausea, vomiting Fever, shivering Circulatory failure Single-, multipleorgan failure CY-1 + PN-2 PN-3 Febrile UTI US-4 US-5 US-6 Investigations Risk factors Treatment Medical and Surgical * Two exceptions: pregnancy and prior to urological procedure Grabe et al. EAU guidelines

22 STEP TWO (2) The degree of severity A continuum

23 Severity Gradient of severity Symptoms No symp toms Clinical diagnosis ABU Local symptoms General symptoms Systemic response SIRS Organ failure Dysuria, frequency, urgency, pain or bladder tenderness Fever, Flank pain Nausea, vomiting Fever, shivering Circulatory failure Single-, multipleorgan failure CY-1 + PN-2 PN-3 Febrile UTI US-4 US-5 US-6 Investigations Risk factors Treatment Medical and Surgical * Two exceptions: pregnancy and prior to urological procedure Grabe et al. EAU guidelines

24 STEP THREE (3) Risk Factor assessment Grouping the Risk Factors

25 Severity Gradient of severity Symptoms No symp toms Clinical diagnosis ABU Investigations Dipstick (MSU Culture + S as required) Risk factors Local symptoms General symptoms Systemic response SIRS Organ failure Dysuria, frequency, urgency, pain or bladder tenderness Fever, Flank pain Nausea, vomiting Fever, shivering Circulatory failure Single-, multipleorgan failure CY-1 + PN-2 PN-3 Febrile UTI Dipstick MSU Culture + S Renal US or I.V. Pyelogram /renal CT US-4 US-5 US-6 Dipstick MSU Culture + S and Blood culture Renal US and/or Renal and abdominal CT Risk factor assessment according to ORENUC (Table 2.1) Uncomplicated UTI Complicated UTI Treatment Medical and Surgical * Two exceptions: pregnancy and prior to urological procedure Grabe et al. EAU guidelines

26 ORENUC Risk Factors O No R RF of recurrence E Extragenital N U C Nephro- Urolog- Cathepathic ical ter related

27 Host Risk Factors in UTI (EAU Guidelines ) Type Category of risk factor Examples of risk factors O No known/associated RF Healthy premenopausal women R RF of recurrent UTI, but no risk of severe outcome Sexual behaviour and contraceptive devices Hormonal deficiency in post menopause Secretory type of certain blood groups Controlled diabetes mellitus E Extra-urogenital RF, with risk of more severe outcome Pregnancy Male gender Badly controlled diabetes mellitus Relevant immunosuppression* Connective tissue diseases* Prematurity, new-born N Nephropathic disease, with risk of more severe outcome Relevant renal insufficiency* Polycystic nephropathy U Urological RF, with risk of more severe outcome, which can be resolved during therapy Ureteral obstruction (i.e. stone, stricture) Transient short-term urinary tract catheter Asymptomatic Bacteriuria** Controlled neurogenic bladder dysfunction Urological surgery C Permanent urinary Catheter and non resolvable urological RF, with risk of more severe outcome Long-term urinary tract catheter treatment Non resolvable urinary obstruction Badly controlled neurogenic bladder dysfunction Bjerklund-Johansen et al. Urological infections. EAU-ICDU, 2010 * Not well defined

28 STEP FOUR (4) Pathogen and its sensitivity

29 Theurapeutic options Microorganism Sensitivity Susceptibility Level Susceptible Reduced susceptibility Multiresistant a b c

30 THE FINAL CODE Clinical presentation Severity Risk factors Pathogen and sensitivity Therapeutic options

31 Additive factors for UTI severity assessment Clinical presentation UR: Urethritis CY: Cystitis PN: Pyelonephritis US: Urosepsis MA: Male genital glands ESIU, MG, 2010 Grabe et al. EAU Guidelines on Urological infections Grade of severity 1: Low, cystitis 2: PN, moderate 3: PN, severe, established 4: US: SIRS 5: US: Organ dysfunction 6: US: Organ failure Risk factors ORENUC O: No RF R: Recurrent UTI RF E: Extra urogenital RF N: Nephropathic RF U: Urological RF C: Catheter RF Treatment: Medical Surgical? Pathogens Species Susceptibility grade Susceptible Reduced susceptibility Multi-resistant

32 PN-3,U:E.COLI (S) US-5,E:PROTEUS (A) CY-1,O:E.coli (s) CY-1,R:E.coli (s) Not validated but a practical tool

33 Severity Gradient of severity Symptoms No symp toms Clinical diagnosis ABU Investigations Dipstick (MSU Culture + S as required) Risk factors Local symptoms General symptoms Systemic response SIRS Organ failure Dysuria, frequency, urgency, pain or bladder tenderness Fever, Flank pain Nausea, vomiting Fever, shivering Circulatory failure Single-, multipleorgan failure CY-1 + PN-2 PN-3 Febrile UTI Dipstick MSU Culture + S Renal US or I.V. Pyelogram /renal CT US-5 US-6 Dipstick MSU Culture + S and Blood culture Renal US and/or Renal and abdominal CT Risk factor assessment according to ORENUC (Table 2.1) Uncomplicated UTI Treatment Medical and Surgical US-4 NO* Empirical 3-5 days Empirical + directed 7-14 days Complicated UTI Empirical + directed 7-14 days Empirical + directed days Consider combine 2 antibiotics Combine 2 antibiotics * Two exceptions: pregnancy and prior to urological procedure Grabe et al. EAU guidelines

34 Severity Gradient of severity Symptoms No symp toms Clinical diagnosis ABU Investigations Dipstick (MSU Culture + S as required) Risk factors Local symptoms General symptoms Systemic response SIRS Organ failure Dysuria, frequency, urgency, pain or bladder tenderness Fever, Flank pain Nausea, vomiting Fever, shivering Circulatory failure Single-, multipleorgan failure CY-1 + PN-2 PN-3 Febrile UTI Dipstick MSU Culture + S Renal US or I.V. Pyelogram /renal CT US-4 US-5 Dipstick MSU Culture + S and Blood culture Renal US and/or Renal and abdominal CT Risk factor assessment according to ORENUC (Table 2.1) Uncomplicated UTI Treatment Medical and Surgical US-6 NO* Empirical 3-5 days Complicated UTI Empirical + directed 7-14 days Empirical + directed 7-14 days Empirical + directed days Consider combine 2 antibiotics Combine 2 antibiotics Drainage/surgery as required * Two exceptions: pregnancy and prior to urological procedure Grabe et al. EAU guidelines

35 SURGICAL FIELD CONTAMINATION LEVEL

36 CLASSIFICATION OF UROLOGICAL PROCEDURES IN RELATION TO LEVEL OF CONTAMINATION Based on CDC Guidelines on prevention of SSI Mangram et al. Infect Control Hosp Epidemiol 1999;20: Adapted for urological procedures by EAU Section on infections in Urology (ESIU) Urological Infections Grabe et al. World J Urol 2011

37 Surgical field contamination: General Surgical contamination Description Principle of antimicrobial prophylaxis Clean (I) Clean-contaminated (II) Contaminated (III) Dirty (IV) Mangram et al, 1999

38 Surgical field contamination: General Surgical contamination Description Clean (I) Urinary, genital or alimentary tracts not entered Uninfected operative wound and no evidence of inflammation. No break in technique. Blunt trauma. Clean-contaminated (II) Urinary, alimentary, pulmonary or genital tracts entered with no or little (controlled) spillage. No break in technique Contaminated (III) Urinary, alimentary, pulmonary or genital tracts entered, spillage of GI content; inflammatory tissue; major break in technique; Open, fresh accidental wounds Dirty (IV) Pre-existing infection; viscera perforation Old traumatic wound Principle of antimicrobial prophylaxis Mangram et al, 1999

39 Surgical field contamination: Urology Surgical contamination Description Clean (I) Urinary, genital or alimentary tracts not entered Uninfected operative wound and no evidence of inflammation. No break in technique. Blunt trauma. Clean but entering the lower UT Clean-contaminated (UT) (IIA) Urinary or genital tracts entered with no or little (controlled ) spillage. No break in technique Clean-contaminated (bowel) (IIB) Gastrointestinal tract entered, no or little (controlled) spillage. No break in technique Contaminated (III) UT or GI tracts entered, spillage of GI content; inflammatory tissue; major break in technique; Open, fresh accidental wounds Bacterial growth in urine Dirty (IV) Pre-existing infection; viscera perforation Old traumatic wound Principle of antimicrobial prophylaxis Grabe et al, WJU 2011 Mangram et al, 1999

40 Surgical field contamination: Urology Surgical contamination Description Principle of antimicrobial prophylaxis Clean (I) Urinary, genital or alimentary tracts not entered Uninfected operative wound and no evidence of inflammation. No break in technique. Blunt trauma. Clean but entering the lower UT No Clean-contaminated (UT) (IIA) Urinary or genital tracts entered with no or little (controlled ) spillage. No break in technique Yes Single dose Clean-contaminated (bowel) (IIB) Gastrointestinal tract entered, no or little (controlled) spillage. No break in technique If prolonged = treatment Contaminated (III) UT or GI tracts entered, spillage of GI content; inflammatory tissue; major break in technique; Open, fresh accidental wounds Bacterial growth in urine Pre-operative control Dirty (IV) Pre-existing infection; viscera perforation Old traumatic wound Treatment Grabe et al, WJU 2011 Mangram et al, 1999

41 Other criteria? Event Example Decision Breach of protecting mucosal layer Cystoscopy Endourological procedures (e.g. URS) Does it change? Small rift, no change Larger rift? Perforation of organ Bladder wall Change from Ureter perforation during prophylaxis to treatment? stone management Kidney pelvic wall perforation during PCNL Necrotic tissue or purulent liquide Resection of prostate or bladder tumour Infected environment Lack of evidence for such decisions

42 Antimicrobial Stewardship (1) Optimise The outcome of prevention and treatment of infection Curbing overuse and misuse of antimicrobial agents Measure of success: Regulating antibiotic prescription Healthcare associated infection = HAI (reporting, feed-back) Emergence of resistant organisms, e.g. Clostridium difficile In urology Urinary tract infections (UTI) Male accessory glands infection (MAGI)

43 Antimicrobial Stewardship (2) The most important components Regular training of staff in best use of antimicrobial agents Adherence to local, national and international guidelines Regular ward visits and consultation with infectious disease physicians Treatment outcome evaluation Monitoring and regular feedback to prescribers of their antimicrobial prescribing performance and local pathogen resistance profile, by Clinic and Ward audits

44 Conclusions message to take home Urological care is accompainied by several different forms of infections and infectious complications A stepwise assessment of each patient is essential for a correct management Localisation of infection Careful risk factor evaluation Expected microorganism and resistance pattern Need for surgical management in addition to medical The surgical field contamination level is a tool to prevent infectious complications in conjunction with urological surgery Antibiotic stewardship programme is a tool for improving the rational and reasonable use of antibiotics