Urinary Tract Infections Michelle Eslami, M.D., FACP Professor of Medicine Division of Geriatrics David Geffen SOM at UCLA Urinary Tract Infection (UTI) One of most common infections in outpatient and inpatient settings UTI-not one size fits all Asymptomatic bacteriuria Acute uncomplicated cystitis (AUC) Recurrent cystitis Complicated cystitis Catheter associated asymptomatic bacteriuria (CA-ABS) Catheter associated UTI ( CA-UTI) Prostatitis Challenges Comorbid conditions may result in similar symptoms to UTI s Cognitive impairment may make reporting of symptoms difficult Older adults can have atypical presentations for infections There is lack of evidence based guidelines for symptomatic UTI s Risk Factors for UTI Premenopausal state Urinary tract instrumentation History of voiding problems Stones or ureteral stents Postmenopausal state Dehydration Screening for UTI No role in men or non-pregnant women Recommended in pregnancy Recommended for men before TURP or other urinary tract instrumentation resulting in mucosal bleeding Screening for Asymptomatic Bacteriuria Asymptomatic bacteriuria does not lead to HTN, CKD or decreased survival Prevalence highest spinal cord patients, hemodialysis, women >80yrs, diabetics No relationship to mortality Screening and treatment not recommended
IDSA Recommendations Routine screening for and treatment of ASB in older individuals in the community is not recommended. Screening for and treatment of ASB in elderly residents in LTCFs is not recommended. Signs and Symptoms of Acute Uncomplicated UTI (ACU) Acute onset dysuria, increased urgency and frequency Meta-analysis in ambulatory women found symptoms of UTI, no vaginal discharge or irritation had >90% probability of acute cystitis Do not need to do urinalysis Do not need a urine culture CID2005;40:643-654 Brent, S. et al. JAMA 2002; 287:2701-10. Complicated UTI Anatomic, functional or metabolic abnormality of the urinary tract Pregnant women, bladder outlet obstruction Men- voiding dysfunction or related prostatic disorders Diabetic, immunocompromised, post menopausal or elderly Catheter, calculi or neurogenic bladder Differential Diagnosis of UTI in Young Women Vaginitis- vaginal discharge and external dysuria Uretheritis- vaginal discharge Irritation- vaginal itching and discharge - fever, malaise, nausea and vomiting, abdominal pain and back/flank pain Signs and Symptoms of UTI in Elderly Elderly patients may be more prone to have changes in mental status from baseline Elderly women--auc v. complicated UTI Elderly men--complicated UTI related to prostate Bacterial organisms include E-coli, Proteus, Klebsiella, Pseudomonas, Enterococus and Staph species are more common > 65 years old Signs and Symptoms of CA-UTI New onset or worsening fevers, AMS, malaise or lethargy without other cause, flank pain, CVA tenderness, acute hematuria or pelvic discomfort UCX > 1000 colonies of one bacterial species Includes foley, suprapubic, condom, intermittent catheterization or catheter removal within 48hrs
Criteria for Surveillance, Diagnosis and Treatment Consensus group recommendations McGeer criteria developed for surveillance and outcome assessments Used by Centers for Medicare and Medicaid Services Loeb criteria recommends minimal set of criteria necessary to initiate antibiotic therapy for UTI Similar to IDSA Guidelines Significance of Bacteriuria Indwelling Catheters Prevalence catheter use US NH residents: 100,000 in use Acute care: 15-25% Prevalence bacteriuria per day catheterization 3-8% short term 9-23% > 30 days 100% Complications BSI < 1% deaths due to BSI 1-4% Hooton TM et al. IDSA Guideline, CID 2010;50:625 Collecting Urine Samples Mid-stream or clean catch specimen for cooperative and functionally capable individuals. However, often necessary For males to use freshly applied, clean condom (external) catheter and monitor bag frequently For females to perform an in-and-out catheterization Residents with long-term indwelling catheters Change catheter prior to collection (sterile technique/equip.) Resident with short-term catheterization (< 30 days) Obtain by sampling through the catheter port using aseptic technique If port not present may puncture the catheter tubing with a needle and syringe If catheter in place > 2 weeks at onset of infection, replace CID 2009;48:149-171 CID 2010;50:625-663 Urinalysis and Culture Urinalysis Positive Nitrate; gram negative bacteria Positive Leukocyte esterase (>10 WBC) White blood cell casts Hematuria Urine culture Not always indicated for AUC in women but useful if no response to initial therapy Complicated UTI Elderly in LTCF or hospital Pyuria Pyuria (> 10 WBC / high-power field) is evidence of inflammation in the genitourinary tract Pyuria is commonly found with ASB Elderly institutionalized residents 90% (Infect Dis Clin North Am 1997;11:647-62) Short-term (< 30 days) catheters 30-75% (Arch IM 2000;160:673-82) Long-term catheters 50-100% (Am J Infect Control 1985;13:154-60) Pyuria Prevalence-Asymptomatic Pts Young women 32% Pregnant women 30-70% Diabetic women 70% Institutionalized elderly 90% Hemodialysis pts 90% Short term catheters 30-75% Long-term catheters 50-100% Nicolle et al. Clin Infect Dis 2005;40:643-654.
Pyuria Other Causes Any inflammatory cause Tuberculosis (sterile pyuria) STDs Interstitial nephritis legionella, leptospirosis, atheroemboli, granulomatous dis (sarcoid), allergy Irritation - stones, catheters Degree of pyuria not helpful re-rx Testing for UTI Blood cultures Diabetes Renal transplant Role of Diagnostic Imaging for UTI Uncomplicated UTI; expert consensus is that imaging adds little benefit except if a stone is suspected Men < 45 years or older men without voiding symptoms or hematuria Microbiology of UTI E-coli > 90% in uncomplicated cystitis and pyelonephritis Klebesiella, Proteus and Coagulase-negative Staph saprophyticus make up 5-10% Complicated UTI; E-coli, coliforms and enterococci CA-UTI short term; E-coli, Hospital acquired pathogens; Klebsiella, Citrobacter and Enterobacter Longterm catheter; polymicrobial Asymptomatic Bacteriuria (ASB) Laboratory diagnosis Positive urine culture Colony count significant (> 10⁵ cfu/ml) Absence of symptoms Clinical Infectious Disease 2010;50:625-663 No Benefit Treating ASB in the Elderly Large long-term studies of ASB in pre and postmenopausal women NO ADVERSE OUTCOMES in women not treated Randomized studies (treatment vs. no treatment) in elderly LTC residents NO BENEFIT to treatment No decreased rate of symptoms No improved survival CID2005;40:643-654
Treatment for ASB Not Indicated Premenopausal, non-pregnant women Diabetic women Older persons living in the community Elderly living in long term care facilities Persons with spinal cord injury Catheterized patients Treatment for ASB Indicated Pregnant women Increased risk for adverse outcomes Urologic interventions TURP Any urologic procedure with potential mucosal bleeding CID2005;40:643-654 Treatment Regimens for Uncomplicated Cystitis Nitrofurantoin 100mg bid for five days Trimethoprim-sulfamethoxazole* bid for three days Fosfomycin 3g single dose Alternative agents Fluroquinolones three day course Beta-lactams three to seven day course Fosfomycin Active against a wide spectrum of gram positive and gram negative organisms including ESBL and VRE Clinical cure of 83% = five day course of cipro ( 81% for AUC) Not tested or reported in most clinical trials *excellent efficacy if local resistance <20% Treatment for Complicated UTI and Acute Pyelonephritis Fluoroquinolones Cipro 500mg bid qd for seven days Levaquin 750mg qd for five days Trimethoprim-sulfamethoxazole 14 day course Beta-lactams 10-14 day course Consider initial IV dose of ceftriaxone or aminoglycoside Catheter Associated UTI (CA- UTI) CA rate bacteruria: 3-8% per day Treat only if symptomatic 100 CFu/mL in newly placed CA 1000 CFu/mL minimum count for CA-UTI or 48 hours after catheter removed Treatment usually seven days for symptoms that promptly resolve; 10-14 days if delayed response
Recurrent UTI >= 3 UTIs within 12 months or >=2 UTIs within six months Postcoital antibiotic prophylaxis- half Bactrim SS Patient initiated therapy Daily or three times a week prophylaxis for 6-12 months Postmenopausal women- topical estrogen Nonpharmcologic Therapies and Prevention Push fluids Cranberry products RCT with twice daily cranberry juice v. placebo--no benefit RCT with cranberry capsule v. TMP-SMX--abx better result No definitive evidence available show that cranberry products help with treatment or prophylaxis Stapleton AE,et al.mayo Clin Proc 2012:87:145-50 Beereport MA,et al. Arch Intern Med2011;171:1270-8 Conclusions UTIs are common E-coli is the most common pathogen in both young and old Guidelines focus on women with acute uncomplicated cystitis/pyelonephritis and are limited to premenopausal, non-pregnant CA-UTI in hospitalized patients is not reimbursed Abundant evidence supports nontreatment of asymptomatic bacteriuria Tool Kits Patient Information http://familydoctor.org http://kidney.niddk.nih.gov Clinical Guidelines www.annals.org/content/149 http://cid.oxfordjournals.org