1. Module 4: Stewardship in Urinary Tract Infections
Benjamin Westley MD FAAP FACP
4120 Laurel St Suite 204
Anchorage, AK 99508

2. Objectives Categorize urinary tract infections by group
Asymptomatic bacteriuria
Cystitis
Pyelonephritis
Complicated urinary tract infection/Catheter-associated UTI
Recognize how to distinguish “Infection” from “Bacteriuria” and when to NOT given antibiotics for “UTI”
Discuss the approach to cystitis
Define pyelonephritis and identify evidence-based therapies
Consider complicated pyelonephritis, catheter-associated UTI (CA-UTI) and treatment of highly-resistant organisms

3. IDSA guidelines Asymptomatic bacteriuria1 Catheter-associated UTI2
Cystitis and pyelonephritis3

4. Asymptomatic bacteriuria (ASB)1
Presence of bacteria in urine in the absence of symptoms
Women: 2 consecutive voided urine specimens with SAME bacterial strain ≥105 cfu/mL
Men: Single clean-catch urine with 1 species ≥105 cfu/mL
Men and women: Single catheterized urine with 1 species ≥102
Pyuria without symptoms is NOT an indication for antimicrobial treatment

5. Asymptomatic bacteriuria1

6. Asymptomatic bacteriuria
DO NOT TREAT ASYMPTOMATIC PATIENTS!!
Not in non-pregnant women, diabetics, old people, institutionalized people, spinal cord injury, or in patients with catheters. Treating even in renal transplant patients is controversial.
UNLESS!!!!!
Pregnant women should be screened in early pregnancy
Treat 3 – 7 days if positive
Prior to TURP
Start night before or immediately pre-procedure, stop post- procedure
Prior to urologic procedure where mucosal bleeding is anticipated

7. Why is asymptomatic bacteriuria over-treated?
20 – 80% of ASB is inappropriately treated
Survey of 95 resident physicians who managed bacteriuria10
32% of ASB inappropriately treated with antibiotics
Presented with 7 vignettes
37% correct
Reasons cited for improperly treating ASB in survey:
Concern for post-op infection
Elevated inflammatory markers
Abnormal urinalysis

8. Lee et al. BMC Infectious Diseases (2015) 15:289

9. Do not screen or treat ASB prior to surgical procedures
No benefit prior to CT or spine surgery11,13
ASB not associated with post-operative joint replacement infections12
Clin Infect Dis 2014;59(1):41–7

10. Cystitis3 Common in otherwise healthy women NO FEVER, NO FLANK PAIN
Nitrofurantoin 100mg bid x5d
Cephalexin 500mg bid x 3-7 days4
AVOID:
Trimethoprim/sulfa: most sites >20% E. coli resistance
Fluoroquinolones: unnecessarily broad, more C. diff, anti- pseudomonal/pneumococcal spectrum not needed
Amoxicillin/clavulanate: poor empiric E. coli activity

11. Pyelonephritis3 Fever, flank pain, and/or nausea and vomiting
Get a urine culture first!!
Option 1:
Oral fluoroquinolone (if local E. coli sensitivity ≥90%)
Higher cure rates than 14 days of trimethoprim/sulfa5
Ciprofloxacin 500mg po bid x7 days5, or
Levofloxacin 750mg po daily x5 days6
If baseline resistance >10%, can consider ceftriaxone 1g x1 then PO quinolone while sensitivities pending if follow-up can be assured
Option 2:
Beta-lactam7 or TMP/SMX5 as follows:
Ceftriaxone 1g IV or IM x1, then cephalexin8 1g PO TID x days total, OR
Ceftriaxone 1g x1 then TMP/SMX DS 1 po bid x14 days

12. Bacteremia and pyelonephritis
If bacteremic and not improving, repeat blood cx and consider imaging to rule-out complicated pyelonephritis
Good data with quinolones and tmp/smx
Caution with oral beta lactam regimen
We give several days IV until clinically improved then finish with high dose oral beta lactam or swap to quinolone to finish

13. “Complicated” UTI Historical, messy term
Cystitis or pyelonephritis accompanied by abnormality of the urinary tract9
Obstruction: strictures, stones, prostatic hypertrophy, congenital
Instrumentation: catheters, tubes, stents, procedures
Poor voiding: reflux, neurogenic bladder, cystocele
Transplant
Infections are harder to eradicate in these patients
If there is hydronephrosis suggesting obstruction, in the presence of infection this is a medical emergency; infected kidneys must be decompressed emergently!
Indwelling catheters are most common cause of complicated UTI

14. Catheter-associated UTI (CA-UTI)
IDSA guideline 20092
SYMPTOMS of UTI plus ≥103 cfu/mL ≥1 organism from catheter specimen or midstream void <48h after catheter removal
Fever, rigors, AMS, malaise, or lethargy with NO other cause
Flank pain, CVA tenderness, acute hematuria, pelvic pain
IF NO SYMPTOMS IT IS CA-ASB!!!!
Smelly or cloudy urine is NOT a symptom!
Massive pyuria is NOT a symptom!
Do NOT screen for ASB prior to or immediately after catheter placement

15. Culturing catheterized patients
Catheters rapidly become colonized at a rate of 3 – 8% each day14
Can’t get CA-UTI without a catheter! When in doubt get it out!!!
If catheter in place 2 weeks or more, replace and send culture from NEW catheter before starting antibiotics
We replace prior to cultures if >72h catheter duration
Do not treat yeast in the urine15
Only 3% treated in large cohort, no complications
29% had catheter changed

16. Preventing CA-UTI and CA-ASB
Minimize catheter use!
Create guideline for post-op removal
Nurse-driven protocol to remove when indication no longer met
Keep system closed
Minimize breaks, bag changes
Do not flush junk into bladder! Do not flush at all… if plugged up, replace
No dependent loops; use securing device
Good perineal care daily

17. CA-UTI treatment2 Tailor to culture results 7 days for prompt response
10-14 days for delayed response
5 days levofloxacin is an option that decreases duration6
3 days if cystitis, female <65, and catheter removed

18. ESBL E. coli and UTI 3% of isolates in Anchorage Limited drug options
Gentamicin 3mg/kg IV or IM q24h
Ertapenem 1g IV q24h
Nitrofurantoin 100mg po bid x5 days (if no allergy, susceptible, and preserved renal function)
Amoxicillin/clavulanate 500/125mg BID x5-7d16
Use ONLY for cystitis and ONLY if MIC ≤8
Cure rate 93% for MIC 8 or less, 54% for MIC 16 or higher
Possible role for amoxicillin/clavulanate PLUS oral 3rd generation cephalosporin but NOT YET DEFINED17

19. ESBL E. coli UTI and Fosfomycin
Broad coverage of GNR and gram positives
Long urinary excretion from single 3g PO dose
Highly active against ESBL E. coli (96%)18
Lower efficacy vs. Klebsiella ESBL (54%)
Poorer microbiologic cure but similar clinical efficacy of ~90%3,19
For cystitis in patients with highly resistant E. coli or with allergies precluding other agents, fosfomycin 3g PO x1 is a feasible option19 that we use in Anchorage once or twice/month

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Clinical Infectious Diseases 2011;52(5):e103– e120
JAMA Jan 4;273(1):41-5.
JAMA 2000; 283:1583–90.
Urology 2008; 71:17–22.
Emerg Med J 2002; 19:19–22.
Obstet Gynecol 1990;76:28–32.
Can J Infect Dis Med Microbiol (6):
Lee et al. BMC Infectious Diseases (2015) 15:289
Interactive CardioVascular and Thoracic Surgery 0 (2016) 1–7
Clin Infect Dis 2014;59(1):41–7
J Korean Neurosurg Soc 47 : , 2010
N Engl J Med 1974; 291:215–219
American Journal of Infection Control 43 (2015) e19-e22
Arch Intern Med. 2008;168(17):
Antimicrob Agents Chemother 60:424 –430.
Antimicrob Agents Chemother 60:1134 –1136.
Antimicrob Agents Chemother 59:7355–7361