1. Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship

2. Objectives Distinguish between asymptomatic bacteriuria (ASB) and different types of active UTIs (complicated vs. uncomplicated) Describe in which patients ASB should be treated Learn how to diagnose a catheter-associated UTIs (CAUTIs) Describe how to determine empiric treatment and how long uncomplicated UTIs should be treated Know how to access and use various antibiograms and other resources

3. What’s the Burden of UTIs? 50% of women will have a UTI in their lifetime – Up to 25% may have a second UTI within 6 months Visits related to UTI – 3 million ED visits in 2010 – Most common primary diagnosis for U.S. women visiting EDs – 100,000 hospitalizations in U.S. – 0.9% of all ambulatory visits Half of all UTIs were among patients age 18 to 44 years Pts visiting the ED have higher acuity than those pts presenting to primary care – 400,000 (13%) were for pyelo (13 visits/10,000 people) – In general population: 1 case/28 cases of cystitis

4. Who is Most Affected by UTIs? Annual Incidence of UTIs – Young, sexually active women: 2 – 4% – Women > 70 yrs: 5 – 10% – Women > 80 yrs: 50% – Institutionalized Women: 40% – Adult men (childhood through middle age): < 1% – Men > 65 yrs: 1 – 3% – Men > 80 yrs: 10% – Institutionalized Men: 25% CAUTIs: ~1 million/year

5. What Are Take Home Points? Assemble the whole clinical picture (i.e., limiting reflexive Rx of positive Urine Cx) Determine the syndrome Distinguish between complicated vs. uncomplicated UTIs Choose appropriate empiric antibiotics based on likely bacterial etiologies and their resistance Adjust antibiotics based on culture results Decide about length of therapy

6. Questions (1 st Set) How do you define asymptomatic bacteriuria ASB? How do you differentiate between asymptomatic bacteriuria and UTI? Which groups need to be treated for ASB? What criteria do you use to define uncomplicated vs. complicated UTIs? Why does distinguishing uncomplicated vs. complicated help? What kinds of questions would you ask to distinguish between uncomplicated and complicated?

7. Asymptomatic Bacteriuria Asx women: 2 consecutive voided urine specimens with isolation of same bacterial strain in quantitative counts ≥ 10 5 cfu/mL Men: single, clean-catch voided specimen with 1 bacterial species isolated in quantitative counts ≥ 10 5 cfu/mL Women or men: single catheterized specimen with 1 bacterial species isolated in quantitative count ≥ 10 2 cfu/mL Infectious Diseases Society of America (IDSA), ASB guidelines 2005

9. ASB Evidence that screening and treatment does not lead to improved clinical outcomes More likely, unnecessary antibiotics may cause harm – Adverse effects – C difficile infection – Antibiotic resistance – Wasted expense

10. UTI Signs/Sx

11. Clinical Presentation – Distinguishing ASB vx. UTI Lower tract signs – Dysuria – Frequent urination – Urgent urination DDX: – STIs – Vaginitis – Exposure to chemical or allergic irritants

12. Clinical Presentation – Distinguishing ASB vx. UTI Upper tract: – Fevers, chills – Nausea – Flank pain – Often also with dysuria/frequency/urgency

13. Which Groups Require Rx for ASB? Definitive: – Pregnant Women – Anyone undergoing TURP or Urologic procedures during which mucosal bleeding is anticipated Maybe: – Renal transplant patients – Neutropenic patients Infectious Diseases Society of America (IDSA), ASB guidelines 2005

14. Uncomplicated vs. Complicated Uncomplicated – premenopausal women – No structural or functional abnormalities in urinary tract – Not pregnant Complicated – – Structural abnormalities (e.g., nephrolithiasis) – Functional abnormalities (e.g., ureteral reflux) – Compromised hosts (e.g., pregnant, diabetic) – UTIs in boys/men: until structural/functional ruled out IDSA, Uncomplicated UTI Guidelines 2011 Dielubanza EJ. ID Clin N Am 2014.

15. Why Distinguish Between Uncomplicated vs. Complicated? Guidelines for uncomplicated but none for complicated UTIs More important than upper tract/lower tract Complicated – May need further evaluation (diagnostics, urology consult) – Increased morbidity and mortality – May encounter more drug resistance (IV ABX) – Duration of therapy will likely be longer Assess conversion from uncomplicated to complicated (may indicated underlying issues)

16. Questions to Distinguish Uncomplicated from Complicated Pregnancy status History of kidney stones Structural/functional GU abnormalities Pelvic surgery DM Neurologic disorders Recent ABX use Recent hospitalization Recent GU instrumentation

17. Questions (2 nd Set) What’s the best way to obtain a urine sample for diagnosing a UTI? What are indications for having a Foley catheter? What tests do you review on a urinalysis to make you consider a UTI? ASB? How do you diagnose a CAUTI?

18. Key Issue – Urine Sample Collection Clean-catch, mid-stream = best In/Out catheterization DO NOT insert Foley catheters for sake of urine collection (unless otherwise indicated)

19. Indications for Foley Catheters Patients with hemodynamic instability (e.g., on pressors) who require urine output monitoring Urinary obstruction/retention Sacral or perineal wounds in patients with incontinence Genitourinary surgery/Placed by a Urologist Requires prolonged immobilization (unstable spine) End of life care CDC (HICPAC) CAUTI Prevention Guidelines, 2009 http://www.cdc.gov/HAI/ca_uti/uti.html

20. Review of UA for Evidence of Infection Check squamous cells first… if > 20, likely a contaminated sample Nitrites – Produced by many Gram-negatives – Requires hours for conversion of nitrate  nitrite – Not by Gram-positives, candida species WBCs – > 10 per high powered field Leukocyte esterase – Enzyme found in neutrophils – If present, indicates neutrophil activity

21. Caveats Pyuria in ASB does not need to be treated Urine samples that sit will have alterations in UA results – Samples analyzed within 2 hours or refrigerated to limit false positive and false negative results

25. Questions (3 rd Set) How do you select an antibiotic for empiric treatment treatment? When do you change from empiric to directed antibiotic therapy? How long do you treat uncomplicated cystitis? Uncomplicated pyelonephritis? How do you treat CAUTIs? For how long? Do you test urine for cure? Why?

26. Treatment of UTIs – What Bugs? Enteric flora colonizing perineum and urethra E. coli – 80% of first infection in women, men, children – 50% of nosocomial UTIs – Most common for acute uncomplicated cystitis – Many episodes of complicated UTIs and pyelo Staphylococcus saprophyticus – 11% of UTIs (sexually active, younger women) Remaining – GNRs (Klebiella, Proteus mirabilis)  increasingly MDROs – Gram-positive cocci (entercoccus and GBS)

27. What’s First Line Therapy (Empiric Treatment)? – Uncomplicated Only! Antimicrobial Stewardship Clinical Pathway (with a focus on inpatients)

28. Change from Empiric to Directed? When you have culture results Look at susceptibility interpretations Determine what has good urine/kidney penetration Lowest MIC ≠ Best ABX selection Questions? Call Antimicrobial Stewardship! (on amion.com)

29. How Long to Treat? It depends! Uncomplicated UTIs – Cystitis  Nitrofurantoin or Bactrim  3 days 20% resistance in isolates is an indication not to use this for empiric coverage Note: nitrofurantoin should not be used in patients with Creatinine clearance < 50 (does not reach bladder) – Pyelonephritis  FQ  5 – 7 days Beta-lactams  10 – 14 days Bactrim  14 days

30. How Long to Treat CAUTIs? 7 days of treatment for patients with CAUTI who have prompt resolution of symptoms 10 – 14 days in patients with delayed response to treatment 3 day regimen may be considered for women ≤ 65 yrs who develop CAUTI without upper tract sx after a catheter has been removed

31. Test of Cure? Nope (please don’t)

32. Other Notes Complicated including CAUTIs – Polymicrobial for longer-term (>30d) indwelling catheters – More drug resistant (ESBLs, P. aeruginosa, or enterococcus faecium) S. aureus – what to do?

33. Treatment of CAUTIs Algorithm to be developed

34. Greatest Overuse of Antibiotics It’s ASB patient’s positive urine cx

35. Unintended Consequences of ABX Drug reactions C difficile infections Selection for drug resistance Stay tuned… impact to the microbiome

36. Resources https://hospitals.health.unm.edu/intranet/Ind ex.cfm https://hospitals.health.unm.edu/intranet/Ind ex.cfm https://hospitals.health.unm.edu/intranet/ant imicrobial/pathways.shtml https://hospitals.health.unm.edu/intranet/ant imicrobial/pathways.shtml http://www.tricore.org/Healthcare- Professionals/Test-Information/Antibiograms http://www.tricore.org/Healthcare- Professionals/Test-Information/Antibiograms ASP – Inpt Antibiograms and Clinical Pathways Tricore – Outpatient Antibiograms