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Best Practices in the Diagnosis and Treatment of Asymptomatic Bacteriuria and Urinary Tract Infections PowerPoint Presentation

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Best Practices in the Diagnosis and Treatment of Asymptomatic Bacteriuria and Urinary Tract Infections Acute Care AHRQ Safety Program for Improving Antibiotic Use AHRQ Pub. No. 17(20)-0028-EF November 2019
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Objectives Explain how to distinguish asymptomatic bacteriuria from a urinary tract infection (UTI). Discuss the patient populations who should and should not be tested and treated for asymptomatic bacteriuria (ASB). Recommend empiric treatments for UTIs. Discuss opportunities for de-escalation of antibiotic therapy for UTIs after additional clinical data are available. Discuss reasonable durations of antibiotic therapy for UTIs. 2
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Treatment of ASB Is Not Beneficial Randomized, controlled trials have demonstrated a LACK of benefit of antibiotic treatment of ASB in the following populations:6-13 Healthy, nonpregnant women aged 18–40 years Diabetic women Patients with long-term indwelling catheters Older women in the community Elderly nursing home residents Renal transplant patients Patients undergoing orthopedic surgery 8
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Mental Status Changes, ASB, and UTI15-17 Bacteriuria and delirium are both independently common in the elderly. Although patients with a symptomatic UTI may present with delirium, no evidence suggests that delirium, falls, or confusion are symptoms of a UTI in the absence of urinary symptoms. Asymptomatic bacteriuria is not associated with a decreased feeling of well-being. 72 elderly residents without traditional UTI symptoms with and without ASB detected in their urine specimens over a 1-year period No differences in insomnia, malaise, fatigue, weakness, or anorexia in the presence or absence of ASB If a patient has signs of systemic infection and delirium, empiric antibiotic therapy may be warranted. 10
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Can I Follow the Same Rules for Candiduria? ~10% of urine cultures in hospitalized patients grow Candida species. Multicenter placebo-controlled trial of fluconazole in patients with Candida in two consecutive urine cultures who were asymptomatic (95%) or minimally symptomatic (5%).18 Fluconazole eradicated candiduria in 2/3. 1/3 had eradication with no therapy. Two weeks after completion of fluconazole, Candida grew in 2/3 of urine cultures in both the fluconazole and placebo groups. 56% of patients had catheters—urine cultures had to grow Candida after the catheter had been removed. No patients developed pyelonephritis or candidemia. 12
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Uncomplicated Cystitis Moment 2: Empiric therapy21 Oral therapy is preferred Avoid giving ceftriaxone or other IV options just because the patient is hospitalized Avoid fluoroquinolones No longer first-line therapy in guidelines due to resistance and side effects Options to consider First-line recommendations Nitrofurantoin Trimethoprim/sulfamethoxazole (TMP/SMX) (check local resistance data) Second-line options Oral cephalosporins For any UTI, look at prior urine culture information to guide empiric therapy. 16
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UTI in Males UTIs in the absence of a urinary catheter in men are considered complicated because they are usually associated with obstructive pathology such as— Renal stones Strictures Enlarged prostate In the absence of these risk factors, UTI is a rare diagnosis in males. Other causes of urinary symptoms in males: prostatitis, epididymitis, sexually transmitted infections. 22
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Other Complicated UTIs Includes UTIs occurring in the presence of urologic abnormalities such as those described on the previous slide and UTIs in pregnancy. Management of the underlying associated process must also occur whenever possible (e.g., relief of obstruction via nephrostomy tubes, stents, transuretheral resection of the prostate). As with CAUTI, antibiotic selection depends on the extent of infection and the severity of illness of the patient. Duration of therapy is based on the clinical response of the patient and the timing of relief of the inciting process. Prompt resolution of symptoms and resolution of the underlying abnormality: 7 days of therapy Delayed response or persistent obstruction: a longer course (e.g., 10–14 days) 23
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Disclaimer The findings and recommendations in this presentation are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this presentation should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. Any practice described in this presentation must be applied by health care practitioners in accordance with professional judgment and standards of care in regard to the unique circumstances that may apply in each situation they encounter. These practices are offered as helpful options for consideration by health care practitioners, not as guidelines.
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References Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 Mar 21. [Epub ahead of print]. PMID: 30895288. Taweel I, Beatty N, Duarte A, et al. Significance of bacteriuria in patients with end-stage renal disease on hemodialysis. Avicenna J Med. 2018 Apr-Jun;8(2):51-4. PMID: 29682478. Warren JW, Tenney JH, Hoopes JM, et al. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J Infect Dis. 1982 Dec;146(6):719-23. PMID: 6815281. Zhanel GG, Harding GK, Nicolle LE. Asymptomatic bacteriuria in patients with diabetes mellitus. Rev Infect Dis. 1991 Jan-Feb;13(1):150-4. PMID: 2017615. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54. PMID: 15714408. Cai T, Mazzoli S, Mondaini N, et al. The role of asymptomatic bacteriuria in young women with recurrent urinary tract infections: to treat or not to treat? Clin Infect Dis. 2012 Sep;55(6):771-7. PMID: 22677710. 29
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References Harding GK, Zhanel GG, Nicolle LE, et al. Antimicrobial treatment in diabetic women with asymptomatic bacteriuria. N Engl J Med. 2002 Nov 14;347(20):1576-83. PMID: 12432044. Warren JW, Anthony WC, Hoopes JM, et al. Cephalexin for susceptible bacteriuria in afebrile, long-term catheterized patients. JAMA. 1982 Jul 23;248(4):454-8. PMID: 7045440. Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med. 1987 Jul;83(1):27-33. PMID: 3300325. Boscia JA, Kobasa WD, Knight RA, et al. Therapy vs no therapy for bacteriuria in elderly ambulatory nonhospitalized women. JAMA. 1987 Feb 27;257(8):1067-71. PMID: 3806896. Nicolle LE, Bjornson J, Harding GK, et al. Bacteriuria in elderly institutionalized men. N Engl J Med. 1983 Dec 8;309(23):1420-5. PMID: 6633618. Origüen J, López-Medrano F, Fernández-Ruiz M, et al. Should asymptomatic bacteriuria be systematically treated in kidney transplant recipients? Results from a randomized controlled trial. Am J Transplant. 2016 Oct;16(10):2943-53. PMID: 27088545.
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References Cordero-Ampuero J, González-Fernández E, Martínez-Vélez D, et al. Are antibiotics necessary in hip arthroplasty with asymptomatic bacteriuria? Seeding risk with/without treatment. Clin Orthop Relat Res. 2013 Dec;471(12):3822-9. PMID: 23430723. Cai T, Nesi G, Mazzoli S, et al. Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections. Clin Infect Dis. 2015 Dec 1;61(11):1655-61. PMID: 26270684. McKenzie R, Stewart MT, Bellantoni MF, et al. Bacteriuria in individuals who become delirious. Am J Med. 2014 Apr;127(4):255-7. PMID: 24439075. Boscia JA, Kobasa WD, Abrutyn E, et al. Lack of association between bacteriuria and symptoms in the elderly. Am J Med. 1986 Dec;81(6):979-82. PMID: 3799658. Nicolle LE, Bentley DW, Garibaldi R, et al. Antimicrobial use in long-term-care facilities. SHEA Long-Term-Care Committee. Infect Control Hosp Epidemiol. 2000 Aug;21(8):537-45. PMID: 10968724. 31
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References Sobel JD, Kauffman CA, McKinsey D, et al. Candiduria: a randomized, double-blind study of treatment with fluconazole and placebo. The National Institute of Allergy and Infectious Diseases (NIAID) Mycoses Study Group. Clin Infect Dis. 2000 Jan;30(1):19-24. PMID: 10619727. Johnson JR, Russo TA. Acute pyelonephritis in adults. N Engl J Med. 2018 Jan;378:48-59. PMID: 29298155. Hooton T, Bradley SF, Cardenas, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infectious Dis. 2010 Mar;50(5):625–63. PMID: 20175247. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20. PMID: 21292654. Talan DA, Stamm WE, Hooton TM, et al. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis in women: a randomized trial. JAMA. 2000 Mar 22-29;283(12):1583-90. PMID: 10735395. 32
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References Sandberg T, Skoog G, Hermansson AB, et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012 Aug 4;380(9840):484-90. PMID: 22726802. Talan DA, Klimberg IW, Nicolle LE, et al. Once daily, extended release ciprofloxacin for complicated urinary tract infections and acute uncomplicated pyelonephritis. J Urol. 2004 Feb;171(2 Pt 1):734-9. PMID: 14713799. Peterson J, Kaul S, Khashab M, et al. A double-blind, randomized comparison of levofloxacin 750 mg once-daily for five days with ciprofloxacin 400/500 mg twice-daily for 10 days for the treatment of complicated urinary tract infections and acute pyelonephritis. Urology. 2008 Jan;71(1):17-22. PMID: 18242357. Harding GK, Nicolle LE, Ronald AR, et al. How long should catheter-acquired urinary tract infection in women be treated? A randomized controlled study. Ann Intern Med. 1991 May 1;114(9):713-9. PMID: 2012351. 33