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Home , Pyelonephritis

CHI Franciscan Health UTI & Summary

UTI/pyelonephritis is one of the most common infectious processes but is also often over-treated. Inappropriate treatment rates vary between 17-26%1,2 and up to 52% in patients with indwelling urinary catheters3. Overtreatment can result in unnecessary side effects, the development of Clostridium difficile resistance4, colonization with drug-resistant organisms, and undue costs to the health system. Pharmacists can play and important role in optimizing drug therapy to include the recommendation to stop inappropriate when their use is not indicated.

 Asymptomatic (ASB): the presence of bacteria in the urine without signs/symptoms of infection5 o McGeer Criteria often used to define infection, particularly in the long-term care setting6 Clinical (at least one of the following) Lab (at least one of the following)

□ Acute □ Voided specimen: positive urine culture □ Acute pain, swelling, or tenderness of testes, (> 105 CFU/mL), no more than 2 epididymis, or organisms □ or with one of the following: □ Straight cath specimen: positive urine ○ Acute CVA pain or tenderness culture (> 105 CFU/mL), any number of ○ Suprapubic pain organisms ○ Gross ○ New or marked increase in incontinence ○ New or marked increase in urgency ○ New or marked increase in frequency □ Two of the preceding symptoms in the absence of fever or leukocytosis o ASB should only be treated in pregnant women and patients undergoing invasive urologic procedures5 o People with ASB also often have WBC in the urine () but, in the absence of symptoms, this is not indicative of infection o Caused by: colonization of the bladder or contamination of the sample . Up to 50% of long-term care residents and up to 19% of the general population are colonized7 . Patients with indwelling catheters will almost universally exhibit bacteriuria by the 4th day as a result of development8 o Due to the risks of unnecessary treatment, routine urinalysis is not recommended unless there are clear signs/symptoms of infection o Change in mental status alone is not enough to diagnose UTI in patients with bacteriuria . Even in febrile institutionalized patients with AMS, bacteriuria has low PPV 8- 11% for UTI9,10 o Patients with chronic catheters are difficult to assess because they may not exhibit classic symptoms such as dysuria or urinary frequency . If catheter has been in place for > 2 weeks, it should be discontinued and replaced prior to obtaining a urine specimen11

Approved by ASP Committee Last Updated March 2014 . Revised McGeer Criteria is often used to define infection in this population6 Clinical (at least one of the following without Lab (must be met) alternate explanation)

□ Fever □ Positive urine culture (>105 CFU/mL), □ Rigors any number of organisms taken off □ New onset hypotension newly placed catheter □ Acute change in mental status OR acute functional decline AND leukocytosis □ New onset CVA pain or tenderness □ New onset suprapubic pain □ Acute pain, swelling, or tenderness of the testes, epididymis, or prostate □ Purulent drainage from around the catheter

 Complicated UTI/pyelonephritis is a urinary tract or infection associated with an underlying condition that increases the risk of failing therapy12 o , , >7 days of symptoms before treatment, hospital acquired infection, renal failure, urinary tract obstruction, indwelling cath, stent, tube, immunosuppression, renal transplantation, functional or anatomic abnormality of urinary tract, neutropenia, HIV, enlarged prostate, renal calculi, neurogenic bladder o Empiric treatment . Patients admitted to the hospital for UTI/pyelo should generally be treated with IV abx until the patient improves clinically (i.e. symptoms resolving), which is best left to the discretion of the provider

Empiric Drug Selection <2 MDRO Risk Factors* Ceftriaxone 1-2 grams IV daily ($1.26) or Cefazolin 1-2 grams IV q8hrs ($1.71) (both agents preferred over due to greater levofloxacin resistance to E. coli, Proteus, and Serratia at FHS) OR Levofloxacin 250-750mg IV daily ($5.21)

> 2 MDRO Risk Factors* Cefepime 1-2 gram IV q12hrs ($13.72) OR Meropenem 500mg q6hrs extended infusion ($19.16)(reserve for H/O MDRO infection or suspected acinetobacter) *Add vanco for suspected MRSA or enterococcus (~$20 per day) *multi-drug resistant organism (MDRO) risk factors: Hospitalized for > 2 days in past 90 days, resident of SNF or extended care facility, received HD in past 30 days, chemotherapy in past 30 days, home wound care, exposure to family member with MDR pathogen, antibiotics in past 180 days, immunosuppression/neutropenia, h/o MDRO, recurrent UTI

Approved by ASP Committee Last Updated March 2014 Streamlining to Pathogen-Specific Antibiotics  Empiric antibiotics should be streamlined to narrowest possible therapy ASAP after cultures have sensitivities available. Many cultures are sensitive to levofloxacin and/or , but can often be streamlined to a narrower spectrum (e.g. cefazolin or cephalexin). o C.difficile rates are MUCH higher for broad spectrum antibiotics. Always use the narrowest spectrum agent possible. High risk Medium risk Low risk Clindamycin β-lactam/β-lactam inhibitors Metronidazole 3rd generation Vancomycin Fluoroquinolones Sulfonamides Tetracyclines  *** Although tetracyclines show up on some panels for urine cultures, doxycycline is not typically a good choice to treat UTIs. It does not concentrate well in the urine often making it subtherapeutic***  Most patients can be changed to oral therapy after 48-72 hours of IV antibiotics. This is pending the patient’s clinical response and disposition and should always be cleared through the provider (levofloxacin can be changed to PO per FHS protocol, but clinical response should still be considered). o PO antibiotics tend to have less risk and lower costs than IV, and the change to PO can sometimes expedite the patient’s discharge

The table below may help you decide between antibiotics when you have several choices

Antibiotic Cost per day Comments

Cephelaxin (Keflex®) $0.16 Little to no risk of C. difficile 500 mg PO every 12 hr Cefazolin (Ancef®, Kefzol®) $1.71 Little to no risk of C. difficile 1-2 gram IV every 8 hours Nitrofurantoin (Macrobid®) $1.40 Ineffective in patients with CrCl < 60 ml/min 100 mg PO every 12 hr with increased risk of peripheral neuropathy Trimethoprim/sulfamethoxazole $0.27 Dose adjustment with CrCl < 30 ml/min, (Septra®, Bactrim DS®) moderate C. difficile risk 160 mg / 800mg PO every 12 hr (Cipro®) PO = $0.28 Fluoroquinolones have a high risk for inducing C. 250 mg PO every 12 hr IV 200 mg = $2.52 difficile infection Ceftriaxone (Rocephin®) $1.26 Third generation cephalosporins have a high risk 1-2 gram IV daily for inducing C. difficile infection Levofloxacin (Levaquin®) PO 250 mg = $0.19 Fluoroquinolones have a high risk for inducing C. 250 mg PO daily IV 250 mg = $2.73 difficile infection

Cefepime 1-2 gram IV q12hrs $13.72 Only if coverage required. High C. difficile risk. Meropenem (Merrem®) $19.16 Only for documented or h/o ESBL producing 500 mg IV q6h organisms. High risk for C. difficile

Approved by ASP Committee Last Updated March 2014 Recommended Durations5,11,12

Bacteriuria ± pyuria in the Pregnant 3-7 days with periodic screening for absence of symptoms recurrent bacteriuria Prior to invasive urologic procedure Through completion of procedure and removal of urinary catheter Any other patient population (including nonpregnant Not indicated women, patients with Diabetes Mellitus, patients with spinal cord injury, catheterized patients, elderly patients, institutionalized patients) Uncomplicated Young and otherwise healthy 3-5 days Pregnant 7 days Post-menopausal 5-7 days Women with Diabetes Mellitus 7-10 days For failure of short course antibiotics, culture and re-treat 14 days Complicated Rapid improvement 7 days (catheter, obstruction, reflux, azotemia, s/p Delayed response 10-21 days transplant, male sex) Pyelonephritis 14 days Pyelonephritis after antibiotic failure Up to 6 weeks

References

1. Hecker MT, et al. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med. 2003;163:972-978. 2. Gandhi T, et al. Importance of to antibiotic use among hospitalized patients. Infect Control Hosp Epidemiol. 2009;30:193-195. 3. Dalen DM, Zvonar RK, Jessamine PG. An evaluation of the management of asymptomatic catheter-associated bacteriuria and candiduria at The Ottawa Hospital. Can J Infect Dis Med Microbiol. 2005;16:166-170. 4. Stevens V, et al. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis. 2011;53:42-48. 5. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40:643-654. 6. Stone ND, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965-977. 7. Nicolle L. Asymptomatic bacteriuria in the elderly. Infect Dis Clin N Am. 1997;11:647-662. 8. Beveridge LA, et al. Optimal management of urinary tract infections in older people. Clin Interv Aging. 2011;6:173-180.Orr P, et al. Febrile urinary tract infection in the institutionalized elderly. Am J Med. 1996;100:71-77. 9. Warren J, et al. Fever, bacteremia, and death as complications of bacteriuria in women with long-term urethral catheters. J Infect Dis. 1987;155:1151-1158. 10. Hooton TM, Bradley SF, Cardenas DD etal. Diagnosis, Prevention and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases 2010;50:625- 663. 11. Gupta K, Hooton TM, Nuber 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 Disease. Clinical Infectious Diseases 201;52(5):e103-e120. 12. Up to Date accessed January, 2014FHS antimicrobial stewardship webpage antibiograms. Accessed January 20, 2014 from http://pharmacyservices/Antimicrobial_Stewardship/FHS%20Approved%20Resources/2012%20FHS%20Antibiogram.pdf 13. American Geriatrics Society. 2012 Beer’s List. 14. Gupta K, 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;52:e103. 15. Hooten TM, 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 Infect Dis. 2010;50:62.

Approved by ASP Committee Last Updated March 2014