- - Summaries: Trial SSTI Related toxicity rare - Evidence/Safety, Q&As/Extras: Nitrofurantion documents/GeriRxFiles-UTI.pdf http://www.rxfiles.ca/rxfiles/uploads/ Adults: UTIinOlder Geri-RxFiles RxFILES EXTRAS FROM lookup/59/2/e10 https://academic.oup.com/cid/article- Infections Tissue Skin &Soft IDSA2014: U.S. TISSUEINFECTIONS SKIN &SOFT assets/files/guidelines/en/1121.pdf https://www.cua.org/themes/web/ UTI Recurrent 2011: CUA 2163(16)34717-X/pdf http://www.jogc.com/article/S1701- UTI Recurrent SOGC 2010: 19April2013.pdf photos/custom/UTI%20Guidelines%20 https://saskpic.ipac-canada.org/ Settings Care UTI inContinuing 2013: SK MOH lookup/52/5/e103 https://academic.oup.com/cid/article- (UTI) Pylonephritis Cystitisand Acute Uncomplicated IDSA2010: U.S. CYSTITIS / UTI http://www.mumshealth.com MUMS Guidelines: http://www.bugsanddrugs.ca/ &Drugs: Bugs CANADIAN LINKS ABX-2 RELATED Skin Abscess: I&D +/- ABX I&D +/-ABX Skin Abscess: Clindamycin vs TMP/SMX vsTMP/SMX Clindamycin GUIDELINES/REFERENCES GUIDELINES/REFERENCES - Antibiotics & Common Infections &CommonInfections Antibiotics Stewardship, Effectiveness, Safety & Clinical Pearls-April2017 & Stewardship, Effectiveness,Safety ( Susceptibility of of Susceptibility 1) CYSTISIS UNCOMPLICATED CAUGHTOUREYE... 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(e.g. allergy mediated atrueIgE will have ___ only “allergy”, penicillin 7) ALLERGY LACTAM BETA cellulitis. of treatment successful inthe essential -often 5) verywell. abscesses penetrate justdon’t ABX thetime. >80%of incure results I&D alone 4) TISSUEINFECTIONS SOFT SKIN and patient basedon Rxissuitable antibiotic Empiric cystitis. uncomplicated acute symptomatic 3) C MACROBID I P Staying Power: > 60 years & still 96% or better! >60years & still96%or Power: Staying Elevation of the affected limb, e.g. above level of the heart the of level above limb,e.g. affected the of Elevation Incision and Drainage (I&D) - key to successful treatment of skin abscess. skinabscess. of treatment tosuccessful -key (I&D) Drainage and Incision Urine cultures are not required - for most most -for required not are cultures Urine R O If you test 1000 patients with you test1000patients If F L L O X symptoms (e.g. dysuria, frequency) & history. &history. frequency) dysuria, (e.g. symptoms A C “I used to be to used “I so strong...” strong...” so &Skin ABX-2: UncomplicatedCystitis I once N ) remains at 96% or better in Saskatchewan (per recent antibiograms). antibiograms). recent (per 96%orbetterinSaskatchewan at ) remains stewardship wereally when for toPreserve” messagingsuggests“Reserve In care, long-term settings,like someinstitutional ciprofloxacin canbeashigh~60%. antimicrobial wonder No need it! ABX-1 E. coli 2) , the most common urinary pathogen, to nitrofurantoin tonitrofurantoin urinarypathogen, , themostcommon were very well received and we know many of you made use of the useof youmade of andweknow many verywellreceived were 60% - Are you kidding?! youkidding?! 60% -Are Line Line 3 3 rd and and For most SSTI, resistance to clindamycin, and safety are are andsafety toclindamycin, mostSSTI,resistance For - Page 2-3 -Page major concerns. betteroptions. usually are There 6) ANTIBIOTIC HARMS ANTIBIOTIC My name is clindamycin - I usually play 3 play -Iusually isclindamycin name My What are thechances? o ? 4-8 -Page Penicillin Allergy Penicillin Allergy www.RxFiles.ca/abx Skip the Urine Req. - Page 9-10 - Page empirically empirically Treat E. coli . resistance to resistance S T > A Y 6 rd I 0 N line. G G Y ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? P E O A W R E S S ? ? ? ? ? ? ? ? R ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? UNCOMPLICATED CYSTITIS IN WOMEN – MANAGEMENT CONSIDERATIONS1-3 www.RxFiles.ca © Apr 2017 PEARLS for the MANAGEMENT of UNCOMPLICATED Cystitis in Women: Treatment Approach For Acute, UNCOMPLICATED Cystitis in Women Nitrofurantoin is a good empiric first choice as it has retained excellent susceptibility Urine culture is not required for most acute, uncomplicated cystitis and (96% ) to Escherichia coli despite ~65 years of use {see Table 2}. asymptomatic bacteriuria (“Symptom-Free Pee, Let It Be”) {see also Geri-RxFiles}. Outpatient Regina, Saskatoon In SK, TMP/SMX is a suitable alternative in those with uncomplicated, 1st episode Consider nitrofurantoin as empiric drug of choice except if CrCl <30 mL/min. cystitis and without UTI or antibiotic use in the past 3-6 months {see Table 3}. Consider TMP/SMX as a suitable alternative to nitrofurantoin in those with low risk A of resistant bacteria (e.g. no history of UTI or antibiotic use in the past 3-6 months). Table 2: Empiric Drug Regimen(s) of Choice {see also RxFiles Antibiotic Comparison-Expanded chart } - avoid if CrCl <30mL/min11 If bacteria is resistant to nitrofurantoin and TMP/SMX, consider fosfomycin. MACROBID 100mg po BID x5 d $19 $20-29 - short-term treatment well tolerated “Test of cure” is not recommended following treatment if patient asymptomatic. MACRODANTIN, g 50-100mg po QID x5 d (esp macro formulations) and SAEs are $14-16 Prior to initiating prophylactic antibiotics in recurrent cystitis, encourage sexually Nitrofurantoin, g 50-100mg po QID x5 d rare (caution/discontinue if symptoms) active women to avoid spermicide & consider an alternative form of contraception. Table 3: Alternative Regimens BACTRIM, $11 Pre Treatment Consideration TMP/SMX * 1 DS tab po BID x3 d - option depending on local resistance SEPTRA, Cotrimoxazole {1DS tab=160/800mg} & if recent history of UTI/antibiotics Urine culture is rarely required in women if uncomplicated & only local symptoms! , g - 1 SS tab BID if CrCl 15-30mL/min 4 $ 12 Symptoms (e.g. dysuria & frequency) associated with high probability of cystitis. Trimethoprim, g * 200mg po daily x3 d - monotherapy option if sulfa allergy Urine culture is typically required in the following patients: - alternate dosing: 100mg po BID CephalexinKEFLEX , g 250mg po QID x7 d $17 - only if susceptible on C&S results Recent (e.g. <3-6 month) hospitalization or travel outside Canada/USA - requires QID; may be less effective MONUROL $38 Early recurrence of cystitis (i.e. less than ~ 1 month) Fosfomycin 3g po given x1 dose - reserve for allergy, resistance, or CI to Previous non-Escherichia coli gram negative organism or previous ESBL cystitis MACROBID & TMP/SMX; po option Suspension (powder sachet; dissolve in ½ cup water); single dose for urinary ESBLs & Pseudomonas Complicated UTI {see Table 1}, pyelonephritis suspected, or pregnancy $19 Amoxicillin/ , g 875/125mg po BID - reserve for more severe infections 5,6 CLAVULIN x7 d Table 1: Factors that Would Classify a UTI as “Complicated”* clavulanate (e.g. pyelonephritis) or when other CIPRO $ 1 5 options lacking (e.g., allergy, high Anatomic abnormality Cystocele, diverticulum, fistula Ciprofloxacin , g 250mg po BID ** x3 d probability/documented resistance) $14 Iatrogenic Indwelling catheter (catheter removal often curative!) Norfloxacin, g 400mg po BID x 3 d is a suitable - extensive fluoroquinolone use Voiding dysfunction Vesicoureteric reflux, neurologic disease alternative to ciprofloxacin. associated with Gm –ve resistance Urinary tract Bladder outlet obstruction, ureteral stricture, ureteropelvic * Caution: potential K +drug interactions **Higher doses of ciprofloxacin used if pyelonephritis (i.e., 500 mg po BID) obstruction junction obstruction, urolithiasis {Note: fosfomycin, nitrofurantoin, norfloxacin & moxifloxacin – should not be used if pyelonephritis is suspected!} 12 Choosing Wisely * may sometimes be considered as complicated: surgery, incontinence, pregnancy, diabetes (especially if long- No role for follow-up culture (“test of cure”) if patient asymptomatic. term complications i.e. neuropathy), male, immunosuppression. Urine culture is NOT indicated in most asymptomatic patients, as there is no benefit Treatment Evidence Summary and potential harm (e.g. resistant bacteria) with antibiotic treatment. Antibiotics are recommended for symptomatic cystitis. In 2 RCTS (n=884, n=78), (Exceptions: pregnancy or those awaiting urinary surgery/manipulation). 7,8 placebo was associated with prolonged symptoms & a small risk of progression to Most Common Pathogen & Susceptibility Concerns (Outpatient/Community)9-10 pyelonephritis (0.4-2.6%, NS vs antibiotic), but also resulted in clinical cure 25-42% of the time. 13,14 With antibiotics, symptom relief may be expected within 36-48 hours. Escherichia coli non-ESBL is the most common pathogen (75-95% of cystitis cases). o Susceptibility to nitrofurantoin in SK: 96% Regina2016, 96% Saskatoon2015 Nitrofurantoin x5-7 days has similar effectiveness to alternative regimens. In RCTs, Susceptibility to TMP/SMX in SK: 76% Regina2016, 77% Saskatoon2015 there was no difference in clinical cure rates vs TMP/SMX x3-7 days, ciprofloxacin o 15-17 Susceptibility to ciprofloxacin in SK: 83% Regina2016, 85% Saskatoon2015 x3 days, & fosfomycin x1 dose. Nitrofurantoin x3 days is not recommended as o 18 this regimen resulted in less clinical/bacterial cure than TMP/SMX x3 days