4.09 - Urology Infections

UMMC UTI Management Pathway

Principles of UTI Management

  • Obtain a thorough history including sexual history.
  • Elderly patients may present with atypical symptoms such as confusion and hypothermia.
  • Do rectal and genital examination to exclude prostatitis, posterior urethritis, epididimytis in all men suspected of UTI.
  • Urine culture should only be sent if the patient has symptoms of UTI, screening in pregnancy and prior to certain urological procedures.
  • Culture should be interpreted in parallel with severity of signs and symptoms, as false negatives can occur.
  • Do not treat asymptomatic bacteriuria unless pregnant or undergoing a urological procedure/manipulation, as it does not reduce mortality or morbidity.
  • Unnecessary antibiotic use leads to complications such as Clostridium difficile infection, emergence of multidrug resistance and other adverse drug effects.






A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Peritoneal Dialysis Related Infection


PD-related Peritonitis

Intra-peritoneal Cefazolin
1 gm single dose then
250 mg q6H
+
Intra-peritoneal Ceftazidime 1 gm single dose then
250 mg q6H

 
Intra-peritoneal Cloxacillin
1 gm single dose then
250 mg q6H
+
Intra-peritoneal Ceftazidime 1 gm single dose then
250 mg q6H


Cefazolin is preferred over Cloxacillin for its longer drug stability after preparation.

International Society of Peritoneal Dialysis guideline recommends coverage for both gram positive and negative organisms.

Duration: 14 days.

Anti-fungal Prophylaxis for high risk PD patients
 
Fluconazole 200 mg PO q48H until the antibiotic therapy is completed
 
High risk patients will include those who are exposed to prolonged IP antibiotic usage.

ISPD recommends use of prophylactic antifungal drug to prevent deadly fungal peritonitis in high risk patients.

 
Surgical prophylaxis for Tenckhoff catheter insertion
 
Cefazolin 1 gm IV 30 minutes before the surgery
 
Vancomycin 1 gm IV 30 minutes before surgery if penicillin allergy

 
 
PD-related exit site infection

Co-amoxiclav 625 mg PO q12H

 
Cephalexin 500 mg PO q6H
 
Duration: 14 days.

Hemodialysis Catheter Related Infections

 
Exit site infection

 
Topical mupirocin ointment
   
Screen for Staphylococcus aureus nasal carrier and nasal carriage eradication if positive (intra-nasal mupirocin ointment q12H for 5 days).
 
Unresolved infection with topical treatment or accompanied purulent discharge

 
Cloxacillin 500 mg PO q6H
  
OR

Cloxacillin 1 gm IV q6H


 
Cefazolin 2 gm IV after each dialysis (3 times / week)

OR

1 gm IV q24H after dialysis on HD days

 
Tunnel infection
Localized infection


Cloxacillin 1 gm IV q6H

 
Cefazolin 2 gm IV after each dialysis (3 times / week)

OR

1 gm IV q24H after dialysis on HD days

 
Require removal of catheter within 24 hours.
 
Dialysis Catheter-Related Bloodstream Infection (CRBSI):
Non-severe illness community onset
 
Cefazolin 2 gm IV after each dialysis (3 times / week)
  
OR 1 gm IV q24H given after dialysis on HD day

±

Vancomycin 20 mg/kg (max 1.5 gm) STAT, followed by dosing according to TDM

 
Cloxacillin 1 gm IV q6H

±

Vancomycin 20 mg/kg (max 1.5 gm) STAT, followed by dosing according to TDM
 
Consider Vancomycin if catheter inserted > 3 days.

Dialysis Catheter-Related Bloodstream Infection (CRBSI):
Severely ill patients, with any of the following condition (s):
1. Critically ill
2. Severe sepsis
3. Neutropenia
 
Piperacillin / Tazobactam 2.25 gm IV q8H

±

Vancomycin 20 mg/kg (max 1.5 gm) STAT, followed by dosing according to TDM


 
Imipenem 500 mg IV q12H 

+

Vancomycin 20 mg/kg (max 1.5 gm) STAT, followed by dosing according to TDM

 
 
Suspected catheter-related candidemia
 
Fluconazole 200 mg IV q24H
 
Risk factors for catheter related candidemia:
1. Prolonged use of broad spectrum antibiotics
2. Colonization due to Candida species at multiple       sites

Kidney Transplantation


Prophylatic antibiotic post kidney transplantation

 
Cefuroxime 750 mg IV q8H
 
Cefazolin 1 gm IV q8H
 
Duration: 7 days

 
Pneumocystis jirovecii prophylaxis

Co-trimoxazole (480 mg) 1 tablet PO q24H

 
Nebulised pentamidine 300 mg can be used monthly if patient can’t tolerate Co-trimoxazole

 
Duration: 6 months

 
CMV prophylaxis

 
Ganciclovir 5 mg/kg/day IV once daily for 7 days/week

OR

6 mg/kg/dose once daily for 5 days/week

Dose adjusted according to kidney function

Valganciclovir 900 mg PO q24H 

The dose depends on the GFR:
>60 ml/min: 900 mg q24H
40 - 59 ml/min: 450 mg q24H
25 - 39 ml/min: 450 mg q48H
10 - 24 ml/min: 450 mg twice weekly

 
Duration: 100 days 
 
TB prophylaxis

 
Isoniazide 300 mg PO q24H + Pyridoxine 10 mg PO q24H

   
Duration: 6 months
 
Empirical treatment for neutropenic sepsis post-transplant

 
Piperacillin / Tazobactam
4.5 gm IV q6H
 
Imipenem 500 mg IV q6H
 

Urinary Tract Infections

 
Asymptomatic Bacteriuria

 
Do NOT require treatment unless:
1. Pregnant
2. Undergoing urological procedure


If treatment required,
Cefalexin 500 mg PO q6H for pregnancy for 5 days

OR

Co-amoxiclav 625 mg PO q8H for 5 days

 







If treatment required,
Co-trimoxazole (480mg) 2 tablets PO q12H for 3 days

 

 
 
Acute Cystitis
Uncomplicated

 
Cefalexin 500 mg PO q6H for pregnancy for 5 days

OR

Co-amoxiclav 625 mg PO q8H for 5 days

 
Co-trimoxazole (480mg) 2 tablets PO q12H for 3 days


 
Complicated

 
Co-amoxiclav 1.2 gm IV q8H

OR

Co-amoxiclav 625 mg PO q8H

 
Cefuroxime 750 - 1500 mg IV q8H

OR

Cefuroxime 500 mg PO q12H

OR

Cephalexin 500 mg PO q6H

 
Acute complicated Cystitis
Male
History of childhood UTI
Immunocompromised
Preadolescent / Postmenopausal
Pregnant
Underlying metabolic disorder (i.e. uncontrolled DM)
Urologic abnormality (i.e. stones, stents, indwelling catheter, neurogenic bladder, polycystic kidney disease) 
Symptoms > 7 days
Recent urinary tract manipulation

Duration: 7 - 14 days

 
Catheter Associated UTI

 
Piperacillin / Tazobactam
4.5 gm IV q6H

 
Cefepime 2 gm IV q8H
 
Duration: 7 days (if prompt resolution);
10 - 14 days (if slow response);
3 days (female less than 65 years old)

 
Pyelonephritis

Take urine culture and blood culture in hospitalized patients.

Considerations for Hospitalization in patients with acute pyelonephritis:
  1. Comorbid conditions (e.g., renal dysfunction, urologic disorders, diabetes mellitus, advanced liver or cardiac disease)
  2. Hemodynamic instability*
  3. Male sex
  4. Metabolic derangement (e.g., renal dysfunction, acidosis)
  5. Pregnancy
  6. Severe flank or abdominal pain
  7. Toxic appearance
  8. Unable to take liquids by mouth
  9. Very high fever (> 103°F [39.4°C])
*Physicians must be alert for the presence of severe sepsis and septic shock, which require urgent specialized management that is beyond the scope of this review.

Reference: Colgan R, Williams M, Johnson JR. Diagnosis and Treatment of Acute Pyelonephritis in Women. Am Fam Physician. 2011 Sep 1:84(5): 519-526.

 
Mild


Co-amoxiclav 625 mg PO q8H


Cephalexin 500 mg PO q6H


Duration: 10 - 14 days
  
Targeted therapy should be based on antimicrobial susceptibility results.

 
Severe

 
Piperacillin / Tazobactam 
4.5 gm IV q6H

OR

Cefepime 2 gm IV q8H

 
Meropenem 1 gm IV q8H
(If there is risk for MDRO or ESBL)
 
Consider US KUB
  • Total duration (IV and Oral): 10 - 14 days (not to exceed 21 days)


Prostatitis
< 35 years old / STD risk


 
Ceftriaxone 250 mg IM single dose
+
Azithromycin 2 gm IV single dose


Ceftriaxone 250 mg IM single dose
+
Doxycycline 100 mg PO q12H for 7 days
 
Duration: 10 - 14 days, 1 month if chronic.

A thorough sexual history needs to be elicited regardless of age.

Test for STD in all (HIV / Hep B / C / Syphilis test/ Gonorrhea).

>35 years old / low STD risk 


 
Co-trimoxazole (480 mg) 2 tablets PO q12H

 
Co-amoxiclav 625 mg PO q8H
 
Asymptomatic bacteriuria

 
No treatment usually required.

However, treatment may need to be considered in immunocompromised (i.e. transplant patient).


Pregnant lady
Cephalexin 500 mg PO q8H

GUT procedures
Tailor to previous C&S and give antibiotic according to the C&S night before or immediately before procedure.

 
If no culture: Co-trimoxazole (480 mg)1 tablet PO q12H for 3 days.
 
Recurrent UTI

 
Cephalexin 250 mg PO q24H (ON)


Co-trimoxazole (480 mg) 2 tablets PO q24H

 
Recurrent UTI: Prophylactic antibiotics lead to resistance.
Specific cases may benefit from short term prophylactic antibiotic.

Duration: 3 - 6 months

Refer ID.

Recurrence:
  • May be due to relapse / reinfection
  • Must investigate - functional, anatomical and metabolic abnormality
  • Treat as per acute cystitis
Prevention of recurrence:
  • Consider non-pharmacological strategies
  • E.g. education re-hygiene, increased fluid intake and use of urinary alkalinizers
  • Prophylaxis can be considered for frequent recurrence: 2 or more in 6 months, 3 or more in 12 months
  • Choice of antibiotics should be based on culture and antimicrobial susceptibilities.


B) Paediatrics

Disease / Etiology

Preferred

Alternative

Comments

 
Acute Cystitis
E. Coli, Proteus sp

 
Trimethoprim 4 mg / kg PO q12H for 1 week

Cephalexin 12.5 mg / kg PO q6H

OR
  
Cefuroxime 10 - 15 mg / kg PO q12H
can be used in children who had prior antibiotics

 
Check G6PD status.

Trimethoprim (as a single agent) is not available in UMMC. In older children, Co-trimoxazole may be used but should be avoided in infants less than 8 weeks old.
 
Acute Pyelonephritis
E. Coli, Proteus sp

 
Cefotaxime 25 mg / kg q8H for 10 - 14 days
 
Cefuroxime 25 mg / kg IV q8H

OR

Gentamicin 5 - 7 mg / kg IV q24H for 10 - 14 days


Repeat culture within 48 hours if poor response.

Antibiotic may be change according to culture and sensitivity. Suggest to continue IV antibiotic until afebrile 2-3 days then change to appropriate oral antibiotic after culture results.

 
Asymptomatic bacteriuria

 
No treatment recommended

   
 
Antibiotic prophylaxis

 
Trimethoprim 1 - 2 mg / kg PO q24H

 
Nitrofurantoin 1 - 2 mg / kg PO q24H

OR
  
Cephalexin 5 mg / kg PO q24H

 
Indications :
- Infants / Children with recurrent symptomatic UTI
- VUR grade III and above

A child who develops an infection while on prophylaxis, treatment should be with a different antibiotic.

Check G6PD status.

Trimethoprim (as a single agent) is not available in UMMC. In older children, Co-trimoxazole may be used but should be avoided in infants less than 8 weeks old.