4.09 - Urology Infections - UMMC Pharmacy Portal v2

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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 5 days	If treatment required, Co-amoxiclav 625 mg PO q8H for 5 days OR Co-trimoxazole (480 mg) 2 tablets PO q12H for 3 days (not recommended for pregnancy)
Acute Cystitis Uncomplicated	Cefalexin 500 mg PO q6H for 5 days	Co-amoxiclav 625 mg PO q8H for 5 days OR Co-trimoxazole (480 mg) 2 tablets PO q12H for 3 days (not recommended for pregnancy)
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: Comorbid conditions (e.g., renal dysfunction, urologic disorders, diabetes mellitus, advanced liver or cardiac disease) Hemodynamic instability* Male sex Metabolic derangement (e.g., renal dysfunction, acidosis) Pregnancy Severe flank or abdominal pain Toxic appearance Unable to take liquids by mouth 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.

Updated: 07 May 2019

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4.09 - Urology Infections