3.09 - Urology Infections [updated]

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

Prevention of PD-related exit-site infection

PD-related Peritonitis

Gentamicin 0.1% Topical once daily

(not available in ummc)

After catheter insertion and at the end of the dialysis session

  

Mupirocin cream/ ointment 2%
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.


Peritoneal Dialysis Related Infection
 
Anti-fungal Prophylaxis for high risk PD patients

  

Fluconazole 200 mg PO q48H until the antibiotic therapy is completed

 

Or

 

Nystatin 500000U PO q6H 


  
Use of Fluconazole prophylaxis should be balanced with the risk for drug-drug interaction and emergence of Fluconazole-resistance (ISPD)

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 p		  
Screen for Staphylococcus aureus nasal carrier and nasal carriage eradication if positive (intra-nasal mupirocin ointment q12H for 5 days).








*use in patient allergy to penicillin/ MRSA colonized.
 
Antibiotic prophylaxis for Tenckhoff catheter insertion

  
Cefazolin 1 gm IV 30 minutes before the surgery

  
*Vancomycin 1 gm IV 30 minutes before surgery
 
PD-related Peritonitis*

Intraperitoneal Cefazolin

Intermittent Peritoneal dialysis (per exchange, once daily): 15mg/kg

 

Continuous Peritoneal Dialysis ( all exchange):

Loading dose 500mg/L bag (1g/2L bag), 125mg for every liter.  (250mg/2L bag q6H)

 

+

Intraperitoneal Ceftazidime

Intermittent peritoneal dialysis (per exchange, once daily):

1000-1500mg

 

Continuous Peritoneal Dialysis (all exchange):

Loading dose 500mg/L bag (1g/2L bag), 125mg for every liter. (250mg/2L bag q6H)


  

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

+ 


Intraperitoneal Ceftazidime

Intermittent peritoneal dialysis (per exchange, once daily):

1000-1500mg

 

Continuous Peritoneal Dialysis (all exchange):

Loading dose 500mg/L bag (1g/2L bag), 125mg for every liter. (250mg/2L bag q6H		  

*Criteria : when at least 2 out of 3 of the following are present:

(1) clinical features consistent with peritonitis, i.e. abdominal pain and/or cloudy dialysis effluent;

 

(2) dialysis effluent white cell count > 100/μL or > 0.1 × 109/L (after a dwell time of at least 2 hours), with > 50% polymorphonuclear;

 

(3) positive dialysis effluent culture 


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

Duration: 14-21 days depending on organism type  (see images from IPSD attached)

 

** Stability of Cloxacillin in peritoneal dialysate is not established.

 
 PD-related exit site infection (ESI)  
Co-amoxiclav 625 mg PO q12H		  

Cephalexin 500 mg PO q6H

 

  

Duration: 14 days.

 

If exit site /tunnel infection is due to pseudomonas, please call ID

Hemodialysis Catheter Related Infections


Exit site infection
Cloxacillin 500 mg PO q6H

  
OR

Cloxacillin 1 gm IV q6H 


Cephalexin 250-mg 500 mg PO q12-24H

Duration depending on severity (superficial/deep) and type of organism

If exit site /tunnel infection is due to pseudomonas, please call ID
Tunnel infection

Cefazolin 2 gm IV AD (3x per week) or;

1 gm IV q24H after dialysis on HD days

Cloxacillin 2 gm IV q6H

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

  

* For patient with penicillin allergic

 

Require catheter removal within 24 hours

 

Refer to the table on top.
 
Dialysis Catheter-Related Bloodstream Infection (CRBSI):

Catheters MUST be removed in

1)     CRBSI presenting with septic shock

2)    CRBSI caused by certain pathogens: S. aureus, non-fermenting Gram-negative bacilli, Candida spp. or Mycobacterium

3)    Metastatic complications (endocarditis, thrombophlebitis or septic pulmonary embolism)

4)    Bacteremia (or candidemia) persisting after 72 h of adequate treatment

5)    Pus is observed at the insertion site

6)    Signs of infection at the subcutaneous tunnel

7)   No possibility of antibiotic lock therapy


Catheter (cuffed and tunneled) retention can be considered in

1)    Coagulase Negative Staphylococci (CONS) CRBSI (except Staph. lugdenensis)

2)    Gram negative bacilli CRBSI

3)    Enterococcal CRBSI  (Only consider in stable patients without local or systemic complications)

4)    Corynebacterium (except Corynebacterium jeikeium) CRBSI?

5)    Suspected CRBSI (i.e. whilst waiting for the blood culture results) provided that the patients are/have

·         hemodynamically stable,

·         without immunosuppressive therapy, intravascular foreign bodies or organ transplantation,

·         no suppuration at the insertion site

·         on-going bacteremia/fungemia





Treatment duration for CRBSI when catheter is removed




NICE 2017; page 6 (https://www.dbth.nhs.uk/wp-content/uploads/2017/12/CRBSI-final.pdf)

Treatment duration for CRBSI when catheter is retained (IDSA 2009)

CONS, Gram negative bacilli CRBSI-  up to 3 weeks of antibiotic lock therapy AND systemic antibiotic  (may shorten this down to 10-14 days)

Enterococcal (uncomplicated CRBSI)- 7-14 days antibiotic lock therapy AND systemic antibiotic

Staph aureus (In the rare circumstance that the catheter is retained) - 4 weeks therapy of antibiotic lock therapy AND systemic antibiotic (please refer to ID team)

 

The use of Antibiotic Lock Treatment (ALT)  

ALT can be considered as catheter salvage strategy and it should be given with systemic antibiotic therapy for CRBSI. The only time that ALT can be used alone is when patients have multiple positive catheter-drawn with concurrent negative peripheral blood cultures involving coagulase-negative staphylococci or Gram-negative bacilli.

ALT should be dwelled for not more than 48 hours except for HD patients; the lock solution can be renewed after every dialysis session.

Antibiotics/agent that can be used for ALT are;

1)    Vancomycin

2)    Cefazolin

3)    Ceftazidime

4)    Ciprofloxacin

5)    Gentamicin

6)    Ampicillin

7)    Teicoplanin

8)    Daptomycin

9)   Ethanol

 

The ideal antibiotics for ALT should have the following characteristics;

1)    High activity against biofilms (ability to penetrate and disrupt the biofilm)

2)    Able to achieve high concentrations (100-1000 times the MIC of planktonic cells)

3)    Prolonged stability at room temperature over several days (enables prepared solutions to be stored and the antibiotic lock to be replaced every 24-72h)

4)    Compatible with anticoagulants

5)    Safe

6)    Low potential for resistance

7)    Cost-effective

 

Preferred Antibiotic choices for ALT:

Methicillin susceptible Staphylococci

Cefazolin 5mg/mL

Methicillin resistant Staphylococci

Vancomycin 2mg/mL (5mg/mL is more efficacious than 1mg/mL in eradicating staphylococci embedded within biofilm)

Gram negative bacteria

Ceftazidime 0.5mg/mL, Gentamicin 2mg/mL or Ciprofloxacin 0.2mg/mL*

 

Ampicillin sensitive Enterococcus species

Ampicillin 10mg/mL

Ampicillin resistant Enterococci other than vancomycin resistant Enterococci

Vancomycin 2mg/mL

Mixed of gram-positive and gram-negative bacterial infections

Ethanol lock 70%

*The maximum concentration of ciprofloxacin is limited because of precipitation at higher concentrations


Dialysis Catheter-Related Bloodstream Infection (CRBSI):
Non-severe illness community onset

Cefazolin 2 gm IV after each dialysis if next dialysis is expected in 48 hours or 3g after dialysis if next dialysis is expected in 72 hours

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 (monitor trough level, if MRSA is suspected)

 
Cloxacillin 1 2 gm IV q6H

±

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

*Consider Vancomycin if catheter inserted > 3 days or if MRSA if suspected

 

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 ( monitor trough level)

Meropenem 500 mg IV q24H (when ESBL is suspected)

+ 

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

Antibiotic lock therapy can be considered if catheter salvage is the goal (NICE 2017)

 

 Suspected catheter-related candidemia

Fluconazole 200 mg IV q24H

 

(From Sanford 100-400 mg q24H, and on HD day to give AD)		Micafungin  100mg IV q24H

 

increase dose to 150-200 mg OD due to adsorption of Micafungin onto HD membrane (for CRRT only)		Deescalate therapy based on antifungal susceptibility result and remove the catheter if the fungal infection is proven.

Risk factors for catheter related candidemia: 
1. Prolonged use of broad spectrum antibiotics 
2. Colonization due to Candida species at multiple sites

Kidney Transplantation

 Vaccination

Ensure up-to-date standard vaccinations at pre-transplant period, include MMR, DTP, Polio, Hib, Hepatitis B

To assess the immunity for the following disease:  Pneumococcal, Meningococcal, Influenza, Varicella, Hepatitis A

If they are not immune to these, they should be vaccinated against them.  Assessment of immunity can be done based on vaccination history. Additionally, antibody levels may be used to assess the patients’ immunity against Varicella zoster and Hepatitis A

 

(Click HERE for the standard vaccinations) 


Post-transplant prophylaxis 


Prophylatic antibiotic post kidney transplantation

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

 
Pneumocystis jirovecii prophylaxis (PJP)
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 if CrCL > 50-90, otherwise reduce this further according to CrCL
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 post transplant

 

(NB in D+/R- kidney transplant recipients, 6 months prophylaxis may be more effective in reducing CMV disease and late-onset CMV disease)

 

pre- premptive Rx/universal prophylaxis is given based on risk stratification  


 
TB prophylaxis

 
Isoniazid 5 mg/kg; max 300 mg PO q24H + Pyridoxine 10 mg PO (up to 50 mg) q24H 		 Refer ID if an alternative LTBI treatment is required IPT is given to all patients after ruling out active TB


Duration: 6 months

 

Perform Chest X-ray in patients undergoing transplant.


 
UTI prophylaxis

 
Co-trimoxazole (480 mg) 1 tablet PO q24H  -(for both PJP and UTI prophylaxis)

 

 Duration: 6 months

Empiric therapy in septic patients with kidney transplant 

Empirical treatment for neutropenic sepsis post-transplant

Piperacillin / Tazobactam 

4.5 gm IV q6H		 
Meropenem 1 gm IV q8H (if ESBL is suspected)


Urinary Tract Infections

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


If treatment is required,
Cephalexin 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
De-escalate/ streamline once C&S result is available.
  







Acute Cystitis
Uncomplicated 		Cefalexin 500 mg PO q6H for 5 daysCo-amoxiclav 625 mg PO q8H for 5 days

OR

Co-trimoxazole (480 mg) 2 tablets PO q12H for 3 days (not recommended for pregnancy)

 Duration: 100 days post transplant

 

(NB in D+/R- kidney transplant recipients, 6 months prophylaxis may be more effective in reducing CMV disease and late-onset CMV disease)

 

pre- premptive Rx/universal prophylaxis is given based on risk stratification  


 Complicated UTI Co-amoxiclav 1.2 gm IV q8H

Cefuroxime 750 - 1500 mg IV q8H


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

IV oral conversion when condition improves
Duration: total 7 - 14 days 

Catheter Associated UTI (CA-UTI)

Definition (CA-UTI):

UTI occurring in a person whose urinary tract is currently catheterized or has been catheterized within the past 48 hours. 

 

The presence or absence of odorous or cloudy urine alone should not be used to differentiate Catheter Associated Asymptomatic Bacteuria (CA-ABU) from CA-UTI


 

Co-Amoxiclav 1.2g IV q8H


 

Cefurozime 750mg-1.5g IV q8H		Duration: 7 days (if prompt resolution);

10 - 14 days (if slow response).


To change the catheters and do not repeat urine culture unless indicated (have signs and symptoms of UTI)

Consider Piperacillin/Tazobactam or Cefepime if patient is colonized/ has history of Pseudomonas aeruginosa.

Consider Meropenem if patient is colonized/ has history of ESBL infection.

 
Pyelonephritis/urosepsis

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

Mild systemic symptoms, low grade fever, loin pain, no nausea or vomiting 


Co-amoxiclav 625 mg PO q8H


Cephalexin 500 mg PO q6H


 Duration: 7-10 days (NICE)
  
Targeted therapy should be based on antimicrobial susceptibility results. 

 

 
Severe

Systemic symptoms (fever, nausea, vomiting, severe pain)

 

 
Piperacillin / Tazobactam 
4.5 gm IV q6H

OR

Cefepime 2 gm IV q8H

 

 

 
Meropenem 1 gm IV q8H 
(If there is a risk for MDRO/ESBL)

 
Consider US KUB

●      Total duration (IV and Oral): 10 - 14 days (not to exceed 21 days)

 

 

Acute Prostatitis with STD risk

Ceftriaxone 250 mg IM single dose 
+ 
Azithromycin 1 gm stat

Ceftriaxone 250 mg IM single dose 
+ 
Doxycycline 100 mg PO q12H for 7 days

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

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

 

Azithromycin 500mg ODx 21 days  for C. Trochomtis or

Metronidazole 500mg TDS x 14 days for T vaginalis

 


Prostatitis/prostatic abscess

 

 
Co-amoxiclav 1.2 gm IV TDS

 

Once improved/ outpatient therapy, change to oral

Co-trimoxazole (480 mg) 2 tablets PO q12H 

 


Co-amoxiclav 875/125mg PO q8H

 

 
Duration: 10 - 14 days (prostatitis); could be longer depending on clinical response.

Until resolution (abscess)

 

Ensure culture are taken before starting antibiotic

For abscesses, please ensure adequate source control.

 

To streamline choice of antibiotic if organism is sensitive to ciprofloxacin

Chronic Prostatitis

Symptoms that persist for at least 3/12.

Symptoms: pain at various locations including the perineum, scrotum, penis and inner part of the leg as well as LUTS 

 Ciprofloxacin 500mg PO q12H for 2 weeks*

 

 

 

 

Co-trimoxazole 480 tab, 2 tabs PO q12H for 2 weeks*

 

Doxycycline 100mg BD X 10 days or

Only for C. trachomatis or mycoplasma infections

*To review after 2 weeks of treatment, if culture positive/ symptom improved, to continue for another 2 weeks (total duration 2-4 weeks)

 

 

 

 

 
Recurrent UTI prophylaxis

 
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

  

0-2 months old
Ampicillin 25-50mg/kg/dose IV

< 1 week old: q12H

> 1 week old: q6H

+

Gentamicin 4-5mg/kg/dose IV q24H

>2 months old

Cefuroxime 25mg/kg/dose IV q8H







Cefuroxime 10-15 mg/kg/dose PO q12H

Cephalexin 25mg/kg/dose                  

< 7 days: q12H

7-21 days: q8H

21-28 days: q6H

> 28 days: 12.5-25mg/kg/dose q6-12H

 

Co-trimoxazole 4-5mg/kg/dose of Trimethoprim PO q12H (G6PD status)

Nitrofurantoin 1-1.5mg/kg/dose q6H (> 3 months old and contraindicated in G6PD deficiency)

  
Recurrent urinary tract infection due to underlying structural anomaly should refer to previous culture for choice of antibiotic. 
 
Acute Pyelonephritis
E. Coli, Proteus sp

  

0-2 months old

Ampicillin 25-50mg/kg/dose IV

< 1 week old: q12H

> 1 week old: q6H

 

+


Cefotaxime 25-50 mg / kg/dose IV q8H for 10 - 14 days

 

> 2 months old

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










Tazobactam 100mg/kg/dose of Piperacillin dose IV q8H
Repeat culture within 48 hours if poor response.

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

  
No treatment recommended

    
 
Antibiotic prophylaxis

  

^Trimethoprim 2mg/kg/dose PO q24H

*Nitrofurantoin 1mg/kg/dose PO q24H


  

^^Co-trimoxazole 1-2 mg/kg/dose of Trimethoprim PO q24H

  

Indications:
- Infants / Children with recurrent symptomatic UTI
- Vesicoureteral 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.

^^Co-trimoxazole should be avoided in infants less than 8 weeks old.

 

*Nitrofurantoin is not available in UMMC


Updated: 08 Sep  2020