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 Bacteriuria | Do 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 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)
| 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:
- 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
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