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

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:

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

Empirical treatment for neutropenic sepsis post-transplant

Empiric therapy in septic patients with kidney transplant

Meropenem 1 gm IV q8H (if ESBL is suspected)

Piperacillin / Tazobactam

4.5 gm IV q6H

Urinary Tract Infections

Asymptomatic Bacteriuria

Acute Cystitis

Uncomplicated

Complicated UTI

Catheter Associated UTI (CA-UTI)

Do NOT require treatment unless:

1. Pregnant

2. Undergoing urological procedure

If treatment is required,

Cephalexin 500 mg PO q6H for 5 days

Cefalexin 500 mg PO q6H for 5 days

Co-amoxiclav 1.2 gm IV q8H

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

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)

Cefuroxime 750 - 1500 mg IV q8H

Cefurozime 750mg-1.5g IV q8H

De-escalate/ streamline once C&S result is available.

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

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

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

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.

B) Paediatrics

Updated: 08 Sep 2020