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Genitourinary Infection – VASP

Asymptomatic Bacteriuria

Background

  • Isolation of bacteria in an appropriately collected urine specimen from an individual without symptoms or signs of urinary tract infection. Bacteriuria, foul odor, urine appearance, pyuria, falls and/or confusion alone are not indicative of infection.
  • Oliguric ESRD pts may have bacteriuria from colonization due to lack of flushing of bladder; avoid sending UA/UCx unless pt is symptomatic
  • Treatment only required for specific populations:
    • Pregnant women (screening performed at 12 – 16 weeks)
    • Anticipated urologic intervention - when requesting, be sure to ask for Micro help in identifying potential pathogens needing treatment vs. likely contaminants
    • Some renal transplant recipients, depending on time since transplant

Complicated UTI and Pyelonephritis

See UTI algorithm on VASP website

Background

  • Fever, pyuria, and costovertebral angle tenderness suggest pyelonephritis.
  • Consider it a complicated UTI if any of the following are present:
    • Renal calculi or other obstructive disease, immunosuppressed host, abnormal urological anatomy or physiology (including stents), presence of a urinary catheter
    • Male sex alone does NOT qualify as complicated
    • Sepsis or bacteremia

Evaluation

  • UA with reflex urine culture ONLY in patients with symptoms
  • If unable to obtain history, evaluate for objective signs of infection (fever, hypotension, tachycardia, leukocytosis, etc.) and evaluate for alternative explanations (O2 requirement suggest pneumonia, post-op fever within 48 hours, etc.)
  • BCx and UCx prior to abx
  • If there is no pyuria, consider an alternative diagnosis, or proximal ureteral obstruction
    • Pyuria is common in the presence of a urinary catheter, kidney stones, urostomy, ileal conduit and other invasive devices, and may not indicate infection

Management

  • Antibiotic Duration: 7-14 days, depending on antibiotic choice
  • Tailor therapy once/if cultures are available. If no improvement in 48h, consider imaging to rule out complications (e.g., perinephric abscess)
    • Transition from IV to PO should be considered for patients who meet the following criteria: able to tolerate enteral medications, signs of clinical improvement (defervesced, afebrile, down-trending WBC, etc.)
    • Days of IV therapy count towards overall treatment duration.
First Line Alternative
Outpatient Amoxicillin-clavulanic acid 875-125mg BID x14 days Ciprofloxacin 500mg BID or levofloxacin 750 mg daily x 7 days

TMP/SMX 1-2 DS BID x 7 days
Inpatient Ceftriaxone 2g q24h
Cefepime 2g q8h
Pip/tazo 3.375g q8h ext infusion

Meropenem 1g q8h (if h/o or confirmed ESBL within the last 90 days) 		Ertapenem 1g q24 instead of Meropenem if no Pseudomonas

Ciprofloxacin 750mg PO BID (500 mg PO BID if bacteremia ruled out) OR 400mg IV BID (if susceptibility confirmed)*

*FQ’s have same bioavailability if given PO or IV so oral is preferred

Uncomplicated Urinary Tract Infection

Background

  • Clinical symptoms of UTI (dysuria/urgency/frequency/ hematuria) in non-pregnant, immunocompetent, neurologically intact pt with normal urologic anatomy and no indwelling urinary catheters Management
  • Empiric therapy
    • Nitrofurantoin monohydrate: 100 mg PO BID x 5 days (avoid if any concern for pyelonephritis or if creatinine clearance <30)
    • Cephalexin 250-500mg q6h x5-7 days
  • Alternative therapies
    • Fosfomycin: 3 grams of powder mixed in water as a single PO dose (avoid if any concern for ascending UTI or pyelonephritis). Susceptibility test results must be requested, only possible for E. coli and E. Faecalis.
    • Amoxicillin-clavulanate: 875-125mg PO BID x5-7 days
    • Ciprofloxacin: 250mg PO BID x3 days
      • FQ’s should be reserved for more serious infections than uncomplicated cystitis, and only after susceptibility results are confirmed given high rates of resistance
      • Adverse effect profile >> beta-lactams (i.e. QT-prolongation, tendinopathies)
  • Avoid amoxicillin, ampicillin, and trimethoprim-sulfamethoxazole (TMP-SMX) due to increasing resistance unless culture data with confirmed susceptibility Additional Information
  • MDR cystitis: ESBL isolates are increasingly common due to antibiotic overuse
    • Before treating, decide if this is a TRUE UTI
    • If true, consider Fosfomycin (if E. coli) or nitrofurantoin (if susceptibility is confirmed – K. pneumoniae and Enterobacter spp are usually resistant), gentamicin or tobramycin 5 mg/kg IV once (even in setting of AKI), or ID consultation
    • Ask the lab to check susceptibility results to these antibiotics for future reference

Catheter Associated Urinary Tract Infection (CAUTI)

Background

  • Culture growth of > 103 cfu/mL of uropathogenic bacteria + signs or symptoms consistent with infection (without another identified etiology) + indwelling urethral/suprapubic catheter or intermittent catheterization.
    • This includes pts with catheters in place during the preceding 48 hours
  • Duration = greatest risk factor (increases 3-10% per day of catheterization)
    • Other risks: female sex, diabetes, elderly, colonization of catheter bag, poor care
  • Bacteriuria, foul odor, pyuria, urine appearance falls and/or confusion alone are not indicative of infection in pts who are otherwise asymptomatic.
  • Ensure clean sample collected
    • Ideally, catheter is removed and midstream sample obtained
    • If catheterization required; removal of old catheter and sample taken from new catheter

Management

  • Distinguish uncomplicated vs complicated UTI (see above)
  • Antimicrobial management:
    • Guided by cultures and susceptibilities
    • Duration: 7 – 14 days depending on abx, clinical response and whether infection constitutes complicated vs uncomplicated UTI
    • Special note regarding Candida UTI management: Candida is generally not pathogenic
      • Presence in urine does not indicate infection (unless perinephric abscess, renal transplant, or complex fistulous disease)
      • Fluconazole achieves excellent urinary penetration while micafungin does not
      • If fluconazole-resistant Candida is cultured or suspected, consult ID
      • Susceptibilities are not routinely run-on Candida from urine cultures and would need to be requested if concern for true infection.
  • Catheter management
    • At the least, catheters should be replaced at the time of antibiotic initiation (preferably removed).
    • If catheterization is necessary, intermittent catheterization is preferred over continuous use with pt educations on cleaning/hygiene prior to catheterization. Condom catheters and pure wicks also preferred over foley catheter.