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URINARY TRACT INFECTIONS




                 Dr.Sudhanshu Mishra
          Co-ordinator : Dr.V.P.Mandora
             PG GUIDE : DR.A.V.Mulay
Urinary tract infections
“When I woke up just after dawn on September
28, 1928, I certainly didn't plan to revolutionize all
medicine by discovering the world's first antibiotic, or
bacteria killer. But I suppose that was exactly what I
did.”
                             –Alexander Fleming
“URINARY TRACT INFECTIONS: SPECTRUM OF ORGANISMS ALONG
WITH THEIR ANTIBIOTIC SENSITIVITY IN INPATIENT AND OUTPATIENT
SET-UPS”



    Total Number of Cases Studied(n) = 200
   INCLUSION CRITERIA:
   This study will include all those patients in whom Urinary
Tract Infections are suspected and their Urine Culture and
Antibiotic sensitivity pattern have been sent.
   Both pediatric and adults of both sexes included .
   Both Inpatients and Outpatients Included.

   EXCLUSION CRITERIA:
   Patients in whom Urine Culture and/or Antibiotic Sensitivity
Pattern have not been done.
   MATERIALS AND METHODS

   This study will be a cross-sectional study of all patients of
    suspected Urinary Tract Infections in whom Urine Culture and
    Antibiotic Sensitivity patterns have been done.

   All patients who are diagnosed to have urinary tract infections
    will be thoroughly studied regarding the organism isolated
    from urine culture as well as their sensitivity pattern to
    antibiotics.

   All the study subjects will be evaluated using the proforma
    attached along with their Urine Culture reports and Antibiotic
    sensitivity pattern.
URINARY TRACT INFECTIONS

 Leadingcause of morbidity and health
 care expenditures in persons of all ages.

 An estimated 50 % of women report
 having had a UTI at some point in their
 lives.

 8.3million office visits and more than 1
 million hospitalizations, for an overall
 annual cost > $1 billion in USA (2010)
ANATOMY
Urinary tract infections
URINE CULTURE SAMPLES




    38         46
                        Culture Positive

                        Culture Negative

         116            Contaminated
                        Sample
DEMOGRAPHY OF UTI

25                        23

20


15
                                                          Males
10                                                        Females
                                                  7
                 5    5
5
                                    2                 2
             1                           1
      0 0                       0            0
0
     0-10   10-20    20-30     30-40    40-50    Above
              Y                                   50
PROFILE OF CULTURE POSITIVE
PATIENTS

                        00



      INPATIENT    18
      OUTPATIENT

                              28
DISTRIBUTION OF INPATIENTS
                               NO.OF PATIENTS
    ICCU                            5
  DELUXE       0
 GENERAL           1
    PAED       0
 GYNAEC                    2                                 NO.OF PATIENTS

NEW ONCO                                    6
  B WARD                                            9
  A WARD                            5

           0           2        4       6       8       10
SPECTRUM OF ORGANISMS
                               Outpatients

            Citrobacter         1


           ESBL E.Coli              2


    Acinetobacter Wolfii                3
                                                           Outpatients

Psedumonas Aeruginosa               2


                 E.Coli                          10


                           0                5   10    15
Inpatients

   Providencia Retigens        1

  Non Albicans Candida         1

   Entrococcus Faecalis                        4

Psedumonas Aeruginosa                                  6            Inpatients


        ESBL Kleibsella                3

           ESBL E.Coli                                         9

                          0        2       4       6       8   10
ANTIBIOTIC RESISTANCE
                            OUTPATIENTS

    TMP-SMX             11.11%


 Nitrofurantoin       5.55%


Cephalosporins                16.66%
                                                         OUTPATIENTS

          FQs                                   44.40%




                  0   0.1     0.2   0.3   0.4    0.5
RESISTANCE PATTERN
                             INPATIENTS




             Colistin   0%
                                               71.43%
                FQs                        57.14%
                              17.86%
      Cotrimoxazole               32.14%                INPATIENTS

           Amikacin             21.43%
                             10.71%
Cefoperazone+Sulba…             21.43%
                                      46.43%
Ampicillin+Sulbactam             28.57%
                   0.00%20.00%40.00%60.00%80.00%
ACUTE UNCOMPLICATED CYSTITIS
                   Sexually active young
                    women.

                   Causes: anatomy and
                    certain behavioral
                    factors, including delays in
                    micturition, sexual
                    activity, and the use of
                    diaphragms and spermicides
                    tract.

                   Aggressive diagnostic work-
                    ups are unwarranted in
                    young women presenting
                    with an uncomplicated
                    episode of cystitis.
ACUTE UNCOMPLICATED CYSTITIS
   The microbiology is limited
    to a few pathogens.

   70%- 85% are caused by
    Escherichia coli

   5-20%are caused by
    coagulase-negative
    Staphylococcus
    saprophyticus

   5-12% are caused by other
    Enterobacteriaceae such as
    Klebsiella and Proteus.
ACUTE UNCOMPLICATED CYSTITIS
               Clinical
                       Features:
               dysuria, frequency, urgency,
               suprapubic pain, hematuria.
                   Fever >38C, flank
                    pain, costovertebral angle
                    tenderness, and nausea or
                    vomiting suggest upper tract
                    infection.
ACUTE UNCOMPLICATED CYSTITIS
   Diagnosis: direct history and PE

   PE: Temperature, abdominal exam, assessment of
    CVA tenderness, pelvic exam.
       H/o STD’s, new sexual partner, partner with urethral
        symptoms, gradual onset.
ACUTE UNCOMPLICATED CYSTITIS
 Guidelines for tx of acute cystitis recommend
  empiric antibiotic tx.
 Unnecessary antibiotic use??
 Clinical criteria for Dx:

    Dysuria, presence of > trace urine
    leukocytes, and presence of nitrites or...
    Dysuria and frequency in the absence of
    vaginal discharge.
ACUTE UNCOMPLICATED CYSTITIS
 UA:Evaluation of midstream urine for
 pyuria.
     White blood cell casts in the urine are Dx of
      upper tract infection.

 Urine   Culture: Not necessary
     Warranted in: Suspected complicated
      infection, persistent symptoms following
      tx, symptoms recur < 1 mo after tx.
ACUTE UNCOMPLICATED CYSTITIS
 Urine   dipsticks:
     Leukocyte esterase (pyuria), sensitivity 75-
      90%, specificity 95%
     Nitrite (Enterobacteriacea), sensitivity 35-
      85%, specificity 95%, false positive with
      phenazopyridine, beets.
     Microscopic evaluation for pyuria or a culture is
      indicated in pt with negative leukocyte esterase
      that have urinary symptoms.
ACUTE UNCOMPLICATED CYSTITIS
 Susceptibility:
     E.coli
       30% isolates resistance to ampicillin and sulfonamides
       Increasing of resistance to TMP-SMX

       Resistance to nitrofurantoin is <5%

       Resistance to fluoroquinolones <5%

     S.saprophyticus
       3% resistant to TMP-SMX
       0% resistant to nitrofurantoin

       0.4% resistant to ciprofloxacin
ACUTE UNCOMPLICATED CYSTITIS
   Treatment:
       Short course vs. prolonged tx
           Short course preferred except with beta-lactam agents
       TMP-SMX (160/800mg BID x 3) first-line tx if: no
        allergy to the drug, no antibiotics in the past 3
        mo, no recent hospitalization.
       Nitrofurantoin (100mg BID x 5 days)
       Analgesia: Phenazopyridine 200mg TIDx2
ACUTE COMPLICATED CYSTITIS
 UTI when/with structural, functional or metabolic
  abnormalities (polycystic, solitary, transplant
  kidney;DM, CRF, indwelling cath, neurogenic
  bladder) or elderly, male, child, pregnant or h/o
  recurrent UTI)
 E.coli accounts for fewer than one third of
  complicated cases.

    Clinically, the spectrum of complicated UTIs may
    range from cystitis to urosepsis with septic shock.
ACUTE COMPLICATED CYSTITIS
   Urine culture and susceptibility are necessary.

   These infections are usually associated with high-
    count bacteriuria (> 10(5) CFU/mL).

   MO:
    Proteus, Klebsiella, Pseudomonas, Serratia, and
    Providencia, enterococci, staphylococci and fungi
    AND E.coli
ACUTE COMPLICATED CYSTITIS
 Empiric therapy for these patients should include an
  agent with a broad spectrum of activity against the
  expected uropathogens:
  fluoroquinolone, ceftazidime, cefepime, aztreon
  am, imipenem-cilastatin. (Obtain Ucx prior to
  Tx)
 Tx x 7-14 days

 Follow-up urine culture should be performed
  within 14 days after treatment???
RECURRENT CYSTITIS
 Up to 27% of young women with acute
  cystitis develop recurrent UTIs.
 The causative organism should be identified
  by urine culture.
 Relapse: infection with the same organism
  (multiple relapses = complicated UTIs).
 Recurrence: infection with different
  organisms.
RECURRENT CYSTITIS
    >3 UTI recurrences documented by urine Cx within
     one year can be managed using one of three
     preventive strategies:
1.   Acute self-treatment with a three-day course of
     standard therapy.
2.   Postcoital prophylaxis with one-half of a TMP-
     SMX double-strength tablet (80/400 mg).
3.   Continuous daily prophylaxis TMP-SMX one-half
     tablet per day (40/200 mg); nitrofurantoin 50 to 100
     mg per day; norfloxacin 200 mg per day.
UNCOMPLICATED PYELONEPHRITIS
   Suspect if:
     Cystitis-like illness and accompanying flank pain
     Severe illness with
      fever, chills, nausea, vomiting, abdominal pain
     Gram-negative bacteremia.
UNCOMPLICATED PYELONEPHRITIS
   DX: Clinical, confirm with:
     UA: pyuria and/or WBC casts
     UCx with > 10 (5) CFU/mL (80%)

   Tx: 14 days total
     Oral: TMP/SMX, fluoroquinolones
     IV: 3rd gen
      cephalosporin, aztreonam, quinolones, aminoglycoside
UNCOMPLICATED PYELONEPHRITIS
   Pt with symptoms after 3 days of appropriate
    antimicrobial tx should be evaluated by renal US or
    CT for obstruction or abscess.
UTI IN MEN
 At risk: Older men with prostatic disease, UT
  instrumentation, anal sex, or partner colonized with
  uropathogens.
 UCx: 10 (3) CFU/mL sensitivity and specificity 97%.

 Additional studies?
       Not necessary in young healthy men who have a single
        episode.
UTI IN MEN
   Tx:
       Uncomplicated cystitis:
             TMP/SMX or fluoroquinolones x 7 days
       Complicated cystitis:
             Fluoroquinolones x 7-14 days
       Bacterial prostatitis:
             Fluoroquinolone x 6-12 weeks
CATHETER-ASSOCIATED UTI
     Risk of bacteriuria is ~ 5%/day (long term catheter
      bacteriuria is inevitable).
     40% of nosocomial infections

     Most common source of gram-negative bacteremia.

     Dx: Ucx 10 (2) CFU/mL
           MO:
            E.coli, Proteus, Enterococcus, Pseudomona, Enterobacter,
            Serratia, Candida
CATHETER-ASSOCIATED UTI
 Mild to mod: oral quinolones10-14days
 Severe infection: IV/oral 14-21days

 Asymptomatic bacteriuria in pt with an indwelling
  Foley should not be Tx unless they are
  immunosuppressed, have risk of bacterial
  endocarditis or pt who are about to undergo urinary
  tract instrumentation.
ASYMPTOMATIC BACTERIURIA
 UCx: > 10(5)CFU/mL with no symptoms
 Three groups of pt with asymptomatic bacteruria
  have been shown to benefit from tx:
     Pregnant
     Renal transplant
     Pt who are about to undergo urinary tract procedures.
PREGNANT PATIENTS
   Asymptomatic bacteriuria: two consecutive voided
    urine specimens with isolation of the same bacterial
    strain >10(5) or a single cath urine specimen.
     Nitrofurantoin 100mg BID x 5-7 days
     Amoxi/Clav 500mg BID or 250 TID x 7days
     Fosfomycin 3g PO x 1
URINARY CATHETER

•   Developed in the 1920s by Dr. Frederick
    Foley
•   The urinary catheter was originally an open
    system with the urethral tube draining into an
    open container.
•   In the 1950s, a closed system was developed
    in which the urine flowed through a catheter
    into a closed bag.

                                              40
Urinary Catheter Utilization
• About 25% of patients during their
  hospitalization
• Almost all of them are placed the same
  admission
• A large number is placed in ED
• Intensive care    medical-surgical units



                                             41
Urinary catheters are not
                harmless…
• Urinary tract infection
• Mechanical trauma to urethra and bladder
• Immobility (restraining patient)*


                                              Prolonged stay?
Pressure Ulcers?         Falls?



                   *Saint S, Ann Intern Med 2002; 137: 125-7

                                                                42
HOSPITAL-ACQUIRED UTI:
PREVALENCE
•   600,000 patients develop hospital-acquired UTI’s
    per year
•   Catheter-associated infections (CAUTI) comprise
    80% of these cases
•   UTIs account for 40% of all hospital-acquired
    infections




                                              43
CATHETER ASSOCIATED UTI (CAUTI)
       Catheter-risk of bacteriuria increases each day of
        use:
    •   Per day: 5%
    • 1 week: 25%
    • 1 month: 100%




                                                       44
BIOFILM: EXTRACELLULAR POLYMERS
(DONLAN, CID 2001; 33:1387–92, LIEDL, CURR OPINION UROL 2001;11:
75-9)

 Organisms attach to
  and grow on a surface
  and produce
  extracellular polymers
 Intraluminal ascent
  (48hours) of bacteria
  faster than extraluminal
  (72-168 hours)
 Most catheters used >1
  week have biofilms                       Staphylococcus aureus biofilm on
                                                     an indwelling catheter.
 Extraluminal more
                                               CDC Public Health Image Library
  important in women
                                                                         45
Usually females




                                                    Usually males




                                                            46
              Maki, Emerg Infect Dis 2001; 7: 1-6
47

Maki, Emerg Infect Dis 2001; 7: 1-6
BACTERIOLOGIC MONITORING
• Not recommended for asymptomatic patients.
• Only culture the urine if the patient has symptoms
  of an UTI such as fever, chills, and abdominal pain
• Cloudy urine ≠infection
• Sediment in urine ≠infection




                                                       48
ASYMPTOMATIC BACTERIURIA
 No  benefit from treatment
 Increased risk of resistance and C. difficile
  disease with treating asymptomatic
  bacteriuria
 Pyuria does not equate infection when
  catheter present
 Avoid urine cultures unless patient is
  symptomatic or if it is a part of sepsis
  workup in a catheterized patient

                                                  49
ACCEPTABLE INDICATIONS FOR
    URINARY CATHETER PLACEMENT
    Acute urinary retention or obstruction
    Perioperative use in selected surgeries
    Assist healing of perineal and sacral wounds
     in incontinent patients
    Hospice/comfort/ palliative care
    Required immobilization for trauma or
     surgery
    Chronic indwelling on admission



                                               50   50
ACUTE URINARY RETENTION OR
OBSTRUCTION

 Outflow obstruction: examples include prostatic
  hypertrophy with obstruction, urethral obstruction
  related to severe anasarca, urinary blood clots with
  obstruction
 Acute urinary retention: this may be medication
  induced, medical (neurogenic bladder) or trauma to
  spinal cord.




                                                    51   51
PERIOPERATIVE USE IN SELECTED
    SURGERIES

 Urologic  surgery or other surgery on
  contiguous structures of the genitourinary
  tract
 Anticipated prolonged duration of
  surgery, large volume infusions during
  surgery, or need for intraoperative urinary
  output monitoring
 Spinalor epidural anesthesia may lead to
 urinary retention; prompt discontinuation of this
 type of anesthesia should prevent need for
 urinary catheter placement
                                                52   52
ASSIST HEALING OF PERINEAL AND SACRAL
     WOUNDS IN INCONTINENT PATIENTS

 Thisis a relative indication when there is
 concern that incontinence is leading to
 worsening skin integrity in areas where
 there is skin breakdown




                                               53   53
HOSPICE/ COMFORT CARE/ PALLIATIVE
   CARE

 Thisis a relative indication. In end-of-life
 situations, it is reasonable to accommodate
 the patient’s wishes on what provides them
 with the best comfort




                                             54   54
REQUIRED IMMOBILIZATION FOR
  TRAUMA OR SURGERY
 This  includes:
1. unstable thoracic or lumbar spine

2. multiple traumatic injuries such as pelvic
   fractures
3. Acute hip fracture is risk for dislocation




                                                55   55
CHRONIC INDWELLING URINARY CATHETER
   UPON ADMISSION

 Patientsfrom home or extended care facility
 with a chronic urinary catheter




                                           56   56
UNACCEPTABLE REASONS FOR
PLACEMENT
 Urine output monitoring OUTSIDE intensive care
 Incontinence

 Morbid obesity

 Immobility

 Confusion or dementia

 Patient request




                                                   57   57
URINE OUTPUT MONITORING OUTSIDE
INTENSIVE CARE
     This includes:
     1.   Close urinary output monitoring by nephrology in
          patients with renal failure
     2.   Monitoring of urine output in patients with congestive
          heart failure on diuretics
     Potential solutions:
1.    Use urinals for men and hats for women (to
      monitor output)
2.    Accurate daily weights.




                                                              58   58
URINE OUTPUT MONITORING OUTSIDE
INTENSIVE CARE
 For patients with congestive heart failure, consider
  involving the patient
 Provide patients with information regarding how to
  document their output and daily weights (consider
  pamphlets)
 This will also help the patient learn to accurately
  measure their output.




                                                     59
INCONTINENCE
   Incontinence should not be a reason for urinary
    catheter placement. Patients admitted from home
    or from extended care facilities with incontinence
    managed their incontinence without problems prior
    to admission. Mechanisms to keep the skin intact
    need to be in place and avoid urinary catheter
    placement in that population.




                                                     60   60
INCONTINENCE: POTENTIAL
SOLUTIONS
       Use Skin Barrier Creams for protection
       Start Toilet Training:
       Offer use of bedpan or assist patient up to commode
        regularly
       Evaluate for any wet bed linen and change if wet
        at the time patient is being turned in bed




                                                              61   61
PATIENTS TRANSFERRED FROM
INTENSIVE CARE TO FLOOR
 The intensive care is an area where high
  prevalence of urinary catheter utilization is present.
 Evaluating those who are transferred to non-
  intensive care units for need of urinary catheter and
  discontinuation of those not needed may
  significantly reduce unnecessary utilization




                                                      62   62
MORBID OBESITY AND IMMOBILITY
 Morbid obesity should not be a trigger for
 urinary catheter placement. Patients that are
 morbidly obese have functioned without a
 urinary catheter prior to admission. The
 association of immobility and morbid obesity
 may lead to more inappropriate catheter
 placement. This may result in more
 immobility with the urinary catheter being a
 “one point restraint”


                                            63   63
IMMOBILITY: POTENTIAL SOLUTIONS
   Start toilet training every 2 hours
   Offer bedpan, urinal or assist patient out
    of bed
   Of 145 hospitalized patients with a high
    risk for pressure ulcers, urinary catheter
    presence was associated with 1.8 times
    risk of pressure ulcer compared to those
    without urinary catheter (p=0.03). The most
    significant association was between
    urinary catheter catheter use and stage 2
    pressure ulcer.
                                             64   64
CONFUSION OR DEMENTIA
   Patients with confusion or dementia should not
    have a urinary catheter placed unless there is an
    indication for placement




                                                    65   65
THE VERY ELDERLY PATIENTS
 Disproportionate use inappropriately in the very
  elderly.
 It may be a marker of immobility, incontinence, and
  dementia?




                                                   66
PATIENT REQUEST
 Although  healthcare workers may report
 that patients want the urinary catheter in, this
 is infrequently documented. The only
 exception is in patients that are end of life or
 palliative care.
 Patient’s    Convenience:
  -   Example: patient on diuretics and does not want
      to move out of bed multiple times
  -   Education is key! Provide reasons to patient of
      increased risk of urinary catheter : urine
      infection, skin breakdown, deep venous
      thrombosis and/or pneumonia due to immobility

                                                   67   67
INCREASED WORK LOAD FOR
   HEALTHCARE WORKERS (HCW)
   Increased acuity of patients or reduction
    of the nurse to patient ratio
   e.g., patient is incontinent and immobile
    and requires multiple changes of sheets
   Potential solution: link it to other initiatives
    (eg. pressure ulcer prevention requires
    frequent repositioning of
    patients), evaluate the nurse to patient
    ratio, shift resources to support the HCW
    that has more responsibilities

                                                  68
WHAT NEEDS TO BE DONE
 Both nurses and physicians should evaluate the
  indications for urinary catheter utilization.
 Physicians should promptly discontinue catheters
  that are no longer needed.
 Nurses evaluating catheters and finding no
  indication should contact physician to promptly
  discontinue catheter.




                                                     69
   THANK YOU
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections
Urinary tract infections

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Urinary tract infections

  • 1. URINARY TRACT INFECTIONS Dr.Sudhanshu Mishra Co-ordinator : Dr.V.P.Mandora PG GUIDE : DR.A.V.Mulay
  • 3. “When I woke up just after dawn on September 28, 1928, I certainly didn't plan to revolutionize all medicine by discovering the world's first antibiotic, or bacteria killer. But I suppose that was exactly what I did.” –Alexander Fleming
  • 4. “URINARY TRACT INFECTIONS: SPECTRUM OF ORGANISMS ALONG WITH THEIR ANTIBIOTIC SENSITIVITY IN INPATIENT AND OUTPATIENT SET-UPS” Total Number of Cases Studied(n) = 200  INCLUSION CRITERIA: This study will include all those patients in whom Urinary Tract Infections are suspected and their Urine Culture and Antibiotic sensitivity pattern have been sent. Both pediatric and adults of both sexes included . Both Inpatients and Outpatients Included.  EXCLUSION CRITERIA: Patients in whom Urine Culture and/or Antibiotic Sensitivity Pattern have not been done.
  • 5. MATERIALS AND METHODS  This study will be a cross-sectional study of all patients of suspected Urinary Tract Infections in whom Urine Culture and Antibiotic Sensitivity patterns have been done.  All patients who are diagnosed to have urinary tract infections will be thoroughly studied regarding the organism isolated from urine culture as well as their sensitivity pattern to antibiotics.  All the study subjects will be evaluated using the proforma attached along with their Urine Culture reports and Antibiotic sensitivity pattern.
  • 6. URINARY TRACT INFECTIONS  Leadingcause of morbidity and health care expenditures in persons of all ages.  An estimated 50 % of women report having had a UTI at some point in their lives.  8.3million office visits and more than 1 million hospitalizations, for an overall annual cost > $1 billion in USA (2010)
  • 9. URINE CULTURE SAMPLES 38 46 Culture Positive Culture Negative 116 Contaminated Sample
  • 10. DEMOGRAPHY OF UTI 25 23 20 15 Males 10 Females 7 5 5 5 2 2 1 1 0 0 0 0 0 0-10 10-20 20-30 30-40 40-50 Above Y 50
  • 11. PROFILE OF CULTURE POSITIVE PATIENTS 00 INPATIENT 18 OUTPATIENT 28
  • 12. DISTRIBUTION OF INPATIENTS NO.OF PATIENTS ICCU 5 DELUXE 0 GENERAL 1 PAED 0 GYNAEC 2 NO.OF PATIENTS NEW ONCO 6 B WARD 9 A WARD 5 0 2 4 6 8 10
  • 13. SPECTRUM OF ORGANISMS Outpatients Citrobacter 1 ESBL E.Coli 2 Acinetobacter Wolfii 3 Outpatients Psedumonas Aeruginosa 2 E.Coli 10 0 5 10 15
  • 14. Inpatients Providencia Retigens 1 Non Albicans Candida 1 Entrococcus Faecalis 4 Psedumonas Aeruginosa 6 Inpatients ESBL Kleibsella 3 ESBL E.Coli 9 0 2 4 6 8 10
  • 15. ANTIBIOTIC RESISTANCE OUTPATIENTS TMP-SMX 11.11% Nitrofurantoin 5.55% Cephalosporins 16.66% OUTPATIENTS FQs 44.40% 0 0.1 0.2 0.3 0.4 0.5
  • 16. RESISTANCE PATTERN INPATIENTS Colistin 0% 71.43% FQs 57.14% 17.86% Cotrimoxazole 32.14% INPATIENTS Amikacin 21.43% 10.71% Cefoperazone+Sulba… 21.43% 46.43% Ampicillin+Sulbactam 28.57% 0.00%20.00%40.00%60.00%80.00%
  • 17. ACUTE UNCOMPLICATED CYSTITIS  Sexually active young women.  Causes: anatomy and certain behavioral factors, including delays in micturition, sexual activity, and the use of diaphragms and spermicides tract.  Aggressive diagnostic work- ups are unwarranted in young women presenting with an uncomplicated episode of cystitis.
  • 18. ACUTE UNCOMPLICATED CYSTITIS  The microbiology is limited to a few pathogens.  70%- 85% are caused by Escherichia coli  5-20%are caused by coagulase-negative Staphylococcus saprophyticus  5-12% are caused by other Enterobacteriaceae such as Klebsiella and Proteus.
  • 19. ACUTE UNCOMPLICATED CYSTITIS  Clinical Features: dysuria, frequency, urgency, suprapubic pain, hematuria.  Fever >38C, flank pain, costovertebral angle tenderness, and nausea or vomiting suggest upper tract infection.
  • 20. ACUTE UNCOMPLICATED CYSTITIS  Diagnosis: direct history and PE  PE: Temperature, abdominal exam, assessment of CVA tenderness, pelvic exam.  H/o STD’s, new sexual partner, partner with urethral symptoms, gradual onset.
  • 21. ACUTE UNCOMPLICATED CYSTITIS  Guidelines for tx of acute cystitis recommend empiric antibiotic tx.  Unnecessary antibiotic use??  Clinical criteria for Dx: Dysuria, presence of > trace urine leukocytes, and presence of nitrites or... Dysuria and frequency in the absence of vaginal discharge.
  • 22. ACUTE UNCOMPLICATED CYSTITIS  UA:Evaluation of midstream urine for pyuria.  White blood cell casts in the urine are Dx of upper tract infection.  Urine Culture: Not necessary  Warranted in: Suspected complicated infection, persistent symptoms following tx, symptoms recur < 1 mo after tx.
  • 23. ACUTE UNCOMPLICATED CYSTITIS  Urine dipsticks:  Leukocyte esterase (pyuria), sensitivity 75- 90%, specificity 95%  Nitrite (Enterobacteriacea), sensitivity 35- 85%, specificity 95%, false positive with phenazopyridine, beets.  Microscopic evaluation for pyuria or a culture is indicated in pt with negative leukocyte esterase that have urinary symptoms.
  • 24. ACUTE UNCOMPLICATED CYSTITIS  Susceptibility:  E.coli  30% isolates resistance to ampicillin and sulfonamides  Increasing of resistance to TMP-SMX  Resistance to nitrofurantoin is <5%  Resistance to fluoroquinolones <5%  S.saprophyticus  3% resistant to TMP-SMX  0% resistant to nitrofurantoin  0.4% resistant to ciprofloxacin
  • 25. ACUTE UNCOMPLICATED CYSTITIS  Treatment:  Short course vs. prolonged tx  Short course preferred except with beta-lactam agents  TMP-SMX (160/800mg BID x 3) first-line tx if: no allergy to the drug, no antibiotics in the past 3 mo, no recent hospitalization.  Nitrofurantoin (100mg BID x 5 days)  Analgesia: Phenazopyridine 200mg TIDx2
  • 26. ACUTE COMPLICATED CYSTITIS  UTI when/with structural, functional or metabolic abnormalities (polycystic, solitary, transplant kidney;DM, CRF, indwelling cath, neurogenic bladder) or elderly, male, child, pregnant or h/o recurrent UTI)  E.coli accounts for fewer than one third of complicated cases.  Clinically, the spectrum of complicated UTIs may range from cystitis to urosepsis with septic shock.
  • 27. ACUTE COMPLICATED CYSTITIS  Urine culture and susceptibility are necessary.  These infections are usually associated with high- count bacteriuria (> 10(5) CFU/mL).  MO: Proteus, Klebsiella, Pseudomonas, Serratia, and Providencia, enterococci, staphylococci and fungi AND E.coli
  • 28. ACUTE COMPLICATED CYSTITIS  Empiric therapy for these patients should include an agent with a broad spectrum of activity against the expected uropathogens: fluoroquinolone, ceftazidime, cefepime, aztreon am, imipenem-cilastatin. (Obtain Ucx prior to Tx)  Tx x 7-14 days  Follow-up urine culture should be performed within 14 days after treatment???
  • 29. RECURRENT CYSTITIS  Up to 27% of young women with acute cystitis develop recurrent UTIs.  The causative organism should be identified by urine culture.  Relapse: infection with the same organism (multiple relapses = complicated UTIs).  Recurrence: infection with different organisms.
  • 30. RECURRENT CYSTITIS  >3 UTI recurrences documented by urine Cx within one year can be managed using one of three preventive strategies: 1. Acute self-treatment with a three-day course of standard therapy. 2. Postcoital prophylaxis with one-half of a TMP- SMX double-strength tablet (80/400 mg). 3. Continuous daily prophylaxis TMP-SMX one-half tablet per day (40/200 mg); nitrofurantoin 50 to 100 mg per day; norfloxacin 200 mg per day.
  • 31. UNCOMPLICATED PYELONEPHRITIS  Suspect if:  Cystitis-like illness and accompanying flank pain  Severe illness with fever, chills, nausea, vomiting, abdominal pain  Gram-negative bacteremia.
  • 32. UNCOMPLICATED PYELONEPHRITIS  DX: Clinical, confirm with:  UA: pyuria and/or WBC casts  UCx with > 10 (5) CFU/mL (80%)  Tx: 14 days total  Oral: TMP/SMX, fluoroquinolones  IV: 3rd gen cephalosporin, aztreonam, quinolones, aminoglycoside
  • 33. UNCOMPLICATED PYELONEPHRITIS  Pt with symptoms after 3 days of appropriate antimicrobial tx should be evaluated by renal US or CT for obstruction or abscess.
  • 34. UTI IN MEN  At risk: Older men with prostatic disease, UT instrumentation, anal sex, or partner colonized with uropathogens.  UCx: 10 (3) CFU/mL sensitivity and specificity 97%.  Additional studies?  Not necessary in young healthy men who have a single episode.
  • 35. UTI IN MEN  Tx:  Uncomplicated cystitis:  TMP/SMX or fluoroquinolones x 7 days  Complicated cystitis:  Fluoroquinolones x 7-14 days  Bacterial prostatitis:  Fluoroquinolone x 6-12 weeks
  • 36. CATHETER-ASSOCIATED UTI  Risk of bacteriuria is ~ 5%/day (long term catheter bacteriuria is inevitable).  40% of nosocomial infections  Most common source of gram-negative bacteremia.  Dx: Ucx 10 (2) CFU/mL  MO: E.coli, Proteus, Enterococcus, Pseudomona, Enterobacter, Serratia, Candida
  • 37. CATHETER-ASSOCIATED UTI  Mild to mod: oral quinolones10-14days  Severe infection: IV/oral 14-21days  Asymptomatic bacteriuria in pt with an indwelling Foley should not be Tx unless they are immunosuppressed, have risk of bacterial endocarditis or pt who are about to undergo urinary tract instrumentation.
  • 38. ASYMPTOMATIC BACTERIURIA  UCx: > 10(5)CFU/mL with no symptoms  Three groups of pt with asymptomatic bacteruria have been shown to benefit from tx:  Pregnant  Renal transplant  Pt who are about to undergo urinary tract procedures.
  • 39. PREGNANT PATIENTS  Asymptomatic bacteriuria: two consecutive voided urine specimens with isolation of the same bacterial strain >10(5) or a single cath urine specimen.  Nitrofurantoin 100mg BID x 5-7 days  Amoxi/Clav 500mg BID or 250 TID x 7days  Fosfomycin 3g PO x 1
  • 40. URINARY CATHETER • Developed in the 1920s by Dr. Frederick Foley • The urinary catheter was originally an open system with the urethral tube draining into an open container. • In the 1950s, a closed system was developed in which the urine flowed through a catheter into a closed bag. 40
  • 41. Urinary Catheter Utilization • About 25% of patients during their hospitalization • Almost all of them are placed the same admission • A large number is placed in ED • Intensive care medical-surgical units 41
  • 42. Urinary catheters are not harmless… • Urinary tract infection • Mechanical trauma to urethra and bladder • Immobility (restraining patient)* Prolonged stay? Pressure Ulcers? Falls? *Saint S, Ann Intern Med 2002; 137: 125-7 42
  • 43. HOSPITAL-ACQUIRED UTI: PREVALENCE • 600,000 patients develop hospital-acquired UTI’s per year • Catheter-associated infections (CAUTI) comprise 80% of these cases • UTIs account for 40% of all hospital-acquired infections 43
  • 44. CATHETER ASSOCIATED UTI (CAUTI)  Catheter-risk of bacteriuria increases each day of use: • Per day: 5% • 1 week: 25% • 1 month: 100% 44
  • 45. BIOFILM: EXTRACELLULAR POLYMERS (DONLAN, CID 2001; 33:1387–92, LIEDL, CURR OPINION UROL 2001;11: 75-9)  Organisms attach to and grow on a surface and produce extracellular polymers  Intraluminal ascent (48hours) of bacteria faster than extraluminal (72-168 hours)  Most catheters used >1 week have biofilms Staphylococcus aureus biofilm on an indwelling catheter.  Extraluminal more CDC Public Health Image Library important in women 45
  • 46. Usually females Usually males 46 Maki, Emerg Infect Dis 2001; 7: 1-6
  • 47. 47 Maki, Emerg Infect Dis 2001; 7: 1-6
  • 48. BACTERIOLOGIC MONITORING • Not recommended for asymptomatic patients. • Only culture the urine if the patient has symptoms of an UTI such as fever, chills, and abdominal pain • Cloudy urine ≠infection • Sediment in urine ≠infection 48
  • 49. ASYMPTOMATIC BACTERIURIA  No benefit from treatment  Increased risk of resistance and C. difficile disease with treating asymptomatic bacteriuria  Pyuria does not equate infection when catheter present  Avoid urine cultures unless patient is symptomatic or if it is a part of sepsis workup in a catheterized patient 49
  • 50. ACCEPTABLE INDICATIONS FOR URINARY CATHETER PLACEMENT  Acute urinary retention or obstruction  Perioperative use in selected surgeries  Assist healing of perineal and sacral wounds in incontinent patients  Hospice/comfort/ palliative care  Required immobilization for trauma or surgery  Chronic indwelling on admission 50 50
  • 51. ACUTE URINARY RETENTION OR OBSTRUCTION  Outflow obstruction: examples include prostatic hypertrophy with obstruction, urethral obstruction related to severe anasarca, urinary blood clots with obstruction  Acute urinary retention: this may be medication induced, medical (neurogenic bladder) or trauma to spinal cord. 51 51
  • 52. PERIOPERATIVE USE IN SELECTED SURGERIES  Urologic surgery or other surgery on contiguous structures of the genitourinary tract  Anticipated prolonged duration of surgery, large volume infusions during surgery, or need for intraoperative urinary output monitoring  Spinalor epidural anesthesia may lead to urinary retention; prompt discontinuation of this type of anesthesia should prevent need for urinary catheter placement 52 52
  • 53. ASSIST HEALING OF PERINEAL AND SACRAL WOUNDS IN INCONTINENT PATIENTS  Thisis a relative indication when there is concern that incontinence is leading to worsening skin integrity in areas where there is skin breakdown 53 53
  • 54. HOSPICE/ COMFORT CARE/ PALLIATIVE CARE  Thisis a relative indication. In end-of-life situations, it is reasonable to accommodate the patient’s wishes on what provides them with the best comfort 54 54
  • 55. REQUIRED IMMOBILIZATION FOR TRAUMA OR SURGERY  This includes: 1. unstable thoracic or lumbar spine 2. multiple traumatic injuries such as pelvic fractures 3. Acute hip fracture is risk for dislocation 55 55
  • 56. CHRONIC INDWELLING URINARY CATHETER UPON ADMISSION  Patientsfrom home or extended care facility with a chronic urinary catheter 56 56
  • 57. UNACCEPTABLE REASONS FOR PLACEMENT  Urine output monitoring OUTSIDE intensive care  Incontinence  Morbid obesity  Immobility  Confusion or dementia  Patient request 57 57
  • 58. URINE OUTPUT MONITORING OUTSIDE INTENSIVE CARE  This includes: 1. Close urinary output monitoring by nephrology in patients with renal failure 2. Monitoring of urine output in patients with congestive heart failure on diuretics  Potential solutions: 1. Use urinals for men and hats for women (to monitor output) 2. Accurate daily weights. 58 58
  • 59. URINE OUTPUT MONITORING OUTSIDE INTENSIVE CARE  For patients with congestive heart failure, consider involving the patient  Provide patients with information regarding how to document their output and daily weights (consider pamphlets)  This will also help the patient learn to accurately measure their output. 59
  • 60. INCONTINENCE  Incontinence should not be a reason for urinary catheter placement. Patients admitted from home or from extended care facilities with incontinence managed their incontinence without problems prior to admission. Mechanisms to keep the skin intact need to be in place and avoid urinary catheter placement in that population. 60 60
  • 61. INCONTINENCE: POTENTIAL SOLUTIONS  Use Skin Barrier Creams for protection  Start Toilet Training:  Offer use of bedpan or assist patient up to commode regularly  Evaluate for any wet bed linen and change if wet at the time patient is being turned in bed 61 61
  • 62. PATIENTS TRANSFERRED FROM INTENSIVE CARE TO FLOOR  The intensive care is an area where high prevalence of urinary catheter utilization is present.  Evaluating those who are transferred to non- intensive care units for need of urinary catheter and discontinuation of those not needed may significantly reduce unnecessary utilization 62 62
  • 63. MORBID OBESITY AND IMMOBILITY  Morbid obesity should not be a trigger for urinary catheter placement. Patients that are morbidly obese have functioned without a urinary catheter prior to admission. The association of immobility and morbid obesity may lead to more inappropriate catheter placement. This may result in more immobility with the urinary catheter being a “one point restraint” 63 63
  • 64. IMMOBILITY: POTENTIAL SOLUTIONS  Start toilet training every 2 hours  Offer bedpan, urinal or assist patient out of bed  Of 145 hospitalized patients with a high risk for pressure ulcers, urinary catheter presence was associated with 1.8 times risk of pressure ulcer compared to those without urinary catheter (p=0.03). The most significant association was between urinary catheter catheter use and stage 2 pressure ulcer. 64 64
  • 65. CONFUSION OR DEMENTIA  Patients with confusion or dementia should not have a urinary catheter placed unless there is an indication for placement 65 65
  • 66. THE VERY ELDERLY PATIENTS  Disproportionate use inappropriately in the very elderly.  It may be a marker of immobility, incontinence, and dementia? 66
  • 67. PATIENT REQUEST  Although healthcare workers may report that patients want the urinary catheter in, this is infrequently documented. The only exception is in patients that are end of life or palliative care.  Patient’s Convenience: - Example: patient on diuretics and does not want to move out of bed multiple times - Education is key! Provide reasons to patient of increased risk of urinary catheter : urine infection, skin breakdown, deep venous thrombosis and/or pneumonia due to immobility 67 67
  • 68. INCREASED WORK LOAD FOR HEALTHCARE WORKERS (HCW)  Increased acuity of patients or reduction of the nurse to patient ratio  e.g., patient is incontinent and immobile and requires multiple changes of sheets  Potential solution: link it to other initiatives (eg. pressure ulcer prevention requires frequent repositioning of patients), evaluate the nurse to patient ratio, shift resources to support the HCW that has more responsibilities 68
  • 69. WHAT NEEDS TO BE DONE  Both nurses and physicians should evaluate the indications for urinary catheter utilization.  Physicians should promptly discontinue catheters that are no longer needed.  Nurses evaluating catheters and finding no indication should contact physician to promptly discontinue catheter. 69
  • 70. THANK YOU