GU infection

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 and/or bacteriuria alone are not indicative of infection.
  • Anuric ESRD patients may have bacteriuria from colonization due to lack of flushing of bladder, avoid sending UA/Ucx unless patient is symptomatic
  • Treatment only required for specific populations:
    • Pregnant women (screening performed at 12 – 16 weeks)
    • Anticipated urologic intervention
    • Some renal transplant recipients, depending on time since transplant

 

Uncomplicated Urinary Tract Infection (UTI)

Background

  • Clinical symptoms of UTI (dysuria/urgency/frequency/ hematuria) in non-pregnant, immunocompetent, neurologically-intact pts with normal urologic anatomy and no indwelling urinary catheters
  • Treatment < 5 days is not adequate when treating with a beta-lactam. Avoid amoxicillin or ampicillin due to increasing resistance
  • Nitrofurantoin cannot be used for ascending UTI or pyelonephritis
  • Antibiotics should be tailored if culture data are available.

 

Evaluation

  • Assessment of urinary symptoms
  • UA + reflex urine Cx (Cx if pt is admitted or has recurrent UTIs)
  • Non-reflex urine Cx: pregnant pts, neutropenia, and pts undergoing urologic procedures

 

Management

  • Empiric therapy
    • Nitrofurantoin monohydrate: 100 mg PO BID x 5 days (avoid if any concern for pyelonephritis or if creatinine clearance <60)
    • 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 of micro lab and are only possible for E. coli and E. Faecalis.
    • Amoxicillin-clavulanate: 500mg PO BID x5 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 from overuse (~25% of E. coli are resistant to ciprofloxacin at VUMC)
      • Adverse effect profile >> beta-lactams (i.e. QT-prolongation, tendinopathies)

 

Additional Information

  • MDR cystitis: ESBL isolates are increasingly common due to antibiotic overuse
  • Before treating, decide if this is a TRUE UTI
  • If true, then for uncomplicated cystitis with ESBL organism, consider Fosfomycin (if E. coli) or nitrofurantoin (if susceptibility is confirmed – K. pneumoniae and Enterobacter spp are usually resistant), or ID consultation
  • Ask the lab to check susceptibility results to these antibiotics, for the future reference

 

Complicated UTI and Pyelonephritis

Background

  • Fever, pyuria, and costovertebral angle tenderness suggest pyelonephritis. If any of the following are present, it is also considered a complicated UTI
  • UTI with any of the following present:
    • Renal calculi or other obstructive disease, Immunosuppressed host, abnormal urological anatomy or physiology, presence of a urinary catheter

Evaluation

          •  
  • UA with reflex urine culture
  • BCx and UCx prior to antibiotics
  • 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

  • Duration: 7-14 days, depending on antibiotic choice
  • Follow up culture to confirm clearance, especially if outpatient
  • Tailor therapy once/if cultures are available. If no improvement in 48h, consider imaging to rule out complications (e.g., perinephric abscess)

 

 

First Line

Alternative

Outpatient

Ciprofloxacin 750 BID

(or 500 BID if bacteremia r/o)

 x 7d

 

Inpatient

- CTX 2g q24h
-
Cefepime 2g q8h


- Meropenem 2g q8h (if h/o or confirmed ESBL w/in last 90 d)

- Ertapenem 1g q24 instead of Meropenem if no Pseudomonas
 

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

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

 

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 and/or bacteriuria alone are not indicative of infection in patients 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

 

Management

          •  
  • Distinguish uncomplicated vs complicated UTI (see above)
  • Antimicrobial management:
    • Guided by cultures and susceptibilities
    • Empiric guidance as per management of uncomplicated/complicated UTI and per prior culture data/susceptibilities when available
    • Duration: 7 – 14 days depending on antibiotic, 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
    • Echinocandins do not, and other azoles are not well studied in UTIs
    • If fluconazole resistant Candida 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, catheters should be removed
    • If catheterization is necessary, intermittent catheterization is preferred over continuous use. Condom catheters and pure wicks preferred over foley catheter