Download RPO UTI Memo

IMPORTANT MEMORANDUM
To:
From:
Subject:
Date:
RPO Providers
Nelson Fernandez, M.D.
UTI Memo
June 19, 2012
Recurrent and/or complicated UTIs are a significant cause of hospital and SNF admissions and
readmissions. Below you will find relevant information regarding preventive strategies and treatment.
UTIs are frequently associated with the following
underlying conditions:
 Diabetes
 Pregnancy
 History of acute pyelonephritis in the past
year
 Symptoms for seven or more days before
seeking care
 Broad-spectrum
antimicrobial
resistant
uropathogen
 Hospital acquired infection
 Renal failure
 Urinary tract obstruction
 Presence of an indwelling urethral catheter,
stent, nephrostomy tube or urinary diversion
 Recent urinary tract instrumentation
 Functional or anatomic abnormality of the
urinary tract
 History of urinary tract infection in childhood
 Renal transplantation
 Immunosuppression
Preventive strategies include:
 Indwelling catheters – remove if no longer
needed;
routine
replacement
not
recommended if flow is adequate, in the
absence of infection.
 For recurrent UTIs (3 or more in 12 months)
strongly consider: Urologic evaluation to R/O
structural and/or functional abnormalities.
 Avoid dehydration in the elderly, and use of
spermicidal agents in younger woman.
 Consider topical estrogen replacement in
post-menopausal woman with recurrent UTIs.
 Inquire about urinary incontinence; if present
– evaluate and treat.
 In
bed-ridden
members
with
fecal
incontinence avoid indwelling catheters and
evaluate and treat any causes of diarrhea.
 Maximize
control
of
Diabetes
and
Immunosuppressive conditions.
 In stable members who have failed PO
medications and who are not candidates for
home IV antibiotics, consider direct SNF
admission for IV antibiotics rather than full
acute admission.
Treatment strategies include:
 Trimethoprim-sulfamethoxazole (160/800 mg [1 double strength tablet] twice-daily for 3 days) is an
appropriate 1st line choice for therapy.
 The fluoroquinolones, ofloxacin, ciprofloxacin, and levofloxacin, are highly efficacious in 3-day regimens but
have a propensity for collateral damage and should be reserved for important uses other than acute cystitis
and thus should be considered alternative antimicrobials for acute cystitis. Moxifloxacin should NOT be used
due to its poor renal penetration.
 Beta-Lactam agents, including amoxicillin-clavulanate, cefdinir, cefaclor, and cefpodoxime-proxetil, in 3–7day regimens are appropriate choices for therapy when other recommended agents cannot be used. Other
beta-lactams, such as cephalexin, are less well studied but may also be appropriate in certain settings.
Ampicillin and amoxicillin should NOT be used due to its poor efficacy.
 Nitrofurantoin while considered an appropriate 1st line choice, is considered a High Risk Medication (HRM)
therefore should be used only when two or more options have been used or a contraindication to other
agents (i.e. allergy). If alternative medication is not appropriate please call 1-800-331-6293 for override
considerations.
 Systemic antimicrobial prophylaxis should not be routinely used in patients with short-term or long-term
catheterization, including patients who undergo surgical procedures, to reduce catheter associated (CA)
bacteriuria or CA-UTI because of concern about selection of antimicrobial resistance.
 Important to follow up after culture and sensitivity information is available for appropriate antibiotic therapy.
 Prompt follow up and monitoring is recommended in complex members with multiple risk factors. If
response is inadequate, please consider outpatient IV antibiotics either at patient’s home or skilled nursing
facility.