Download 2013

TO SEND OR NOT TO SEND?
THE ROLE OF URINE
CULTURES IN
UNCOMPLICATED UTI
Patricia Moriarty, MSN, FNP-BC, APRN
June 3, 2016
OBJECTIVES
1.
2.
3.
4.
List the indications for a urine culture.
Define an uncomplicated UTI
Define a complicated UTI
List three first-line antibiotic regimens for the treatment of
lower UTI.
Pop Quiz: WHAT DO YOU KNOW
ABOUT CYSTITIS?
(Medscape 4/1/2016)
•
A.
B.
C.
D.
Which of the following causes most uncomplicated cystitis
cases?
Proteus mirabilis
Escherichia coli
Klebsiella pneumonia
Enterococcus faecalis
Pop Quiz: WHAT DO YOU KNOW
ABOUT CYSTITIS?
(Medscape 4/1/2016)
•
A.
B.
C.
D.
Which of the following is the most important risk factor for
cystitis in women?
Interference with the flow of urine (eg. stone in the bladder)
Antibiotic use
Allergies
Sexual activity
Pop Quiz: WHAT DO YOU KNOW
ABOUT CYSTITIS?
(Medscape 4/1/2016)
•
A.
B.
C.
D.
Which of the following symptoms is suggestive of
pyelonephritis rather than cystitis?
Nausea and vomiting
Hematuria
Dysuria
Flank pain
Pop Quiz: WHAT DO YOU KNOW
ABOUT CYSTITIS?
(Medscape 4/1/2016)
•
A.
B.
C.
D.
Which of the following is the criterion standard for diagnosis
of a UTI?
Urine microscopy
Dipstick testing
Urine Culture
Nitrate test
Pop Quiz: WHAT DO YOU KNOW
ABOUT CYSTITIS?
(Medscape 4/1/2016)
Which of the following statements is true regarding the
treatment of uncomplicated acute cystitis in women?
A. Women who receive effective antibiotic treatment still
typically experience severe symptoms for at least 7 days.
B. Without treatment, a significant number of uncomplicated
cystitis cases in women spontaneously resolve.
C. The likelihood of uncomplicated acute cystitis that goes
untreated progressing to pyelonephritis is high.
D. The first-choice agents for treatment of uncomplicated acute
cystitis are beta-lactam antibiotics.
•
FEMALE ANATOMY
Reason for UTI TQI Study
•
Visits for urinary tract infections (UTIs) account for many patient visits at
Student Health Services:
– According to ICD 9 599.0 (now ICD 10 code N39.0) (UTI), the following
encounters were noted:
• 671 patient encounters from 8/1/2012 to 7/31/2013 (716 encounters
from 8/1/2011 to 7/31/2012)
• 270 patient encounters from 1/1/2013 to 5/31/2013 (352 encounters
from 8/1/2012 to 12/19/2012)
•
•
•
Inconsistencies amongst providers ordering urine cultures had been originally
proposed and confirmed at the 2012 audit (49% did not meet evidence based
criteria for obtaining a urine culture).
A follow up audit was indicated to note any change in practice after 1/2013
education and the implementation of a UTI template for SHS EMR.
Per ACOG, “a urine culture is not required for the initial treatment of women
with a symptomatic lower urinary tract infection (UTI)…..”
Purpose of UTI TQI Study
•
Whether evidence-based practice interventions regarding the ordering of
urine cultures utilized at SHS changed after education and implementation of
a UTI template for SHS EMR.
 Research reveals a urine culture is NOT indicated for the vast majority of
UTIs.
 To identify the role of urine cultures in uncomplicated UTIs according to
evidence-based practice at SHS.
 To identify the cost effectiveness of urine culture tests performed at SHS.
• urine culture: $48.00
• plus urine sensitivity: $47.00
• TOTAL: $95.00
UTIs
•
According to UpToDate 2016:
 “Urine dipstick in the absence of a urine culture is sufficient for diagnosis
of uncomplicated cystitis if symptoms are consistent with a UTI unless
there is reason to suspect antimicrobial resistance or other complicating
features!”
Co-Morbidities &
Complicating Factors
•
•
•
•
•
•
•
•
•
•
•
•
DM
Immunosuppression
Urologic Structural/Functional Abnormality
Spinal Cord Injury
Nephrolithiasis
Recent hospitalization/Catheter
Symptoms for > 7 days
Pregnancy
Vaginitis symptoms/STD concerns
Pyridium use
Recent UTI treatment
Travel outside the U.S. in the preceding 3-6 months
Uncomplicated UTI
Dysuria, urinary frequency, urgency, suprapubic pain and/or
hematuria are consistent with symptoms of an uncomplicated
UTI
• Absence of fever, chills, flank pain, CVAT, N/V or other
suspicion for pyelonephritis
• Able to take oral medication
• No antimicrobial therapy for a UTI
within 6 months
•
Urine Culture Indications
•
•
•
•
If symptoms are not characteristic of an uncomplicated UTI
If there are the presence of co morbidities
If symptoms persist for > 7 days or recur within 6 months of antimicrobial
therapy
If a complicated infection is suspected such as pyelonephritis
Urine Dipsticks
•
•
•
Leukocyte esterase may be used to detect > 10 leukocytes per high power
field (sensitivity of 75-96%; specificity of 94-98%).
The nitrite test is fairly sensitive and specific though it lacks adequate
sensitivity for detection of other organisms so negative results should be
interpreted with caution.
Dipstick analysis is the least expensive and time intensive test.
Microbial Spectrum
•
•
E. coli (75-95%)
Enterobacteriaceae such as Proteus mirabilis and Klebsiella
pneumoniae
• Staphylococcus saprophyticus
•
Resistance rates > 15-20%
necessitate a change in
antibiotic class
E. coli Sensitivity Updated
1/22/2013
94.92
0
CIPROFLOXACIN
33
617
67.08
139
CEPHALOTHIN
75
436
82.62
0
SULFAMETHOXAZOLE
113
% Sensitive
537
Intermediate Sensitivity
Resistent
99.54
3
0
NITROFURANTOIN
sensitive
647
80.62
0
TETRACYCLINE
126
524
60.77
40
AMPICILLIN
215
395
0
100
200
300
400
Total Cases Treated
500
600
700
Klebsiella Sensitivity Updated
1/22/2013
100.00
0
0
CIPROFLOXACIN
49
83.67
4
CEPHALOTHIN
2
41
87.76
1
SULFAMETHOXAZOLE
4
43
% Sensitive
71.43
Intermediate Sensitivity
9
NITROFURANTOIN
3
Resistent
35
Sensitive
81.63
0
TETRACYCLINE
7
40
0.00
1
AMPICILLIN
48
0
0
20
40
60
Total Cases Treated
80
100
120
Enterobacter aerogenes Sensitivity Updated 1/22/2013
100.00
0
0
CIPROFLOXACIN
22
4.55
1
CEPHALOTHIN
20
1
100.00
0
0
SULFAMETHOXAZOLE
22
% Sensitive
68.18
Intermediate Sensitivity
6
NITROFURANTOIN
1
Resistent
15
Sensitive
90.91
1
1
TETRACYCLINE
20
4.55
0
AMPICILLIN
21
1
0
20
40
60
Total Cases Treated
80
100
120
Staph. saprophyticus
UPDATED
1/22/2013
Sensitivity
96.49
1
LEVOFLOXACIN
0
55
28.07
0
ERYTHROMYCIN
33
% SENSITIVE
16
Intermediate Sensitivity
Resistent
94.74
sensitive
0
SULFAMETHOXAZOLE
2
54
87.72
0
TETRACYCLINE
6
50
0
20
40
60
Total Cases Treated
80
100
120
Treatment Regimens For Uncomplicated
Acute Bacterial Cystitis
Antimicrobial Agent
Dose
When to avoid
Nitrofurantoin
 SHS cost $27.00
100mg PO BID x 5 days
 Suspicion for early
pyelonephritis and is
contraindicated when
creatinine clearance is
< 60mL/min
Bactrim DS
• SHS cost $12.00
One tab PO BID x 3 days
 Avoid if resistance rate
> 20%.
 Avoid if use in the past 3-6
months and travel,
particularly international
travel.
Fosfomycin
• Not offered at SHS
• Expensive
• No generic
3 gm single dose
 Avoid if there is suspicion
for early pyelonephritis
Second-Line Therapy For
Uncomplicated Acute Bacterial
Cystitis
Antimicrobial Agent
Fluoroquinolones (FQ) are effective but should
be reserved for more invasive infections.
Infectious Disease Society of
America (IDSA)
• IDSA first published clinical practice guidelines for
the treatment of UTI in 1999 followed by an update
in 2010.
• “Macrobid is under-prescribed, while TMP/SMX and
Cipro are over-prescribed” per IDSA.
TQI UTI AUDIT 2013 Findings
Was a UTI History Obtained by the
Provider?
2012
74 out of 75 charts did!
98.7%
2013
80 out of 80 charts did!
100%
The following was noted:
30%
25%
20%
2012
15%
2013
10%
5%
0%
No LMP noted
No mention of sx duration
The following were not always
routinely asked:
70%
60%
50%
Last UTI HX
40%
Comorbidities
30%
Vaginitis sx
Pyridium use
20%
STD concerns
10%
0%
2013
Were there any complicating
factors such as:
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Symptoms > 7
days
Vaginitis type
symptoms
Pyridium use
prior to visit
On menses at
time of the visit
Any Co-morbidities noted?
2%
1%
1%
0%
2012 comorbidities
2013 comorbidities
Was a Urinalysis Multistix Done?
2012 urine dip done
Yes:
93.3%
No: 6.7%
2013 urine dip done
YES: 95%
NO: 5 %
Reasons for Not Having a Urine
Multistix Done:
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
2012 why
Multistix not done
2013 why multistix
not done
Was a Urine Culture Done?
2013
2012
YES: 52%
NO: 48%
YES:
56.25%
NO:
43.75%
Uncomplicated UTI & Urine Culture
50
45
40
35
30
25
20
15
10
5
0
2012
2013
Uncomplicated UTI
Urine C & S
How many patients did NOT meet
evidence based criteria for obtaining a
urine culture?
Complicated UTI & Urine Culture
40
35
30
25
20
2012
15
2013
10
5
0
No Urine Culture
Complicated UTI
Complicated UTI
8
7
6
5
4
2012
3
2013
2
1
0
UTI < 6 months
Sx's > 7 days
Kidney Stones
Was a Temperature taken?
2013
2012
Yes: 94.7%
No: 5.3%
YES: 98.7%
No: 1.3%
Was an Abdominal/CVAT exam
Performed?
2013
2012
Yes:
80%
Yes:
92.5%
No: 20%
No: 7.5%
Analysis of no documentation of an
abdominal and/or CVAT Exam
60%
50%
40%
30%
2012
2013
20%
10%
0%
No abdominal
or CVAT exam
Abdominal
exam only
CVAT exam
only
Antibiotic prescribed?
70%
60%
50%
40%
30%
2012
20%
2013
10%
0%
Urine Culture Results
60%
50%
40%
30%
20%
10%
0%
2012
2013
Bactrim Resistance in sample
70%
60%
50%
40%
30%
20%
10%
0%
2012
2013
E. Coli
Bactrim
prescribed
Those
prescribed
Bactrim with
resulting
resistance
Any follow-up needed related
to the UTI?
90.00%
80.00%
70.00%
60.00%
50.00%
2012
40.00%
2013
30.00%
20.00%
10.00%
0.00%
Yes
No
Analysis of patients requiring follow-up:
6
5
4
3
2
1
0
2012
2013
UTI EMR Scenario for UTI
Telephone Management Strategy for Acute
Uncomplicated Cystitis
JAMA. 2014;312(16):1677-1684. doi:10.1001/jama.2014.12842
Example of a Telephone Management Strategy for Acute Uncomplicated Cystitis
• Individuals Eligible for Telephone Management
– Adult women with acute onset (duration, <7-10 days) of at least 1 of the
following: dysuria, frequency, urgency, or gross hematuria.
– No flank or abdominal pain
– No fever (>100.5° F)
– Ability to urinate in past 4 hours
– Able to take oral medications
– Not pregnanta
– No comorbid conditions (eg, immunosuppression)a
– No voiding abnormalities (eg, neurogenic bladder)
– No history of sexually transmitted disease or new sex partner
– No vaginal symptoms
– No recent urinary tract infection (past 4-6 weeks) or urological procedure
Telephone Management Strategy for Acute
Uncomplicated Cystitis
JAMA. 2014;312(16):1677-1684. doi:10.1001/jama.2014.12842
Therapy Regimens
• Modify based on local susceptibility rates.
• Preferred:
– Fosfomycin, one 3-g dose
– Nitrofurantoin, 100 mg twice a day for 5 days
– Trimethoprim-sulfamethoxazole, 1 double-strength tablet
twice daily for 3 days
• Alternative:
– Ciprofloxacin, 250 mg twice daily for 3 days
CONCLUSION
• Acute uncomplicated UTI in women can be
diagnosed without an office visit (telephone)
or a urine culture.
• Define an uncomplicated UTI.
Uncomplicated UTI
• Uncomplicated UTIs are defined as:
– Acute onset of dysuria, urgency, and/or
frequency in a healthy pre-menopausal nonpregnant woman without known functional or
anatomical abnormalities of the urinary tract!
– Absence of fever
– Absence of vaginal symptoms
Complicated UTI
•
•
•
•
•
•
•
•
•
•
•
•
DM (some research questions)
Immunosuppression
Urologic Structural/Functional Abnormality
Spinal Cord Injury
Nephrolithiasis
Recent hospitalization/Catheter
Symptoms for > 7 days
Pregnancy
Vaginitis symptoms/STD concerns
Pyridium use
Recent UTI treatment
Travel outside the U.S. in the preceding 3-6 months
Post Test Questions
• A 20-year-old woman with NKDA presents to the
university student health service with a 2-day history of
increasing urinary frequency along with urgency and
dysuria. Her urine is reportedly blood tinged. She has no
history of a prior UTI. The patient had recently become
sexually active and she was using a barrier
contraception with spermicide.
1. Is this a complicated or uncomplicated UTI?
2. Does this patient need a urine culture?
3. Would a telephone visit be appropriate?
4. What antibiotic should this pt receive?
5. What other questions would you ask?
Post Test Questions
• Now this same 20 y/o female college student returns
in one month with the same urinary symptoms plus
genital pain. Patient denies any other related
symptoms and this patient is asking for Bactrim DS
that she received one month ago because “it
worked”.
1.
2.
3.
4.
Complicated or uncomplicated UTI?
Does this patient need a urine culture?
Does this patient need an exam?
Would you prescribe Bactrim DS because it worked last
time to resolve her urinary symptoms?
UTI Differential Diagnosis?
• Ideas????????????
UTI Differential Diagnosis
(Some)
• Herpes simplex (HSV)
N. gonorrhoeae
Chlamydia
Trichomonas
Vaginitis
Nephrolithiasis
Trauma
GU tuberculosis
GU neoplasm
Intra-abdominal abscess
Sepsis - source other than GU system
REFERENCES
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•
•
•
•
•
•
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Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary Tract infections: epidemiology,
mechanisms of infection and treatment options. National Review of Microbiology. May 2015;
13(5): 269-284.
Geerlings S. Urinary tract infections: a common but fascinating infection, with still many research
questions. Current Opinion in Infectious Diseases. February 2015; 28: 86-87.
Grigoryan L, Gupta K. Diagnosis and Management of Urinary Tract Infections in the Outpatient
Setting. JAMA. 2014;312(16):1677-1684. doi:10.1001/jama.2014.12842
Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment
of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious
Disease Society of America and the European Society For Microbiology and Infectious disease.
Clin Infect Dis. 2011; 52:e103-120.
Hooten TM, Gupta K. Acute uncomplicated cystitis and pyelonephritis in women. 2016 UpToDate.
Kim M, Lloyd A, Condren M, Miller MJ. Beyond antibiotic selection: concordance with the IDSa
guidelines for uncomplicated urinary tract infections. Infection. 2015; 43:89-84.
Slekovec C, Leroy J, Vernaz-Hegi N, et al. Impact of a region wide antimicrobial stewardship
guideline on urinary tract infection prescription patterns. Int J Clin Pharm. 2012; 34:325-329.
Stapleton AE. Urine culture in uncomplicated UTI: Interpretation and significance. Curr Infect Dis
Rep. 2016; 18:15.
QUESTIONS??
Contact: Patricia Moriarty APRN
[email protected]