Urinary tract infections

Course content

Course roadmap
Basic concepts

Common infections

2
 "The thoughtless person playing with
penicillin treatment is morally
responsible for the death of the man
Sir Alexander who succumbs to infection with the
Fleming penicillin-resistant organism.”

Nobel prize winner

for the discovery of
penicillin, 1945

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 Core Competencies
Core competencies for
antimicrobial prescribing
C1: Understands the patient and the patient’s clinical needs
C2: Understands treatment options and how they support the
patient’s clinical needs
C3: Works in partnership with the patient and other healthcare
professionals to develop and implement a treatment plan
C4: Communicates the treatment plan and its rationale clearly to
the patient and other health professionals
C5: Monitors and reviews the patient’s response to treatment

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 Objectives
• Understand the frequent occurrence and implications of
contaminated urine cultures and of asymptomatic bacteriuria
• Illustrate the complexity of using urinalysis and urine culture to
support the diagnosis of urinary tract infections
• Demonstrate the use of local evidence-based guidelines based
upon local antimicrobial resistance data in managing urinary tract
infections

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Positive urine cultures could be due to:

Contaminated culture

Asymptomatic bacteriuria

Urinary tract infection (UTI)

WHO/A. Kristensen

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 Antibiotics commonly inappropriately
prescribed for asymptomatic bacteriuria
Antimicrobial
use

Antimicrobial resistance

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 Core Competencies 1, 2, 3 & 4

PART 1:
Asymptomatic bacteriuria
WHO/A. Kristensen

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 Clinical case 1
Diagnostic
work-up
Clinical
Clinical Therapeutic re-assessment Modify
assessment decisions antimicrobials
Data
Patient review
education
Initial evaluation Subsequent evaluation

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45 year-old female with:
a positive urine culture 3 weeks ago

urine culture performed because of

dysuria & urinary frequency

now asymptomatic

normal physical exam

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 Clinical case 1

Should she submit

another sample for
urine culture?

WHO/O. Karatuna

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Obtain urine culture only when you
suspect UTI
• Contaminated urine
cultures and
asymptomatic
bacteriuria (ASB) are
common
WHO/O. Karatuna

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 Urinalysis interpretation
• high numbers of
squamous epithelial cells
suggests specimen
contamination

• absence of pyuria
provides reassurance
against a UTI
WHO/O. Karatuna

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 Asymptomatic bacteriuria (ASB)
• Limited indications for ASB treatment
– Pregnancy
– Invasive urologic procedure

• Test of cure cultures should NOT be performed

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 Clinical case 1

Should she submit

another sample for
urine culture?

WHO/O. Karatuna

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Review the microbiologic data

• The presence of 3
organisms suggests a
contaminated
specimen.
• Was it necessary?
WHO/O. Karatuna

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 Core Competencies 1, 2, 3 & 4

Clinical case 1

Should she submit another sample for urine culture? NO!

• She is asymptomatic.
• No indication for culture.
• Provide patient education

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 Core Competencies 1, 2, 3, 4 & 5

PART 2:
Using guidelines to manage cystitis
WHO/A. Kristensen

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 Clinical case 2

Diagnostic
work-up
Clinical
Clinical Therapeutic re-assessment Modify
assessment decisions antimicrobials
Data
Patient review
education
Initial evaluation Subsequent evaluation

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45 year-old female with:
Dysuria, urinary frequency

Denies vaginal discharge

Subjective fevers

Physical exam normal

Received trimethoprim-sulfamethoxazole
2 months ago

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 Core Competencies 1 & 2

An informed choice

Drug Patient
Severity Source resistance factors Cultures

Optimal antibiotics

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 How severe is the patient’s condition?

Drug Patient
Severity Source resistance factors Cultures

Stable outpatient

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 What is the likely source?

Drug Patient
Severity Source resistance factors Cultures

• Cystitis
• Most common uropathogen: E. coli

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 What is the likely source?

Drug Patient
Severity Source resistance factors Cultures

• Consider reasons for recurrent cystitis

and/or alternative diagnoses

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 How likely is resistance?

Drug Patient
Severity Source resistance factors Cultures

• Recent antimicrobial use? YES

• Local cumulative susceptibility data?

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 No. isolates

4792
56
Ampicillin

72
Cezafolin

86
Ceftriaxone

90
99 Cefepime

Ertapenem
86

Gentamicin
92

Amikacin
69

Ciprofloxacin
92

Nitrofurantoin
of E. coli isolated from urine

Trimethoprim-
70

sulfamethoxazole
Example: annual cumulative antibiogram

Percent susceptible
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to given drug
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 Core Competency 2

Empiric regimen per guidelines

2010 IDSA/ESCMID Guidelines
Uncomplicated Cystitis in Women
• Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily
• Fosfomycin trometamol 3 gm single dose
• Pivmecillinam 400 mg twice daily

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 Core Competency 2

Empiric regimen per guidelines

2016 Public Health England
Uncomplicated Cystitis in Women
First line:
• Nitrofurantoin monohydrate/macrocrystals 100 mg twice daily
Alternatives:
• Trimethoprim 200 mg twice daily
• Pivmecillinam 200 mg three times daily

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 Core Competency 2

Adapting guidelines
2010 IDSA/ESCMID Guidelines
2016 PHE Guidance
• Adapt based upon local drug availability and resistance
patterns.

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 Core Competency 2

Adapting guidelines
2010 IDSA/ESCMID Guidelines
2016 PHE Guidance
• Adapt based upon local drug availability and resistance
patterns.

• Avoid fluoroquinolones for uncomplicated UTI when alternative

antibiotics are possible.

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 Clinical case 2
Local guidelines
Diagnostic
work-up
• E. coli
Clinical
urine isolates
Clinical Therapeutic re-assessment
susceptibility pattern:Modify
assessment decisions antimicrobials
• 85% trimethoprim-
Data
Patient review
sulfamethoxazole
education
Initial evaluation • 92% nitrofurantoin
Subsequent evaluation

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 Other considerations?

Drug Patient
Severity Source resistance factors Cultures

• Allergies? NO
• Renal or liver dysfunction? NO
• Pregnant? NO

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 Do I need cultures?

Drug Patient
Severity Source resistance factors Cultures

Urine culture

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An appropriate urine sample for culture
• Clean the skin
• Collect midstream
• Use sterile container
• Transportation delays impact
accuracy
• Contribute data for local
surveillance
WHO/O. Karatuna

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 Return to case

Drug Patient
Severity Source resistance factors Cultures

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 Core Competency 2

Duration per guidelines

2010 IDSA/ESCMID Guidelines
Uncomplicated Cystitis in Women
• Nitrofurantoin monohydrate/macrocrystals 100 5 days
mg bid
• Trimethoprim-sulfamethoxazole 160/800 mg bid 3 days
• Fosfomycin trometamol 3 gm 1 dose
• Pivmecillinam 400 mg bid 5 days

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 Core Competency 2

Duration per guidelines

Public Health England
Uncomplicated Cystitis
First line: Women:
• Nitrofurantoin 100 mg BID 3 days
Alternatives:
• Trimethoprim 200 mg BID Men:
• Pivmecillinam 200 mg TDS 7 days

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 Core Competencies 1, 2, 3, 4 & 5

Clinical case 2
Diagnostic
work-up
Clinical
Clinical Therapeutic re-assessment Modify
assessment decisions antimicrobials
Data
Patient review
education
Initial evaluation Subsequent evaluation

40
 Core Competencies 1, 2, 3, 4 & 5

Clinical case 2
Diagnostic
work-up
Clinical
Clinical Therapeutic re-assessment Modify
assessment decisions antimicrobials
Data
Patient review
education
Initial evaluation Subsequent evaluation

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Review: Urinary Tract Infections
Drug

prescription
Dose .............
.............
Route
.............

Duration

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 Review: Urinary Tract Infections
Obtain urine culture ONLY when Drug
you clinically suspect a UTI.

prescription
Dose .............
.............
Route
.............

Duration

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 Review: Urinary Tract Infections
Obtain urine culture ONLY when Drug
you clinically suspect a UTI.

Obtain an appropriate urine

prescription
sample for culture. Dose ............. Route
.............
.............

Duration

44
 Review: Urinary Tract Infections
Obtain urine culture ONLY when Drug
you clinically suspect a UTI.

Obtain an appropriate urine

prescription
sample for culture. Dose ............. Route
.............
.............
Use local guidelines to guide
empiric antimicrobial choice
and duration.
Duration

45
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