Ø 4B TOOL: UTI Guidelines Form

Tools and Resources

Purpose: Urinary tract infection (UTI) treatment guidelines. Gives background, local microbiology data, and suggested empiric regimens.

Source: F. Palmieri, Bronx-Lebanon Hospital.

Instructions: Review and adapt as appropriate.

Background

Escherichia coli constituted 91 percent of community-acquired urinary isolates in the past year in BLHC.
Bacterial resistance to sulfamethoxazole/trimethoprim (SMZ/TMP) and fluoroquinolones has increased.
Urine culture and susceptibility (C & S) tests are strongly recommended for any therapy changes.
Modify therapy according to BLHC UTI guidelines.
Do not use SMZ/TMP as empiric therapy or ciprofloxacin as initial therapy due to high resistance to E. coli.

% Sensitive Urinary Isolates, Community Acquired (2010)

E. Coli	Antibiotics
45	Ampicillin/sulbactam
75	Amoxicillin/clavulanate
92	Ceftriaxone
78	Cefazolin
74	Ciprofloxacin
87	Cefuroxime
94	Nitrofurantoin
95	Piperacillin/tazobactam
63	Sulfamethoxazole/trimethoprim
88	Gentamicin
39	Ampicillin

Guideline Recommendations

Step 1: Urinalysis

Urinalysis (UA).
Urine micro.
Urine culture:
- Before antibiotics are started.
- For ED patients.
- Inpatients with UTIs.
- All patients with suspected pyelonephritis.

Step 2: Empiric Antibiotics

Refer to table.

Step 3: Pathogen-Directed Therapy

With culture and susceptibility results, change antibiotic to pathogen-specific agent.
Follow up on all discharged patients to provide appropriate therapy based on culture and sensitivity results.
SMZ/TMP can be used at this point as dictated by the C & S results.
Reserve fluoroquinolones for pyelonephritis and major systemic infections due to resistance development.

Step 4: Duration

As important as the therapy itself.
Excessive use can lead to:
- Adverse reactions.
- Increased antimicrobial resistance.
Refer to table for specific duration recommendations.

Step 5: Epidemiologic Surveillance

With time and selective pressure, resistance patterns will change.
At least once a year, susceptibility patterns will be reassessed and the need to change treatment recommendations evaluated.

Asymptomatic Bacteriuria

Asymptomatic bacteriuria is defined as isolation of a specific quantitative count of bacteria in an appropriately collected urine specimen from an individual without sign or symptoms of a urinary tract infection.
Avoiding treatment of asymptomatic bacteriuria is important for reducing the development of antibiotic resistance.
Treatment of asymptomatic bacteriuria is not appropriate for: women (premenopausal, nonpregnant), diabetics, elderly people, nursing home residents, or patients with spinal cord injury or indwelling urethral catheters.
Treatment of asymptomatic bacteriuria is appropriate for pregnant women and for patients undergoing urologic procedures in which mucosal bleeding is expected.

Empiric Therapy Regimen

Acute Uncomplicated Cystitis

Antibiotic Recommendations	Caution	Duration	Possible Side Effects (selected)
Nitrofurantoin (Macrobid) 100 mg twice daily	Do not use if CrCl <60. Do not use for elderly patient >65 years old. Do not use during pregnancy at term (38 to 42 weeks gestation). Caution in cholestatic jaundice and hepatic dysfunction.	5 days	GI intolerance; Lupus-like reactions; rash Rare: peripheral neuropathy; trigeminal neuralgia pulmonary reactions; hepatitis; hemolytic anemia in G6PD deficiency
Cefuroxime 250 mg oral q12h	Avoid in penicillin allergy. If CrCl <10mL/min, administer once daily.	7 days	Anaphylaxis (PCN allergic); diarrhea; other super infections; eosinophilia; positive Coombs test; interstitial nephritis; hemolytic anemia
Cefpodoxime 100 mg oral q12h	Avoid in penicillin allergy. If CrCl <30mL/min, administer once daily.	7 days	As above
Ciprofloxacin 250 mg oral q12h—3rd line therapy due to resistance. If selected, urine culture with followup is recommended.	If CrCl <30mL/min, administer once daily.	5 days	C. difficile colitis; QTc prolongation; nephritis; tendon rupture; neuropathy

Acute Uncomplicated Pyelonephritis

Antibiotic Recommendations	Caution	Duration	Possible Side Effects (selected)
Initial Therapy
Ceftriaxone 1 g IV/IM 1^st dose	Avoid in serious, type-I PCN allergy	Initial dose	As above for cefuroxime plus pseudocholelithiasis
Gentamicin IV 3 mg/kg x1 dose	No adjustment for *initial dose* needed for renal failure	Initial dose	Renal function
Followup Therapy—Tailor Therapy to Culture and Sensitivity Report; Otherwise:
Ciprofloxacin 500 mg oral q12h	As above	7 to 14 days	As above
Cefuroxime 250 mg oral q12h	As above	7 to 14 days	As above
Cefpodoxime 200 mg oral q12h	As above	7 to 14 days	As above

References

1. 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 Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011:52(5):e103-20. Review.

2. Nicolle LE, Bradley S, Colgan R, et al Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54.

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Current as of September 2012

Internet Citation: Ø 4B TOOL: UTI Guidelines Form: Tools and Resources. September 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/cdifftoolkit/cdiffl2tools4b.html