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Asymptomatic Bacteriuria

Residents With a Positive Urine Culture OR�a Positive Urinalysis

NO SYMPTOMS of Infection

Have Asymptomatic Bacteriuria… and Should NOT Be Treated.

NOT �a UTI!

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Asymptomatic Bacteriuria, continued¹

Asymptomatic bacteriuria affects around 50% of residents
It is not associated with increased morbidity or mortality
Unnecessary antibiotics are associated with:

Adverse side effects
C. difficile infections
Public health outcomes such as widespread antibiotic resistance

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Diagnosing a UTI

Dysuria �(pain with urination)

Systemic Signs

(fever or chills)

One or more symptoms that localize to the genitourinary tract�(frequency, urgency, bladder or pelvic pain, hematuria, new or worsening urinary incontinence)

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Case 1: Melba

Melba is an 88-year-old resident
Admitted for rehabilitation after a hip replacement

It hurts a lot when I urinate. I feel like I have to go and then nothing comes out.

Otherwise, I’m doing OK.

Based on Melba’s symptoms, a urinalysis and culture should be obtained

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Case 1: Allergy Assessment

Before making antibiotic choices, review the resident’s chart to determine if there are any contraindications to specific antibiotics.

Melba’s Chart

Most recent labs:

Normal creatinine
Normal liver function tests

Allergies: penicillin

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Case 1: Allergy Assessment, continued

Ask Melba if she remembers what her allergy was to penicillin.

This sounds like a severe penicillin allergy.

I had it in the hospital. I had hives and itching. The doctor told me it was a penicillin allergy.

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Common Urinary Pathogens

CIP Ciprofloxacin

LFX Levofloxacin

NIT Nitrofurantoin

TRM Trimethoprim/Sulfamethoxazole

AM Ampicillin/Amoxicillin

AMC Amoxicillin/Clavulanate

CFZ Cefazolin/Cephalexin

ORGANISM	# OF ISOLATES	AM	AMC	CFZ	CIP	LFX	NIT	TRM
Enterobacter cloacae	40	5%	5%	3%	88%	88%	33%	88%
Escherichia coli	213	55%	84%	82%	65%	66%	97%	86%
Klebsiella pneumoniae	31	0%	84%	74%	68%	68%	97%	94%
Serratia marcescens	16	0%	0%	0%	94%	94%	0%	0%

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Case 1: What Empiric Antibiotic Should We Use?^2,3

Antibiotic	Decision	Reason
Ciprofloxacin	Not a great choice for this situation.	There are rising rates of fluoroquinolone resistance, particularly in long-term care.
Cephalexin	Not a great choice for this situation.	Cephalosporins have a <5% cross reactivity rate of allergy to penicillins, so they should be avoided if the patient reports a severe reaction such as hives or anaphylaxis. They can be used in patients who report a self-limited rash after receiving penicillins.
Nitrofurantoin	Great choice for this situation.	Nitrofurantoin is safe for use for uncomplicated cystitis and can be used in residents with reduced renal function when used for 5 days.
Trimethoprim-sulfamethoxazole (TMP-SMX)	Great choice for this situation.	There is no cross-reactivity with penicillin, and resistance rates are dependent on the local epidemiology (review the local antibiogram).

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Common Antibiotics Used To Treat UTIs^2,3

Antibiotic	Route	Information About Antibiotic	Most Common Adverse Events/Notes
TMP-SMX (Bactrim)	Oral	Concentrates in urinary tract	Hyperkalemia, rash, warfarin interaction
Nitrofurantoin (Macrobid)	Oral	Urinary tract only; few short-term systemic effects	Only use for 5 days to avoid side effects
Cefazolin/ Cephalexin	IV/oral	Less data for use in UTIs; excreted by kidneys into the urinary tract system	Rash
Ampicillin/ Amoxicillin	IV/oral	Less data for use in UTIs; excreted by kidneys into the urinary tract system	Rash
Fosfomycin	Oral	Concentrates in bladder, associated with diarrhea	Most Gram-negative organisms besides E. coli are resistant to fosfomycin; expensive
Ciprofloxacin	Oral	Broad-spectrum; fairly high level of resistance	Tendonitis, confusion, QTc prolongation; strong association with C. difficile infection; warfarin interaction

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Recommended Antibiotic Durations

Uncomplicated cystitis

Female, no catheter, no stones
A 3- to 5-day course is sufficient

Complicated UTI

Male, catheter, possible stones, urological abnormalities
Prescribe a 7- to 14-day course

Follow up initial urine culture results and adjust therapy based on antibiotic sensitivities

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Case 1: Urine Culture Results

Urine culture results: organism is resistant to every antibiotic tested except meropenem
Melba still has dysuria and some incontinence

No fevers
Vital signs otherwise normal
Eating well

Consider fosfomycin

>100,000 cfu/mL

E. coli

Ampicillin R
Cefoxitin R
Meropenem S
Nitrofurantoin R
TMP-SMX R
Ciprofloxacin R

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Antibiotic-Resistant Infections⁴

For resistant and uncomplicated infections, consider fosfomycin

One 3-gram dose is sufficient to treat uncomplicated cystitis
Fosfomycin can be considered for E. coli, but since most Gram-negative organisms are resistant to fosfomycin, it may not be effective for other Gram-negative organisms including Klebsiella species and Pseudomonas aeruginosa
Can cause diarrhea

Fosfomycin

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Case 2: Billy

Billy is a 83-year-old resident

History of a cerebrovascular accident
Nonverbal
Has an indwelling urinary catheter due chronic urinary retention

Refuses his dinner and seems to be sleeping more than usual
Temperature of 100.5^oF
Does not have a cough, tachypnea, or increased oxygen requirements
Appears to have some suprapubic tenderness

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Case 2: Should We Test His Urine?

Billy has a long-term indwelling urinary catheter and has a new fever and a change in mental status.

Analysis

No other signs suggest another source of infection
It is reasonable to send a urinalysis and culture

Yes

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Interpreting Urine Culture Results⁵

>100,000 CFU/mL ESCHERICHIA COLI

ANTIBIOTIC	MIC (ug/ML)	INTERPRETATION
AMPICILLIN	>16	R
AMPICILLIN/SULBACTAM	8/4	I
CEFAZOLIN	<=4	S
CIPROFLOXACIN	<=0.25	S
TMP-SMX	<=0.5/9.5	S
NITROFURANTOIN	>16	S

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Case 2: What Antibiotic Should We Use?

No known allergies to antibiotics

>100,000 µg/mL E. coli

MIC INT

Ampicillin >16 R
Ampicillin-sulbactum 8/4 S
Cefdinir <=1 R
Meropenem <=0.5 S
Nitrofurantoin <16 S
TMP-SMX <=0.5/9.5 S
Ciprofloxacin <=0.25 S

Recent Lab Review Reveals:

Cr 1.9 mg/dL (GFR 30)
AST 31 (normal)
ALT 25 (normal)
WBC 11.4K

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Case 3: Shirley

Shirley fell while getting up to go to the bathroom
Sent to the emergency department (ED) for evaluation and x rays

X rays were normal

The ED sent a urinalysis (UA)

UA returned positive with >100 WBCs/hpf, positive nitrites, and positive leukocyte esterase

ED sent her back to the facility with a prescription for a 7-day course of ciprofloxacin

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Do You Think Shirley Needs an Antibiotic?

Had not complained of any urinary symptoms the day before her fall
Still reports no urinary symptoms
Says that she got up to go to the bathroom and tripped over her call button
Does not report fatigue, fever, chills, or any other issues�

Together, Shirley and her health care team agree to stop the antibiotic.

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Important To Understand

Changing the plan does not reflect poorly on the prescribing clinician.
All antibiotic prescriptions that come from the hospital should be re-evaluated when the resident transfers to long-term care.

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Key Points

Choose the most narrow-spectrum antibiotic based on cultures to treat UTIs�
Fluoroquinolones should be avoided as an empiric choice due to resistance and side effects�
Antibiotics should be continued for 3–5 days for uncomplicated cystitis and 7–14 days for complicated UTI depending on response�
Follow up culture results (even from the hospital) and narrow or stop treatment accordingly

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Activities To Complete

Activity, Stewardship Team	Activity, Frontline Providers
Hold monthly antibiotic stewardship team meetings Analyze data from ongoing interventions Share the results with frontline staff, the senior executive, other stakeholders Celebrate results! Collect and analyze data using the Monthly Data Collection Form	Introduce the Learning From Antibiotic-Associated Adverse Events form and encourage staff to use this when a resident was harmed or had the potential to be harmed (“near-miss”) by an antibiotic Review the Talking With Residents and Family Members About Urinary Tract Infections poster and display in common areas, such as break rooms and work stations Distribute the Urinary Tract Infections one-pager to prescribing clinicians and other frontline staff Apply the Four Moments of Antibiotic Decision Making Form to 5–10 residents each month
Supporting Materials
Urinary Tract Infections and Asymptomatic Bacteriuria one-pagers Talking With Residents and Family Members about Urinary Tract Infections poster Antibiotic Side Effects one-pager Four Moments of Antibiotic Decision Making Form Monthly Data Collection Form Learning From Antibiotic-Associated Adverse Events

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Disclaimer

The findings and recommendations in this presentation are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this presentation should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Any practice described in this presentation must be applied by health care practitioners in accordance with professional judgment and standards of care in regard to the unique circumstances that may apply in each situation they encounter. These practices are offered as helpful options for consideration by health care practitioners, not as guidelines.
Use of brand, manufacturer, or vendor names is for identification only and does not imply endorsement by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services.

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References

Nicolle LE, SHEA Long-Term-Care-Committee. Urinary tract infections in long-term-care facilities. Infect Control Hosp Epidemiol. 2001 Mar; 22(3):167-75. PMID: 11310697.
Viray M, Linkin D, Maslow JN, et al. Longitudinal trends in antimicrobial susceptibilities across long-term-care facilities: emergence of fluoroquinolone resistance. Infect Control Hosp Epidemiol. 2005 Jan;26(1):56-62. PMID: 15693409.
Oplinger M, Andrews CO. Nitrofurantoin contraindication in patients with a creatinine clearance below 60 mL/min: looking for the evidence. Ann Pharmacother. 2013 Jan;47(1):106-11. PMID: 23341159.
Huttner A, Kowalczyk A, Turjeman A, et al. Effect of 5-day nitrofurantoin vs single-dose fosfomycin on clinical resolution of uncomplicated lower urinary tract infection in women: a randomized clinical trial. JAMA. 2018 May 1;319(17):1781-9. PMID: 29710295.
Centers for Disease Control and Prevention. Public Health Image Library (PHIL). Office of the Associate Director for Communications, Division of Public Affairs. https://phil.cdc.gov/phil/details.asp. Accessed September 29, 2017.

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