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The not-so-simple Urinary Tract Infection Sampling, prescribing and referring in General Practice

The not-so-simple Urinary Tract Infection Sampling, prescribing and referring in General Practice. Dr. Nicholas Foster Consultant Microbiologist, LTHT. Introduction Modern context of antibiotic prescribing Antibiotic resistance Complications of antibiotics : HCAI Sampling: the MSU explained

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The not-so-simple Urinary Tract Infection Sampling, prescribing and referring in General Practice

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  1. The not-so-simple Urinary Tract InfectionSampling, prescribing and referring in General Practice Dr. Nicholas Foster Consultant Microbiologist, LTHT

  2. Introduction Modern context of antibiotic prescribing Antibiotic resistance Complications of antibiotics : HCAI Sampling: the MSU explained UTI in different patient groups Healthy non-pregnant female patients Upper urinary tract infection (ie. loin pain, fever etc.) Pregnant women Catheterised patients Children Male patients

  3. Urinary Tract Infection Common condition (most common bacterial infection in women); 3% GP workload. Most frequent specimen sent to the lab (700 specimens/day) 50% women will be affected in their life Significant % of simple UTI’s will resolve without antibiotics Antibiotics reduce symptom duration and rare complications

  4. Modern context of antibiotic prescribing • Antibiotic resistance • The down sides to antibiotics : HCAI

  5. Psst! Hey kid! Wanna be a Superbug….? Stick some of thisinto your genome…. Even ciprofloxacin won’t be able to harm you…! It was on a shortcut through the ward that Albert was first approached by a member of the Antibiotic Resistance

  6. Modern Context- Antibiotic Resistance

  7. Modern Context- Antibiotic Resistance

  8. Modern Context- Antibiotic Resistance

  9. Modern Context- Antibiotic Resistance

  10. Modern Context- Antibiotic Resistance

  11. Modern Context- Antibiotic Resistance Clinical details Ref number: Dysuria, frequency Antibiotic therapy Received: 09.03.10 12:49 None stated Authorized: 12.03.10 11:42 Final report -------- Urine MSU WBC count: 6968 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Present Microscopy Culture >10^5 cfu/ml Coliform SENSITIVITY Amox/Ampicillin RESISTANT Ciprofloxacin RESISTANT Cefradine/Cefalexin RESISTANT Nitrofurantoin RESISTANT Trimethoprim RESISTANT Augmentin RESISTANT Pivmecillinam RESISTANT Doxycycline RESISTANT Comments Multi-resistant coliform (ESBL+ve). Limited oral antibiotic options.

  12. Modern Context- Complications of antibiotic use • Antibiotics viewed as “no-risk” intervention • Overgrowth of other organisms (eg. Yeast) • Allergy (excludes range of ABx making subsequent management problematic) • Disruption of “natural flora”- GI upset • Selection pressure for resistance eg. MRSA, ESBL, MDR-TB, VRE. • Clostridium difficile infection

  13. Modern Context- Complications of antibiotic use • Fluoroquinolones (ciprofloxacin) and cephalosporins are most highly implicated antibiotics for causing CDI • These agents should only be used where an alternative agent is not available • New antibiotic treatment guidelines soon to be published • Various initiatives within the PCT to help reduce the use of these agent

  14. Monthly count of C. difficile infections for patients 2 years and over – NHS Leeds (HPA data) Modern Context- Complications of antibiotic use

  15. Sampling • Adults: Mid Stream specimen • Women should part labia • Men should retract the foreskin • Pass the first part into the bowl • Without interrupting the flow pass some urine into the bottle (Red top bottle, boric acid) • Children: clean catch • Try and catch it when the child passes! • Babies: nappy pad sample • Clean babies perineum as much as possible • Fresh nappy with pad, collect by squeezing out into a bottle as soon passed water

  16. Report Clinical details Ref number: Dysuria, frequency, symptoms persisting Antibiotic therapy Received: 24.02.10 09:38 trimethoprim Authorized: 25.02.10 11:33 Final report -------- Urine MSU WBC count: 468 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Present Microscopy Culture >10^5 cfu/ml Coliform SENSITIVITY Amox/Ampicillin RESISTANT Cefradine/Cefalexin Sensitive Nitrofurantoin Sensitive Trimethoprim RESISTANT

  17. Report Clinical details Ref number: Dysuria, frequency, symptoms persisting Antibiotic therapy Received: 24.02.10 09:38 trimethoprim Authorized: 25.02.10 11:33 Final report -------- Urine MSU WBC count: 468 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Present Microscopy Culture >10^5 cfu/ml Coliform SENSITIVITY Amox/Ampicillin RESISTANT Cefradine/Cefalexin Sensitive Nitrofurantoin Sensitive Trimethoprim RESISTANT

  18. Report Clinical details Ref number: Dysuria, frequency, symptoms persisting Antibiotic therapy Received: 24.02.10 09:38 trimethoprim Authorized: 25.02.10 11:33 Final report -------- Urine MSU WBC count: 468 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Present Microscopy Culture >10^5 cfu/ml Coliform SENSITIVITY Amox/Ampicillin RESISTANT Cefradine/Cefalexin Sensitive Nitrofurantoin Sensitive Trimethoprim RESISTANT

  19. Report Clinical details Ref number: Dysuria, frequency, symptoms persisting Antibiotic therapy Received: 24.02.10 09:38 trimethoprim Authorized: 25.02.10 11:33 Final report -------- Urine MSU WBC count: 468 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Present Microscopy Culture >10^5 cfu/ml Coliform SENSITIVITY Amox/Ampicillin RESISTANT Cefradine/Cefalexin Sensitive Nitrofurantoin Sensitive Trimethoprim RESISTANT

  20. Report Clinical details Ref number: Dysuria, frequency, symptoms persisting Antibiotic therapy Received: 24.02.10 09:38 trimethoprim Authorized: 25.02.10 11:33 Final report -------- Urine MSU WBC count: 468 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Present Microscopy Culture >10^5 cfu/ml Coliform SENSITIVITY Amox/Ampicillin RESISTANT Cefradine/Cefalexin Sensitive Nitrofurantoin Sensitive Trimethoprim RESISTANT

  21. Report Clinical details Ref number: Dysuria, frequency, symptoms persisting Antibiotic therapy Received: 24.02.10 09:38 trimethoprim Authorized: 25.02.10 11:33 Final report -------- Urine MSU WBC count: 468 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Present Microscopy Culture >10^5 cfu/ml Coliform SENSITIVITY Amox/Ampicillin RESISTANT Cefradine/Cefalexin Sensitive Nitrofurantoin Sensitive Trimethoprim RESISTANT

  22. Report Clinical details Ref number: Dysuria, frequency, symptoms persisting Antibiotic therapy Received: 24.02.10 09:38 trimethoprim Authorized: 25.02.10 11:33 Final report -------- Urine MSU WBC count: 468 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Present Microscopy Culture >10^5 cfu/ml Coliform SENSITIVITY Amox/Ampicillin RESISTANT Cefradine/Cefalexin Sensitive Nitrofurantoin Sensitive Trimethoprim RESISTANT

  23. Report Clinical details Ref number: Dysuria, frequency, symptoms persisting Antibiotic therapy Received: 24.02.10 09:38 trimethoprim Authorized: 25.02.10 11:33 Final report -------- Urine MSU WBC count: 468 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Present Microscopy Culture >10^5 cfu/ml Coliform SENSITIVITY Amox/Ampicillin RESISTANT Cefradine/Cefalexin Sensitive Nitrofurantoin Sensitive Trimethoprim RESISTANT

  24. Cases

  25. Case 1: 34 yr old woman presenting with symptoms of dysuria and frequency

  26. Case 1: 34 yr old woman presenting with symptoms of dysuria and frequency • Diagnosis based on symptoms not Ix • Presence of dysuria and frequency: UTI >90% likely • Greatly reduced if vaginal discharge present • Urine appearance has sensitivity of 90% • Dipsticks (use Leucocytes AND Nitrites) are only helpful if patient has limited symptoms • Routine culture felt to be unnecessary

  27. Case 1: 34 yr old woman presenting with symptoms of dysuria and frequency • Options (BMJ article) • Give antibiotics empirically • Give delayed prescription (reduce ABx use by 20-25%) • Use Dipstick to target antibiotics • Use symptom severity score to target antibiotics • Send MSU and target antibiotics according to results • No difference in symptom severity or duration for 1-4 • Possible prolongation of symptoms for 5 • Concludes routine MSU is unnecessary but highlights the need to identify those with UTI’s caused by resistant pathogens • Infection with resistant organisms associated with prolonged symptoms

  28. Case 1: 34 yr old woman presenting with symptoms of dysuria and frequency Pt presents with ≥ 2 symptoms Pt presents with <2 symptoms Pt with recurrent UTI’s Dipstick urine to define diagnosis Send MSU to determine organism and sensitivity Delayed Px or Empiric Px No improvement in symptoms

  29. LTHT Data: GP specimens, n = 3151, collected 1st Jan ’10 - 1st March’10

  30. Case 1: 34 yr old woman presenting with symptoms of dysuria and frequency • First Line: • Trimethoprim 200mg 12-hourly for 3 days OR • Nitrofurantoin 50mg 6-hourly for 3 days • Second line: should be determined by sensitivities

  31. Case 1: 34 yr old woman presenting with symptoms of dysuria and frequency “Why not just use ciprofloxacin as it has the lowest resistance rate” • Very useful agent- increasing resistance • Complications: Diarrhoea inc.CDI, MRSA

  32. …same patient presenting feeling unwell, history of chills, sweats and loin pain • Clinical history of Upper UTI (pyelonephritis) • Always send MSU before starting treatment • Adjust treatment according to culture results • Oral treatment suitable for mild infection only • Consider admission for IV therapy if clinically unwell or if no response to therapy within 24 hours. • Relapse and re-infection common- require further investigation • First Line: • Ciprofloxacin 500mg 12-hourly for 7 days • Alternatives: • Cefalexin 500mg 12-hourly for 10 days • Trimethoprim 200mg 12-hourly for 10 days

  33. Case 2: You are given the urine result of a 24 yr old woman 29/40 pregnant. Urine: Dipstick “positive” at antenatal visit. MW sent for MSU. ReportClinical details Ref number: Pregnant 29 weeks gestation Blood in urine Protein in urine Antibiotic therapy Received: 01.03.10 19:22 Authorized: 02.03.10 15:30 Final report -------- Urine MSU WBC count: 46 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Present Microscopy Culture >10^5 cfu/ml Coliform SENSITIVITY Amox/Ampicillin Sensitive Cefradine/Cefalexin Sensitive

  34. Case 2: You are given the urine result of a 24 yr old woman 29/40 pregnant. Urine: Dipstick “positive” at antenatal visit. MW sent for MSU. • Asymptomatic bacteriuria in pregnancy should be treated • Reduces risks of: • Progression to UUTI • Pre-term delivery • Low birth weight babies • If contamination suspected then confirm with 2nd MSU • Symptomatic bacteriuria requires MSU and empiric ABx • First Line: • Cefalexin 500mg 12-hourly for 7 days (shown to be as effective as continuous throughout pregnancy) • Repeat MSU at each subsequent antenatal visit

  35. Case 3: 83 yr old nursing home resident noted to have “cloudy looking urine” in catheter bag. CSU sent by nursing staff. Report Clinical details Ref number: Cloudy urine Antibiotic therapy Received: 05.03.10 14:51 None stated Authorized: 06.03.10 12:03 Final report -------- Urine CSU WBC count: 646 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Present Microscopy Culture >10^5 cfu/ml Coliform

  36. Case 3: 83 yr old nursing home resident noted to have “cloudy looking urine” in catheter bag. CSU sent by nursing staff. • “Cloudy/Smelly Urine” has poor predictive value • Diagnosing UTI in catheterised individual is challenging • WBC / RBC / NIT etc. normal finding in CSU • Dipstick unhelpful in making diagnosis • Asymptomatic “positive” results DO NOT require antibiotics • CSU should only be sent once diagnosis made • Treating symptomatic catheter-related UTI is futile without catheter change.

  37. Case 4: 68 yr old woman registering with the practice has NIT ++ and Prot + on Dipstick. An MSU is sent and the result passed to you. ReportClinical details Ref number: No clinical details given Antibiotic therapy Received: 24.02.10 09:38 None stated Authorized: 25.02.10 11:33 Final report -------- Urine MSU WBC count: <40 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Nil Present Microscopy Culture >10^5 cfu/ml Coliform SENSITIVITY Amox/Ampicillin Sensitive Cefradine/Cefalexin Sensitive Nitrofurantoin Sensitive Trimethoprim Sensitive

  38. Case 4: 68 yr old woman registering with the practice has NIT ++ and Prot + on Dipstick. An MSU is sent and the result passed to you. • Asymptomatic bacteriuria can be a normal finding in women and men over 65yrs of age • Antibiotic treatment offers no benefit but contributes to morbidity (antimicrobial resistance, side effect of medication)

  39. Case 5: mother with her 4 year old girl complaining of pain on passing water. Child otherwise well.

  40. Case 5: mother with her 4 year old girl complaining of pain on passing water. Child otherwise well. Infant or child <3 months Child ≥3 months Upper UTI Lower UTI Bug Sensitive to ABx prescribed Dipstick Clean Catch Commence Rx Review in 48h (with MSU results) No better Better Urgent refer to Paediatric Specialist Resistant bug on MSU -Change ABx -Review in further 48h No better

  41. Case 5: mother with her 4 year old girl complaining of pain on passing water. Child otherwise well.

  42. Case 5: mother with her 4 year old girl complaining of pain on passing water. Child otherwise well. • First Line: • Trimethoprim (dose dependent on age) for 3 days • Second Line (if already on trimethoprim prophylaxis): • Cephalexin (dose dependent on age) for 3 days • Prophylaxis • Antibiotic prophylaxis should not be routinely recommended in infants and children following first-time UTI. • Antibiotic prophylaxis may be considered in infants and children with recurrent UTI (trimethoprim is usual regimen). • Asymptomatic bacteriuria in infants and children should not be treated with prophylactic antibiotics.

  43. Case 6: A 62 year old man presents with a 3 day history of dysuria

  44. Case 6: A 62 year old man presents with a 3 day history of dysuria. • MSU should be taken in all men with symptoms of a UTI. • As samples from male patients are less likely to be contaminated a lower threshold (colony count) for infection can be taken (ie. <10^4 coliform may be significant). • 50% of patients with recurrent UTI’s and 90% of febrile UTI’s have prostatic involvement. • Men who have recurrent episodes, fail to respond to appropriate ABx or have features of Upper UTI should be referred to a Urologist for further investigation.

  45. Case 6: A 62 year old man presents with a 3 day history of dysuria Report Clinical details Ref number: No clinical details given Antibiotic therapy Received: 24.02.10 09:38 None stated Authorized: 25.02.10 11:33 Final report -------- Urine MSU WBC count: 72 /uL (normal range <40 /uL) RBC count: <140 /uL (normal range <140 /uL) Epithelial cells : Nil Present Microscopy Culture <10^4 cfu/ml Coliform SENSITIVITY Amox/Ampicillin Sensitive Cefradine/Cefalexin Sensitive Nitrofurantoin Sensitive Trimethoprim Sensitive

  46. Case 6: A 62 year old man presents with a 3 day history of dysuria • First Line: • Trimethoprim 200mg BD for 7 days • If relapse/recurrence or symptoms or signs suggestive of prostate involvement: • Ciprofloxacin 500mg BD for 14 days (guided by culture results)

  47. Summary • Not quite so simple • Potential to over prescribe antibiotics with severe long term consequences • Potential to under treat in certain groups • Use ciprofloxacin only when necessary • Taylor approach to different patient groups

  48. Further reading • NICE- Urinary Tract Infection in Children • SIGN- Management of Suspected Bacterial Urinary Tract Infection in Adults • Leeds Health Pathways- Antimicrobial Guidelines resource

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