alaska urinary tract infection treatment toolkit · 2020-05-19 · alaska urinary tract infection...

Alaska Urinary Tract Infection Treatment Toolkit

Urinary Tract Infection Treatment Guidelines These clinical guidelines are intended to aid in the selection of antimicrobial therapy for patients residing in Alaska who present with a urinary tract infection. Treatment guidelines available for the following Alaska care setting:

Inpatient Adult UTI Clinical Pathway Outpatient Adult UTI Clinical Pathway Long term care Adult UTI Clinical Pathway Pediatric UTI Clinical Pathway

These guidelines will help Alaska physicians and pharmacists

ensure patients receive the right antibiotic at the right time and only when necessary. UTI Guidelines are available for download on the A2SC website: https://www.ashnha.com/antimicrobial-stewardship/a2sc-resources/uti/ May 2019 Clinical Pearls for Providers: Urinary Uncertainty: Demystifying Culture Collection in Urinary Tract Infections The clinical pearls focus on knowing which clinical syndromes require urine culture and how to navigate typical urinalysis (UA) and urine culture order variations. Clinical pearls available for download on the A2SC website https://www.ashnha.com/wp-content/uploads/2019/05/UTI-diagnostics-Culture-Collections-Feb-2019.pdf Educational webinar Stewardship in Urinary Tract Infections – Dr. Ben Westley Webinar recording: https://ashnha.adobeconnect.com/pxzyyd28jhfx/?proto=true Alaska Antibiogram As a companion to the guidelines the 2017 Alaska State Antibiogram is also available to help guide the best antibiotic choice. https://www.ashnha.com/wp-content/uploads/2018/11/AK-2017-Antibiograms.pdf Patient education on antibiotic awareness This Alaska specific newsletter focuses on antibiotic awareness and UTI. https://www.ashnha.com/wp-content/uploads/2019/05/Newsletter-Feb-2019-1.pdf

About Alaska Antimicrobial Stewardship Collaborative

The Alaska Antimicrobial Stewardship Collaborative (A2SC) is an active partnership of hospitals and other health care stakeholders dedicated to developing innovative strategies to ensure appropriate antibiotic use. A2SC’s goal is a simple one: all patients in Alaska will receive the right antibiotic at the right time and only when necessary.

The emergence of antibiotic-resistant bacteria caused by the misuse and overuse of antibiotics is pushing the healthcare industry to re-evaluate how medicine is practiced. Together we will accelerate positive changes to achieve this critical goal.

https://www.ashnha.com/antimicrobial-stewardship/a2sc-resources/uti/

https://www.ashnha.com/antimicrobial-stewardship/a2sc-resources/uti/

https://www.ashnha.com/wp-content/uploads/2019/05/UTI-diagnostics-Culture-Collections-Feb-2019.pdf

https://www.ashnha.com/wp-content/uploads/2019/05/UTI-diagnostics-Culture-Collections-Feb-2019.pdf

https://ashnha.adobeconnect.com/pxzyyd28jhfx/?proto=true

https://www.ashnha.com/wp-content/uploads/2018/11/AK-2017-Antibiograms.pdf

https://www.ashnha.com/wp-content/uploads/2019/05/Newsletter-Feb-2019-1.pdf


Executive Summary: International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: CID 2011;52(5):561–564. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: CID 2010; 50:625–663. IDSA Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. CID 2005; 40:643–54. 2015 Updated Beers Criteria. The Alaska Antimicrobial Stewardship Collaborative (A2SC) and all participating organizations and individuals assume no duty to correct or update these guidelines. Although efforts are made to include material within these guidelines that is accurate and represents the current best practice, there are no representations or warranties regarding errors, omissions, completeness or accuracy of the information provided. These guidelines are not an attempt to practice medicine or provide specific medical advice and should not be used to make a diagnosis or to replace or overrule a qualified health care provider's judgment.

Alaska Antimicrobial Stewardship Collaborative (A2SC) Adult INPATIENT Urinary Tract Infection Treatment Guideline (Last Updated 10-2018)

Category Asymptomatic Bacteriuria Acute Cystitis Acute Pyelonephritis Complicated UTI / Catheter-Associated UTI (CAUTI)

Symptoms and/or

Risk Factors

Isolation of a specific quantity of bacteria in an appropriately collected urine specimen (≥105 cfu/mL or from catheter; ≥102 cfu/mL) from an individual WITHOUT signs or symptoms of infection.

General symptoms: Acute onset dysuria, frequency or urgency

Upper UTI is frequently associated with general symptoms PLUS back/flank pain, fever & chills.

Complicated UTI: Infection in males or in the presence of an anatomic/functional abnormality (e.g. enlarged prostate, calculi, obstruction, catheter or stent, neurogenic bladder, neutropenia).

Consider deviation from the below recommendations (or consult to ID provider) if any of the following risk factors for multidrug resistant organisms are present: antibiotic exposure within 90 days, presence of urinary invasive device(s), history of UTI with multi-drug resistant organism.

Culture & Susceptibility

(C&S) Investigation

Routine C&S is NOT indicated in asymptomatic patients unless screening in pregnancy or prior to urologic procedure with compromise of the urothelial mucosa.

If patient requires inpatient admission for acute cystitis, acute pyelonephritis, or complicated/catheter associated cystitis, urine C&S are critical in order to optimize therapy. Urine cultures should be collected from a midstream void prior to antibiotics or a freshly placed urinary catheter.

Recommended Treatment and

Duration

Treatment is NOT recommended for patients who fail to meet the below criteria (e.g. pregnancy or those undergoing urologic procedures). Pregnant women: (select one option) • Nitrofurantoin 100mg PO BID x

5d ** Note: contraindicated at 38-42 weeks gestation • Cephalexin 500mg PO BID x 5d

Urologic procedure: Direct treatment based on pre-procedure screening C&S.

First Line: (select one option) • Nitrofurantoin 100mg PO BID x

5d • Cephalexin 500mg PO BID x 7d Fluoroquinolone FDA Safety Alert: Disabling & potentially permanent adverse effects outweigh benefit in cystitis. Only use when no other alternatives exist. Second Line: • Ciprofloxacin 250mg PO BID x 3d **Note: If at risk for STIs w/ symptoms of urethritis, consider screening for chlamydia.

First Line: • Ceftriaxone 1g IV Q24H Second Line: • Ciprofloxacin 400mg IV Q12H • Levofloxacin 750mg IV Q24H Above recommendations are for empiric antimicrobial therapy, tailor maintenance therapy to C&S report. Duration: • Duration may vary based upon final antibiotic selection. • Shorter courses (7 days) are reasonable, if symptoms promptly resolve. • Longer courses (10-14 days) if delayed response, regardless if catheterized or not. • If female and < 65 years of age, a 3-day regimen may be considered for CAUTI with

catheter removal.

• Scope of this guideline is limited to immunocompetent adults >18 y/o without history of renal transplant. • Nitrofurantoin is contraindicated for CrCl < 30mL/min and in pregnancy at term (38-42wks). • Statewide E. coli susceptibility to TMP/SMX is <80% and should be avoided as empiric therapy, but may be considered if confirmed by C&S for complicated UTI or pyelonephritis (2 week duration). • If patient reports penicillin allergy, inquire about onset and severity of symptoms, as well as prior beta-lactam exposure and update patient medical record. Severe or life-threatening allergic reactions may include:

anaphylaxis, angioedema, urticaria, Stevens-Johnson Syndrome (SJS), etc. • Patients with recurrent UTIs should have empiric therapy selected based upon prior C&S results. • Chronic antibiotic prophylaxis for most patients with risk factors for recurrent, complicated UTI is NOT typically recommended. Risk of resistance outweighs the slight reduction in infection rate.

Note: This guideline is intended to aid in the selection of antimicrobial therapy in adult INPATIENTS residing in Alaska who are diagnosed with a urinary tract infection. It is not

intended to replace the clinical judgment of the prescribing provider or to be used for those residing outside the State of Alaska.

Executive Summary: International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: CID 2011;52(5):561–564. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: CID 2010; 50:625–663. IDSA Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. CID 2005; 40:643–54. 2015 Updated Beers Criteria. The Alaska Antimicrobial Stewardship Collaborative (A2SC) and all participating organizations and individuals assume no duty to correct or update these guidelines. Although efforts are made to include material within these guidelines that is accurate and represents the current best practice, there are no representations or warranties regarding errors, omissions, completeness or accuracy of the information provided. These guidelines are not an attempt to practice medicine or provide specific medical advice and should not be used to make a diagnosis or to replace or overrule a qualified health care provider's judgment.

Alaska Antimicrobial Stewardship Collaborative (A2SC) Adult OUTPATIENT Urinary Tract Infection Treatment Guideline (Last Updated 10-2018)

Category Asymptomatic Bacteriuria Acute Cystitis Acute Pyelonephritis Complicated UTI / Catheter-Associated UTI (CAUTI)

Symptoms and/or

Risk Factors

Isolation of a specific quantity of bacteria in an appropriately collected urine specimen (≥105 cfu/mL or from catheter; ≥102 cfu/mL) from an individual WITHOUT signs or symptoms of infection.

General symptoms: Acute onset dysuria, frequency or urgency Risk factors for resistance: • Antibiotic exposure within 90d • Hospitalization within 90d • Presence of invasive device(s)




(C&S) Investigation

Routine C&S is NOT indicated in asymptomatic patients unless screening in pregnancy or prior to urologic procedure with compromise of the urothelial mucosa.

Routine C&S is NOT indicated unless risk factor(s) for resistance exist; consider if prescribing 2nd line therapy

Urine C&S are critical in order to optimize therapy. Urine cultures should be collected from a midstream void prior to antibiotics or a freshly placed urinary catheter.


Duration

Treatment is NOT recommended for patients who do not meet the below criteria (e.g. pregnancy or those undergoing urologic procedures). Pregnant women: (select one option) • Nitrofurantoin 100mg PO BID x 5d ** Note: contraindicated at 38-42 weeks gestation • Cephalexin 500mg PO BID x 5d

Urologic procedure: Direct treatment based on pre-procedure screening C&S.

First Line: (select one option) • Nitrofurantoin 100mg PO BID x

5d • Cephalexin 500mg PO BID x 7d Fluoroquinolone FDA Safety Alert: Disabling & potentially permanent adverse effects outweigh benefit in cystitis. Only use when no other alternatives exist. Second Line: • Ciprofloxacin 250mg PO BID x 3d **Note: If STI risk w/ symptoms of urethritis, consider treatment for chlamydia.

First Line: • Ceftriaxone 1g IM/IV x 1 dose If severe or life-threatening beta-lactam allergy consider Gentamicin 5mg/kg IM/IV x 1 dose Followed by: First line: • Cephalexin 1g PO TID x 10-14d Second line: • Ciprofloxacin 500mg PO BID x 7d Tailor maintenance therapy to C&S report.

Base empiric treatment on prior culture data. If stable vitals & afebrile, provide definitive therapy when new C&S result. Duration: • Shorter courses (7 days) are reasonable,

if symptoms promptly resolve. • Longer courses (10-14 days) if delayed

response, regardless if catheterized or not.

• If female and < 65 years of age, a 3-day regimen may be considered for CAUTI with catheter removal.

• Scope of this guideline is limited to adults>18 y/o without signs of severe physiologic disturbance. This guideline should not be used for patients who are immunocompromised or kidney transplant recipients. • Nitrofurantoin is 1st line for most patients without symptoms of pyelonephritis. Contraindicated for CrCl < 30mL/min and in pregnancy at term (38-42wks). • Statewide E. coli susceptibility to TMP/SMX is <80% and should be avoided as empiric therapy, but may be considered if confirmed by C&S for complicated UTI or pyelonephritis (2 week duration). • For ESBL (Extended Spectrum Beta-lactamase) producing organisms, treat according to reported susceptibility with nitrofurantoin, TMP/SMX or ciprofloxacin. If resistant to all tested antibiotics or multiple allergies, consult

Infectious Diseases for potential alternatives. ESBL pyelonephritis may require inpatient admission and/or IV antibiotics. • If patient reports penicillin allergy inquire about onset and severity of symptoms, as well as prior beta-lactam exposure and update patient medical record. Severe or life-threatening allergic reactions may include: anaphylaxis,

angioedema, urticaria, Stevens-Johnson Syndrome (SJS), etc. • Antibiotic prophylaxis for most patients with risk factors for recurrent, complicated UTI is NOT typically recommended. Risk of resistance outweighs the slight reduction in infection rate.

Note: This guideline is intended to aid in the selection of antimicrobial therapy in adult OUTPATIENTS residing in Alaska who present with a urinary tract infection. It is not

intended to replace the clinical judgment of the prescribing provider or to be used for those residing outside the State of Alaska.

Alaska Antimicrobial Stewardship Collaborative Adult LONG TERM CARE Urinary Tract Infection Treatment Guidelines (Last Updated 10-2018)

INDICATION FOR URINALYSIS IN NON-CATHETERIZED RESIDENTS – FOLLOW THE LOEB/MCGEER CRITERIA: Acute dysuria alone OR Fever > 100 F AND 1 of the following → New or worsening: urgency, frequency, suprapubic pain, gross hematuria, costovertebral tenderness, urinary incontinence (Note: urinalysis is NOT indicated in non-catheterized patients for work up of worsening mental status changes without other symptoms of UTI) INDICATION FOR URINALYSIS IN CATHETERIZED RESIDENTS: New onset suprapubic pain or costovertebral tenderness, swelling/tenderness of the testes, epididymis or prostate, or purulent discharge from around the catheter; OR Fever > 100 F, rigors, acute change in mental status, new-onset hypotension, with NO alternate diagnosis or site of infection

Category

Asymptomatic Bacteriuria

Acute Cystitis

Acute Pyelonephritis

Complicated UTI/ Catheter-Associated UTI (CAUTI)

Symptoms and/or Risk

Factors

Presence of bacteria in urine (≥105 cfu/mL or from catheter; ≥102 cfu/mL) from an individual WITHOUT signs or symptoms of infection.

General symptoms: Acute onset dysuria, frequency or urgency




(C&S) Investigation

Routine C&S is NOT indicated in asymptomatic patients unless screening in pregnancy or prior to urologic procedure with compromise of urothelial mucosa.

Urine C&S are critical in order to optimize therapy. Urine cultures should be collected from a midstream void prior to antibiotics or a freshly placed urinary catheter.


Duration

Treatment is NOT recommended for patients who do not meet the below criteria (e.g. pregnancy or those undergoing urologic procedures) Pregnant women: (select one option) • Nitrofurantoin 100mg PO BID x 5d ** Note: contraindicated at 38-42 weeks gestation • Cephalexin 500mg PO BID x 5d Urologic procedure: Direct treatment based on pre-procedure screening C&S. **Note: when NOT giving antibiotics, close monitoring is recommended

First Line: (select one option) • Nitrofurantoin 100mg PO BID x 5d

• Cephalexin 500mg PO BID x 7 days Fluoroquinolone FDA Safety Alert: Disabling & potentially permanent adverse effects outweigh benefit in cystitis. Only use when no other alternatives exist. Second Line: • Ciprofloxacin 250mg PO BID x 3 days **Note: If STD risk w/ symptoms of urethritis, consider treatment for chlamydia.

First Line: • Ceftriaxone 1g IM/IV x 1 dose If severe or life-threatening beta-lactam allergy consider Gentamicin 5mg/kg IM/IV x 1 dose Followed by: First line: • Cephalexin 1g PO TID x 14 days Second line: • Ciprofloxacin 500mg PO BID x 7d Tailor maintenance therapy to C&S report.

Base empiric treatment on prior culture data. If stable vitals & afebrile, provide definitive therapy when new C&S result. Duration: • Shorter courses (7 days) are

reasonable, if symptoms promptly resolve.

• Longer courses (10-14 days) if delayed response, regardless if catheterized or not.

• If female and < 65 years of age, a 3-day regimen may be considered for CAUTI with catheter removal.

• Scope of this guideline is limited to adults>18 y/o without signs of severe physiologic disturbance. This guideline should not be used for patients who are immunocompromised or kidney transplant recipients. • Nitrofurantoin is 1st line for most patients without symptoms of pyelonephritis. Contraindicated for CrCl < 30mL/min and in pregnancy at term (38-42wks). • Statewide E. coli susceptibility to TMP/SMX is <80% and should be avoided as empiric therapy but may be considered if confirmed by C&S for complicated UTI or pyelonephritis (2 week duration). • Risk factors for resistance: Antibiotic exposure within 90 days, hospitalization within 90 days, presence of invasive device(s) • For ESBL (Extended Spectrum Beta-lactamase) producing organism, treat according to reported susceptibility with nitrofurantoin, TMP/SMX or ciprofloxacin. If resistant to all tested antibiotics or multiple allergies, consult

Infectious Diseases for potential alternatives. ESBL pyelonephritis may require inpatient admission and/or IV antibiotics. • If patient reports penicillin allergy inquire about onset and severity of symptoms as well as prior beta-lactam exposure and update patient medical record. Severe or life-threatening allergic reactions may include:

anaphylaxis, angioedema, urticaria, Stevens-Johnson Syndrome (SJS), etc. • Antibiotic prophylaxis for most patients with risk factors for recurrent, complicated UTI is NOT typically recommended. Risk of resistance outweighs the slight reduction in infection rate.

Note: This guideline is intended to aid in the selection of antimicrobial therapy in adult LONG TERM CARE residents in Alaska who present with a urinary tract infection. It is not intended to replace the clinical judgment of the prescribing provider or to be used for those residing outside the State of Alaska.

Executive Summary: International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: CID 2011;52(5):561–564. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: CID 2010; 50:625–663. IDSA Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. CID 2005; 40:643–54. 2015 Updated Beers Criteria. Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference: Infect Control Hosp Epidemiol 2012; 33(10):965-77. The Alaska Antimicrobial Stewardship Collaborative (A2SC) and all participating organizations and individuals assume no duty to correct or update these guidelines. Although efforts are made to include material within these guidelines that is accurate and represents the current best practice, there are no representations or warranties regarding errors, omissions, completeness or accuracy of the information provided. These guidelines are not an attempt to practice medicine or provide specific medical advice and should not be used to make a diagnosis or to replace or overrule a qualified health care provider's judgment.

The Alaska Antimicrobial Stewardship Collaborative (A2SC) and all participating organizations and individuals assume no duty to correct or update these guidelines. Although efforts are made to include material within these guidelines that is accurate and represents the current best practice, there are no representations or warranties regarding errors, omissions, completeness or accuracy of the information provided. These guidelines are not an attempt to practice medicine or provide specific medical advice and should not be used to make a diagnosis or to replace or overrule a qualified health care provider's judgment.

Pediatric FEBRILE Urinary Tract Infection Treatment Guideline (2-24 months)

Symptoms Diagnostic Criteria for Acute Pyelonephritis1 Risk Factors1

• Fever • Poor feeding • Vomiting • Irritability • Strong-smelling urine

Urinalysis results that suggest infection • Positive nitrite OR • Leukocyte esterase OR • Pyuria AND • >50,000 CFUs per mL of a uropathogen cultured from a urine

specimen obtained through catheterization or SPA

Girls Age <12 months Temp >39 C Fever >2 days

Boys Temp >39 C Fever >24 hours Uncircumcised

Absence of another source of infection

Test Treat Imaging1 Obtain urine culture PRIOR to starting antibiotics

Adjust therapy based on sensitivity testing • Renal/bladder ultrasound for 1st febrile UTI • VCUG for 2nd febrile UTI or if abnormalities seen on

renal/bladder ultrasound

Antibiotic Selection1 Ambulatory Empiric Treatment Inpatient Empiric Treatment Duration of Therapy

Preferred Treatment1

Cephalexin 50mg/kg/day PO divided TID or QID

(max 4gm/day)

Ceftriaxone 50mg/kg IV Q24H (max

2gm/day) 7-10 days

Beta-lactam allergic1 Sulfamethoxazole/trimethoprim 4-5mg/kg PO BID (trimethoprim component for dosing; max

160mg trimethoprim/dose) Gentamicin 5mg/kg/day IV

1. Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595-610.

Pediatric Urinary Tract Infection Treatment Guideline (>24 months)

Symptoms2 Risk Factors2 Test/Treat Preverbal • Fever • Abdominal/flank pain • Vomiting • Poor feeding • Lethargy • Malodorous urine

Verbal • Frequency • Dysuria • Hesitancy • Urgency • Abdominal/flank pain

Prior history of UTI • Review prior organism/susceptibilities for

guidance on empiric therapy selection if recurrent UTI

Fever ≥ 2 days or prolonged ≥ 5 days

Obtain urine culture PRIOR to starting antibiotics Adjust therapy based on sensitivity testing

Antibiotic Selection2

Ambulatory Empiric Treatment Inpatient Empiric Treatment Duration of Therapy

Preferred Treatment2

Cephalexin 50mg/kg/day PO divided TID or QID (max 4gm/day)

Ceftriaxone 50mg/kg IV Q24H (max

2gm/day) 7-10 days

Beta-lactam allergic2 Sulfamethoxazole/trimethoprim 4-5mg/kg PO BID (trimethoprim component for dosing; max

160mg trimethoprim/dose) Gentamicin 5mg/kg/day IV

Adopted Nov. 2018 - Approved 2018

2. Shaw K, et al. Pathway for the Evaluation and Treatment of Children with Febrile UTI. Children’s Hospital of Philadelphia. https://www.chop.edu/clinical-pathway/urinary-tract-infection-uti-febrile-clinical-pathway. Accessed Oct 2018.

Urinary Uncertainty: Demystifying Culture Collection in Urinary Tract Infections (UTI)

Obtaining urine culture from patients with various forms of UTI can represent an important step in providing definitive therapy. In others, cultures may not be indicated and, in fact, may lead to inappropriate treatment. Knowing which clinical syndromes require urine culture and how to navigate typical urinalysis (UA) and urine culture order variations will assist the clinician in providing superior care to patients.

General Guidelines for Appropriate Urine Culturing:

When obtaining urine cultures it is important to collect culture specimens in a manner that minimizes the potential for culture

contamination. Additionally, urine cultures should be obtained prior to the administration of antibiotics in order to maximize the diagnostic yield of the culture.1-3

Urine cultures in non-catheterized patients should be collected from a clean-catch, midstream void.1,2 When urine cultures are indicated in a catheterized patient and the catheter has been in place for longer than 2 weeks, the catheter should be changed prior to obtaining the culture with the collected specimen coming from the freshly placed catheter. If the catheter can be discontinued at the time the culture is indicated then the specimen should be obtained via a clean-catch, midstream void.3

Asymptomatic Bacteriuria (ASB):

The Infectious Diseases Society of America (IDSA) defines ASB as “isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen obtained from a person without symptoms or signs referable to urinary infection”.1 The only two patient populations which have shown benefit from antimicrobial management of ASB are pregnant patients and those scheduled to undergo urologic procedures that will compromise the urogenital mucosa. In patients with the above two indications routine screening is appropriate with the use of a urine culture. When screening for ASB the UA with reflex culture should NOT be used given that screening for pyuria has a low sensitivity for the identification of bacteriuria. Use of the UA with reflex culture order may result in cultures not being performed due to a lack of pyuria and, therefore, lack of identification of bacteriuric patients. If the patient does not have one of the above listed indications for screening and treatment then no routine screening or culturing of the urine is recommended.1

Acute Cystitis and Pyelonephritis:

Acute bacterial cystitis implies the patient is acutely experiencing urinary symptoms; however, is another condition which may not always require obtaining urine culture to guide management.2 In the outpatient care setting, in women without risk factors for resistant pathogens (i.e. antibiotic exposure/hospitalization in the previous 90 days or previous infection/colonization with multidrug resistant bacteria) empiric management can be initiated using agents with adequate local bacterial susceptibility rates. In outpatient complicated cystitis (i.e. infection in males, those with urogenital structural abnormalities, or recurrence), inpatient acute cystitis (complicated or uncomplicated), or acute pyelonephritis appropriate obtainment of urine cultures and antimicrobial sensitivities is critical to the management of antimicrobial therapy. In these cases providers should consider utilization of an

order for UA with urine culture. The UA with reflex culture if indicated is NOT recommended in this scenario as a culture is likely indicated due to the presence of symptoms regardless of UA findings.2 In the cases where the patient is unable to provide information regarding symptoms and cystitis or pyelonephritis is possible (i.e. fever or sepsis of unknown origin), it may be reasonable to utilize the UA with reflex culture if indicated order.

Catheter Associated UTI:

Patients with urinary catheters are at a higher risk for the development of UTI. Urinalysis and/or urine cultures should ONLY be collected in catheterized patients when symptom(s) are present. Conversely, it is important to NOT perform urinalysis and/or urine cultures when the only symptoms present are malodorous urine, cloudy appearance, or change in color.3 In most cases, if the catheter is functioning properly and the patient does NOT have urinary symptoms (i.e. urgency, suprapubic tenderness, or back/flank pain, or fever), then UA and culture will only identify ASB/pyuria related to catheter colonization. This is typically clinically insignificant and should not be empirically treated with antibiotics. When high suspicion of catheter associated urinary tract infection exists due to the presence of symptoms a UA with urine culture should be utilized. Similar to non-catheterized patients, in catheterized patients with fever or sepsis of unknown origin it is reasonable to utilize the UA with reflex culture if indicated order.

For more information on the diagnosis, testing, and treatment of urinary tract infections please refer to the Alaska Antimicrobial Stewardship Collaborative’s statewide UTI guidelines for inpatients, outpatients, and those residing in long term care facilities (attached).

References:

1. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America Guidelines for the diagnosis and treatment of asymptomatic bacteriuria. CID 2005;40:643-54.

2. 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. CID 2011;52(5):e103-e120.

3. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. CID 2010;50:625-663.

A2SC Patient Education Resources

Antibiotic awareness posters for providers

A recommended strategy is to put posters in exam rooms or waiting rooms with physician pictures and an antimicrobial stewardship message that “we promise not to give you antibiotics if you don’t need them because we care about your health”

Mountain Pacific Quality Health will provide posters co-branded with hospital or physician logo, name and photo.

Order on-line to receive custom, laminated copies of the poster.

A Commitment to Our Patients About Antibiotics Poster Order Form - https://www.mpqhf.org/QIO/quality-improvement-tools-resources/antibiotic-stewardship/#commitmenttoparents

CDC Be Antibiotics Aware - national effort to help fight antibiotic resistance and improve antibiotic prescribing and use. https://www.cdc.gov/antibiotic-use /index.html Patient education on antibiotic awareness This Alaska specific newsletter focuses on antibiotic awareness and UTI. https://www.ashnha.com/wp-content/uploads/2019/05/Newsletter-Feb-2019-1.pdf

About Alaska Antimicrobial Stewardship Collaborative

The Alaska Antimicrobial Stewardship Collaborative (A2SC) is an active partnership of hospitals and other health care stakeholders dedicated to developing innovative strategies to ensure appropriate antibiotic use. A2SC’s goal is a simple one: all patients in Alaska will receive the right antibiotic at the right time and only when necessary.

The emergence of antibiotic-resistant bacteria caused by the misuse and overuse of antibiotics is pushing the healthcare industry to re-evaluate how medicine is practiced. Together we will accelerate positive changes to achieve this critical goal.

https://www.mpqhf.org/QIO/quality-improvement-tools-resources/antibiotic-stewardship/#commitmenttoparents

https://www.mpqhf.org/QIO/quality-improvement-tools-resources/antibiotic-stewardship/#commitmenttoparents

https://www.cdc.gov/antibiotic-use%20/index.html


the early 2000s. During this

lull in antibiotic development,

antibiotic resistance started

becoming more prevalent.

Modern antibiotics have been

around for a relatively short

time frame. In 1928, Sir Alex-

ander Fleming accidentally

discovered the first antibiotic,

penicillin. He noticed that a

bacterial culture was not

growing in an area that had

been contaminated with

mold. This mold was Penicilli-

um notatum. Commercial

penicillin was not developed

until the 1940s. During one of

his speeches in the 1940s,

Fleming warned of the possi-

bility of antibiotic resistance if

this new antibiotic was used

inappropriately.

Throughout the next three

decades, a majority of the

antibiotics we have today

were developed. No new

antibiotics were discovered

between the late 1980’s and

Modern Antibiotic History

What is Antibiotic Resistance?

Some bacteria, when exposed

to antibiotics, have the ability

to change and become re-

sistant. This usually occurs if

the dose is too low, antibiot-

ics are used too often, or the

wrong antibiotics are being

used. When resistance devel-

ops, bacteria can no longer

be killed by certain antibiot-

ics, ultimately resulting in

infections that are harder to

treat or that cannot be treat-

ed. These infections can

spread to other people, re-

sulting in widespread re-

sistance.

According to the CDC, two

million people in the US are

diagnosed with antibiotic

resistant infections each year.

Of these two million people,

at least 23,000 die. This is

why antibiotic resistance is a

growing public health threat

and antibiotics need to be

used appropriately. Without

antibiotics, we would be una-

ble to treat bacterial infec-

tions.

February 2019

Antibiotic Awareness

Do I Need Antibiotics?

Many infections, especially

those caused by viruses, do

not require antibiotics. If you

have the common cold, the

flu, or a runny nose, even if

the mucus is green or yellow,

antibiotics will not help you

feel better. In fact, taking them

may harm you.

When are Antibiotics Necessary?

Sometimes, antibiotics are

necessary to treat a bacterial

infection and the benefits out-

weigh the risks of taking an

antibiotic. The following are

common infections that re-

quire antibiotics:

Pneumonia

Strep Throat

Urinary Tract Infections

Whooping Cough

Some* cases of sinus in-

fections or bronchitis

*not all sinus infections or

cases of bronchitis require

antibiotics to treat. Some will

resolve on their own.

Do I have a UTI?

It is common to go to the

doctor or hospital for an ill-

ness and be asked to provide

a urine sample. Your urine can

sometimes give the doctor

clues to what is wrong. How-

ever, just because there is

bacteria in your urine , does

not mean you have an infec-

tion. Often bacteria can live in

your bladder without causing an

infection. If you are told you

have a urinary tract infection

but have NOT had symptoms

such as burning with urination,

having to urinate more often,

the urge to urinate when your

bladder is empty, or pain in

your lower abdomen or low

back, let your doctor know.

There are of course excep-

tions, such as if you are

pregnant or having certain

bladder surgeries, so do not

be afraid to double check

with your doctor that antibi-

otics are really necessary.

The Alaska Antimicrobial Stewardship Collaborative is an active partnership of acute care and long-term care hospi-

tals dedicated to developing innovative strategies to ensure appropriate antibiotic use. A2SC’s goal is a simple one: all

patients in Alaska will receive the right antibiotic at the right time and only when necessary. While at one time, antibi-

otics revolutionized the practice of medicine by providing a rapid cure to many illnesses that were once fatal, those

days may soon be gone. The emergence of antibiotic-resistant bacteria caused by the misuse and overuse of antibiot-

ics is pushing the healthcare industry to re-evaluate how medicine is practiced. Together we will accelerate positive

changes to achieve this critical goal.

2017 State Antibiograms- SURVEILLANCE DATA ONLY

2017 Alaska State Antibiogram

The following tables show the proportion of isolates of various bacterial species that tested susceptible to various antibiotics during 2017. These data were aggregated from the

antibiograms produced by Alaska hospitals in order to create aggregate regional resistance pattern summaries. These antibiograms can be helpful for health care providers in selecting

appropriate “presumptive” antimicrobial therapy for their patients until specific individual laboratory test results are available. They can also be helpful for determining antibiotic stewardship

priorities within hospitals and emerging resistance patterns in a broader service area.

Methodology: Individual hospitals prepared their own facility antibiograms, which were shared with the Alaska Section of Epidemiology. Aggregated susceptibility percentages were

calculated as the proportion of all tested isolates for the region that were susceptible. Values are only reported when more than one facility provided data for the given species-

antibiotic combination. Intrinsic resistance is indicated with an “R”, following the guidance of CLSI document M100-S24.

Multi-Drug Resistant Organisms of Note:

o Vancomycin-resistant Staphylococcus aureus (VRSA): no cases of VRSA have ever been reported in Alaska. VRSA is reportable to the Alaska Section of Epidemiology.

o Carbapenem-resistant Enterobacteriaceae (CRE): there were 6 cases of CRE reported in Alaska in 2017.

Legend:

o The top value in each square is the percent of isolates of that species that tested susceptible to that antibiotic.

o The lower value in each square indicates the number of tested isolates for that bacteria-antibiotic combination.

o “R” indicates intrinsic resistance to that antibiotic, while “S” indicates definitional susceptibility.

o “NED” indicates that there was Not Enough Data to report the value: either only one facility reported data for that drug-bug combination or <30 isolates were tested.

Limitations: Individual facilities often use different methods to test for antimicrobial susceptibility, different methods to build their antibiograms, and different antibiotics in their

pharmacies. These factors limit interpretation of these data. Additionally, antimicrobial susceptibility testing done in the laboratory does not always predict how effective that drug will

be when used to treat a patient. Data are not stratified by infection site, which influences antibiotic choice and effectiveness.

Contributing Facilities: Thanks to all the hospitals in Alaska for participating in this project to the extent of their ability. These statewide data include all the hospitals used in the

Regional Antibiograms, plus Fairbanks Memorial Hospital.

For more information and the methods used for the analyses, please see the “Regional Antibiogram Project — Alaska, 2014–2015” Epidemiology Bulletin.


Species Pen

icill

in

Am

pic

illin

Oxa

cilli

n

Am

pic

illin

-su

lbac

tam

Am

oxi

cilli

n

Cef

azo

lin

Cef

tria

xon

e

Cef

ota

xim

e

Cip

rofl

oxa

cin

Levo

flo

xaci

n

Mo

xifl

oxa

cin

Dap

tom

ycin

Clin

dam

ycin

Eryt

hro

myc

in

Van

com

ycin

Gen

tam

icin

Gen

t Sy

n

Trim

eth

op

rim

-su

lfam

eth

oxa

zole

Lin

ezo

lid

Tetr

acyc

line

Nit

rofu

ran

toin

Qu

inu

pri

stin

-dal

fop

rist

in

Rif

amp

in

Total Staphylococcus aureus 9% 0% 66% 65% 67% 70% 64% 71% 74% 84% 96% 84% 38% 99% 99% 98% 99% 96% 96% 99% 94%

(1605) (186) (3620) (288) (288) (609) (736) (1276) (1815) (494) (170) (3616) (1811) (3620) (2288) (3620) (2646) (3502) (2929) (170) (1096)

MSSA 10% 0% S 99% 99% 99% 100% 89% 91% 94% 97% 87% 67% 99% 99% 93% 99% 97% 99% 100% 99%

(920) (150) (215) (215) (427) (493) (738) (1070) (349) (130) (2287) (1068) (2290) (1391) (2290) (1807) (2205) (1905) (130) (645)

MRSA 0% 0% R 0% 0% NED 0% 34% 41% 64% 99% 78% 20% 99% 99% 97% 99% 96% 95% 99% 99%

(457) (70) (70) (70) (277) (379) (586) (179) (74) (1095) (586) (1096) (740) (1096) (796) (1063) (811) (74) (183)

Staphylococcus lugdunensis NED 88% 95% 98% 78% 78% 100% 100% NED NED 100% 100%

(40) (40) (40) (40) (40) (40) (40) (40) (40)

Coag-negative Staphylococcus 18% 0% 49% 48% 48% 35% 48% 76% 81% 63% NED 62% 37% 99% 21% 78% 99% 89% 95% NED 99%

(348) (115) (822) (122) (122) (37) (341) (488) (665) (142) (700) (542) (823) (2576) (527) (569) (757) (615) (172)

Enterococcus faecalis 98% 99% R R R 91% 96% NED R 5% 99% R 86% R 99% 40% 96% R 48%

(129) (299) (218) (266) (84) (299) (241) (205) (253) (251) (42)

Enterococcus spp. 98% 99% NED 93% 99% 84% 50% 97%

(422) (422) (369) (422) (265) (422) (369)

Group B Streptococcus 100% S 57% NED 100% NED

(106) (106) (106)

Streptococcus pneumoniae (all) 93% 95% 100% 100% 100% 80% 83% 100% 87% 96%

(68) (59) (59) (59) (237) (149) (141) (237) (144) (53)

S. pneumoniae - oral 77%

(145)

S. pneumoniae - non-CSF 97% 98% 99%

(133) (185) (133)

S pneumoniae - meningitis 78% 95% 95%

(133) (185) (133)

Statewide data


Species Am

oxi

cilli

n+

cla

vula

nic

aci

d

Am

pic

illin

Am

pic

illin

+Su

lbac

tam

Pip

erac

illin

+Ta

zob

acta

m

Tica

rici

llin

- ca

lvan

ula

nic

aci

d

Cef

azo

lin

Cef

uro

xim

e

Cef

tria

xon

e

Cef

tazi

dim

e

Cef

epim

e

Cef

ota

xim

e

Cef

ote

tan

Cef

oxi

tin

Cep

hal

oth

in

Azt

reo

nam

Gen

tam

icin

Tob

ram

ycin

Am

ikac

in

Erta

pen

em

Imip

enem

Mer

op

enem

Cip

rofl

oxa

cin

Levo

flo

xaci

n

Trim

eth

+Su

lfa

Tetr

acyc

line

Nit

rofu

ran

toin

Citrobacter freundii R R R 87% R R 82% 82% 100% NED R R NED 93% 96% NED NED NED 100% 89% 89% 87% NED 93%

(45) (45) (45) (45) (45) (45) (45) (45) (45) (45) (43)

Enterobacter aerogenes R R R 89% R R 86% NED NED NED R R NED 97% NED NED NED NED 100% 97% 97% 97% 97% 30%

(35) (35) (35) (35) (35) (35) (35) (30) (30)

Enterobacter cloacae R R R 88% R R 84% 88% 98% NED R R 85% 89% 99% 100% 98% 97% 100% 99% 96% 93% 95% 47%

(180) (180) (149) (134) (106) (180) (153) (106) (62) (62) (133) (180) (180) (180) (39) (161)

Escherichia coli 87% 57% 65% 97% 88% 90% 86% 97% 97% 97% 98% 100% 96% 36% 98% 93% 95% 99% 99% 99% 99% 86% 86% 77% 80% 97%

(3207) (6602) (5059) (6602) (642) (5277) (2250) (6602) (5485) (4977) (829) (642) (2616) (642) (2179) (6602) (5557) (2250) (4136) (3565) (3793) (6602) (6602) (6602) (1760) (5110)

ESBL E. coli NED 0% NED 97% 0% NED 0% 0% 87% NED 100% 36% 36% 38% 49% 100%

(39) (39) (39) (39) (39) (39) (39) (39) (39) (39) (39) (37)

Klebsiella oxytoca 100% NED 64% 97% 66% 93% 98% 98% 98% NED NED 95% 97% 97% 100% NED 100% 98% 98% 93% NED 88%

(2) (58) (58) (58) (56) (58) (56) (58) (56) (58) (58) (56) (56) (58) (58) (58) (58)

Klebsiella pneumoniae 99% R 86% 98% 98% 96% 90% 97% 97% 98% 97% 98% 97% 72% 96% 98% 99% 100% 100% 100% 99% 47% 98% 95% 96% 52%

(242) (548) (548) (47) (538) (297) (538) (497) (484) (74) (47) (120) (47) (297) (538) (278) (297) (278) (211) (391) (1128) (492) (538) (92) (528)

Proteus mirabilis 99% 92% 94% 99% 100% 97% 99% 99% 99% 99% 100% 100% 93% 85% 94% 95% 95% 99% 100% 55% 100% 93% 94% 93% R R

(170) (364) (303) (364) (63) (259) (126) (364) (324) (326) (51) (44) (163) (41) (126) (364) (326) (126) (251) (221) (187) (364) (364) (364)

Pseudomonas aeruginosa R R R 98% R R R 92% 94% R R R 84% 88% 97% 95% R 59% 95% 87% 85% R R R

(467) (467) (454) (38) (467) (454) (248) (224) (276) (467) (467)

Serratia marcescens R R R 16% R R 100% 100% 100% R R 100% 100% 93% 97% NED NED 97% 97% 97% 100% 0% R

(31) (31) (31) (31) (31) (30) (30) (30) (30) (30) (30) (30) (4)

Statewide data


2017 Alaska State Antibiogram: Anchorage-Mat-Su Region

The following tables show the proportion of isolates of various bacterial species that tested susceptible to various antibiotics during 2017. These data were aggregated from the antibiograms

produced by Alaska hospitals in order to create aggregate regional resistance pattern summaries. These antibiograms can be helpful for health care providers in selecting appropriate

“presumptive” antimicrobial therapy for their patients until specific individual laboratory test results are available. They can also be helpful for determining antibiotic stewardship priorities

within hospitals and emerging resistance patterns in a broader service area.






o Carbapenem-resistant Enterobacteriaceae (CRE): there were 4 cases of CRE in Anchorage/Mat-Su residents in 2017.

Legend:








Contributing Facilities: Thanks to the following facilities for providing data in support of this project:

o Alaska Native Medical Center

o Alaska Regional Hospital

o Providence Alaska Medical Center

o Mat-Su Regional Medical Center

o JBER DOD/VA Hospital


Species Pen

icill

in

Am

pic

illin

Oxa

cilli

n

Cef

azo

lin

Cef

tria

xon

e

Cef

ota

xim

e

Cip

rofl

oxa

cin

Levo

flo

xaci

n

Clin

dam

ycin

Eryt

hro

myc

in

Van

com

ycin

Gen

tam

icin

Gen

t Sy

n

Trim

eth

op

rim

-su

lfam

eth

oxa

zole

Lin

ezo

lid

Tetr

acyc

line

Nit

rofu

ran

toin

Total Staphylococcus aureus 15% NED 60% NED 58% 63% 79% 34% 99% 99% 98% 95% 99%

(468) (2079) (857) (389) (2079) (389) (2079) (1611) (2079) (1611) (2079)

MSSA NED NED S 99% 85% NED 82% NED 100% 99% 98% 96% 100%

(210) (454) (454) (454) (999) (454) (999) (454)

MRSA NED NED R NED 28% 34% 72% 5% 99% 99% 98% NED 95% 99%

(403) (179) (836) (179) (836) (612) (836) (612) (836)

Coag-negative Staphylococcus 4% NED 59% 67% 74% 76% 62% 40% 100% 86% 69% NED 89% 100%

(123) (275) (70) (159) (125) (275) (125) (275) (241) (275) (193) (227)

Enterococcus faecalis 98% 98% R R R 80% 88% R 35% 100% R NED R NED 29% 100%

(108) (209) (101) (101) (101) (209) (101) (176)

Enterococcus spp. 98% 99% R R R NED 93% R NED 98% R NED R NED NED 95%

(212) (212) (212) (212) (212)

Streptococcus pneumoniae (all) 99% 72% 73% 100%

(144) (93) (51) (144)

S. pneumoniae - oral 75%

(108)

S. pneumoniae - non-CSF 98% 98% 99%

(144) (129) (144)

S pneumoniae - meningitis 73% 93% 92%

(144) (129) (144)

Anchorage+

Mat-Su Region


Species Am

oxi

cilli

n+

cla

vula

nic

aci

d

Am

pic

illin

Am

pic

illin

+Su

lbac

tam

Pip

erac

illin

+Ta

zob

acta

m

Cef

azo

lin

Cef

uro

xim

e

Cef

tria

xon

e

Cef

tazi

dim

e

Cef

epim

e

Cef

ota

xim

e

Azt

reo

nam

Gen

tam

icin

Tob

ram

ycin

Am

ikac

in

Imip

enem

Mer

op

enem

Cip

rofl

oxa

cin

Levo

flo

xaci

n

Trim

eth

+Su

lfa

Tetr

acyc

line

Nit

rofu

ran

toin

Citrobacter freundii R R R 84% R R 86% 82% 100% NED NED 91% 91% 100% 100% 96% 96% 89% NED NED

(45) (45) (45) (45) (45) (45) (34) (34) (45) (45) (45)

Enterobacter spp. R R R 89% R R 92% 94% 99% NED 77% 99% 98% 100% 100% 96% 97% 94% NED 62%

(72) (102) (102) (72) (72) (102) (54) (54) (17) (102) (102) (102) (78)

Enterobacter cloacae R R R 85% R R 81% 84% 98% 81% 83% 98% 98% 100% 100% 97% 98% 95% 94% 47%

(197) (197) (151) (197) (106) (151) (197) (197) (151) (197) (197) (197) (197) (106) (106)

Escherichia coli 84% 55% 61% 96% 89% 86% 94% 95% 96% 92% 95% 93% 94% 100% 100% 100% 84% 84% 80% 80% 97%

(1448) (2869) (3369) (2447) (3369) (3369) (3369) (2447) (3369) (1448) (2447) (3369) (3369) (1947) (526) (2869) (3369) (3369) (3369) (1448) (3369)

Klebsiella oxytoca NED 59% 93% 76% 90% 96% 99% 99% NED 95% 98% 97% 100% 100% 98% 98% 47% NED 90%

(105) (105) (82) (105) (105) (105) (105) (105) (105) (78) (78) (78) (105) (105) (105) (105)

Klebsiella pneumoniae 93% R 85% 93% 94% 93% 97% 97% 97% 99% 97% 80% 97% 100% 100% 99% 79% 73% 90% 83% 52%

(217) (548) (548) (548) (548) (440) (436) (548) (217) (436) (545) (440) (328) (105) (328) (548) (543.5) (548) (217) (548)

Proteus mirabilis 96% 86% 91% 100% 96% 95% 99% 100% 100% 99% 97% 96% 96% 100% 100% 87% 88% 86% R R

(85) (160) (186) (186) (186) (186) (186) (144) (186) (85) (144) (186) (186) (118) (160) (186) (186) (186)

Pseudomonas aeruginosa R R R 96% R 90% 95% R 43% 92% 97% 96% 92% 95% 86% 85% R R R

(351) (351) (290) (141) (351) (351) (290) (80) (290) (351) (351)

Serratia marcescens 98% 98% 100% 100% 100% 95% 98% 98% 95% 95% 100% NED

(44) (44) (44) (44) (44) (44) (44) (44) (44) (44) (44)

Anchorage+

Mat-Su Region


2017 Alaska State Antibiogram: Gulf Coast Region










o Carbapenem-resistant Enterobacteriaceae (CRE): there was 1 case of CRE in a Gulf Coast resident in 2017.

Legend:









o Central Peninsula Hospital

o South Peninsula Hospital


Gulf Coast

Region data


2017 Alaska State Antibiogram: Northern Region










o Carbapenem-resistant Enterobacteriaceae (CRE): there were no cases of CRE reported in the Northern Region in 2017

Legend:









o Maniilaq Health Center

o Norton Sound Health Center


Northern

Region data


2017 Alaska State Antibiogram: Southeast Region










o Carbapenem-resistant Enterobacteriaceae (CRE): there was 0 case of CRE reported in a Southeast resident in 2017.

Legend:









o Bartlett Regional Hospital Petersburg Medical Center

o Peacehealth Ketchikan Medical Center Sitka Community Hospital

o SEARHC Wrangell Medical Center


Southeast

Region data


2017 Alaska State Antibiogram: Southwest Region










o Carbapenem-resistant Enterobacteriaceae (CRE): there were 0 cases of CRE reported in Southwest residents in 2017.

Legend:









o Yukon-Kuskokwim Health Center

o Bristol Bay Area Health Center


Southwest

Region data

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