Guideline for the treatment of urinary tract infections in adults

Transcription

1 Title of guideline Guideline for the treatment of urinary tract infections in adults Contact Name and Job Title (author) Mr R Parkinson, Consultant Urologist Dr S Holden, Consultant Microbiologist Dr A Joseph, SpR Microbiology Annette Clarkson, Specialist Clinical pharmacist antimicrobials and Infection Control Riya Savjani (November 2016 update), Senior Clinical Pharmacist: Antimicrobials Directorate & Speciality All adult directorates except Obstetrics Date of submission May 2015 (updated November 2016) Explicit definition of patient group to which it applies (e.g. inclusion Inclusion: Adult patients including Urology and exclusion criteria, diagnosis) patients Exclusion: Pregnant patients, refer to guideline for antibiotics in obstetrics Version 1.1 Changes from previous guideline If this version supersedes another clinical guideline please be explicit about which guideline it replaces including version number Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-5) 1a meta analysis of randomised controlled trials 1b at least one randomised controlled trial 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasiexperimental study 3 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practise based on the clinical experience of the guideline developer New guideline Addition of PO pivmecillinam as second line treatment option for lower UTI. Addition of PO ciprofloxacin as third line treatment option for lower UTI. Change in oral stepdown for upper UTI and sepsis of urinary tract origin from PO co-amoxiclav to PO ciprofloxacin. UTI diagnosis algorithm updated. Meropenem dose updated. To replace guideline Treatment of urological infections in adult urology patients. Guideline number 2062 IDSA guideline for treatment of uncomplicated cystitis and pyelonephritis in women 2010 Local microbiological sensitivity surveillance and local audit of E. coli bacteraemias. Recommended best practice based on clinical experience of guideline developers. Public Health England. Management of infection guidance for primary care for consultation and local adaptation Nov 2014 BASHH Prostatitis 2008 European Association of Urology Guidelines on Urological Infections 2014 BASHH 2011 guidelines epididymitis orchitis GRASP 2012 report: The gonococcal resistance to antimicrobials surveillance programme. Cochrane Database of Systematic s: Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women 2008 Consultation Process Nottingham University Hospitals Antibiotic Guidelines Committee Ratified by: Nottingham University Hospitals Antibiotic Date Guidelines Committee Target audience: Doctors, Pharmacists date: May 2017 This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Nottingham Antibiotic Guidelines Committee Page 1 of 12

2 Contents Urinary tract infection diagnosis algorithm Lower urinary tract infection (cystitis) Catheter-associated urinary tract infection Prophylaxis for change of long-term catheters Recurrent urinary tract infections Upper urinary tract infections (pyelonephritis and sepsis of urinary tract origin) Multi-resistant urinary tract infection Acute prostatitis Epididymitis and Orchitis Page 3 Page 4 Page 5 Page 5 Page 6 Page 6 Page 8 Page 9 Page 10 Nottingham Antibiotic Guidelines Committee Page 2 of 12

3 UTI Diagnosis Algorithm Nottingham Antibiotic Guidelines Committee Page 3 of 12

4 Lower Urinary Tract Infection (Cystitis) Defined as infection of the bladder or lower urinary tract, without features of pyelonephritis or systemic sepsis. For patients with a urinary catheter in situ please see the section on page 5. Use algorithm on page 3 to determine if treatment is needed. Antibiotics are not indicated for asymptomatic bacteriuria, unless pregnant or awaiting urology surgery where bleeding is expected. previous cultures prior to prescribing. If a multiresistant isolate is present or the following choices are unsuitable, discuss with Microbiology regarding other treatment options. First line: PO Nitrofurantoin MR 100mg BD or if to be used via an enteral feeding tube PO Nitrofurantoin 50mg QDS. Avoid in patients with a CrCl <45ml/min as will be less effective and increased risk of adverse events. See intranet guidance: pairment/nitrofurantoin.aspx Second line (if unable to use nitrofurantoin due to renal impairment or resistant organism): PO Pivmecillinam 400mg as the first dose then 200mg TDS Pivmecillinam is a penicillin antibiotic and should not be used in penicillin allergy Or if known to be sensitive from microbiology result for this episode of illness: PO Trimethoprim 200mg BD Third line: PO Ciprofloxacin 500mg BD o If patient is previous C.difficile positive (PCR or toxin) or has MRSA colonization, this requires Microbiology approval before use antibiotic choice at hours with urine culture results. Duration of therapy: For simple lower UTI in women, 3 days is usually sufficient. For male patients, diabetics, those with a structural or functional abnormality of the urinary tract, or recent urinary surgery / instrumentation (excluding urinary tract catheterisation), treat for 7 days. Nottingham Antibiotic Guidelines Committee Page 4 of 12

5 Catheter-associated Urinary Tract Infections (CA-UTI): In patients with urinary catheters in situ, bacteriuria is commonly present and treatment is not indicated in the absence of symptoms. Urine dipstick is not clinically useful. Do not send catheter-specimen urine (CSU) for culture as a routine "screen" in the absence of symptoms. Only send a CSU for culture if the patient is symptomatic, or has signs of pyelonephritis or systemic sepsis. The results of CSU samples should always be interpreted in conjunction with clinical parameters. Clinical assessment should be made regarding whether infection is likely to involve only the lower urinary tract, or upper urinary tract (pyelonephritis and systemic sepsis of urinary tract origin), see the Sepsis Guideline for further information. a.aspx The ongoing need for the urinary catheter should be assessed, alternatives considered, and the catheter should be removed if possible. If an indwelling catheter has been in place for longer than 2 weeks at the onset of CA-UTI (and there is ongoing need for a urinary catheter) the catheter should be changed during the treatment course. previous Microbiology results prior to prescribing, send a pre-treatment CSU sample, and follow the treatment choices outlined in either the lower or upper urinary tract sections of this guideline according to the clinical assessment. Duration of antibiotic therapy for CA-UTI: 7 days. In women who have had the catheter removed, this can be shortened to 3 days if rapid clinical response to antibiotics. Prophylaxis for change of long-term catheters Routine antibiotic prophylaxis is not recommended Urine dipstick is not clinically useful, only send CSU if the patient has symptoms. Do not send a catheter-specimen urine (CSU) for culture as a routine "screen". Consider prophylaxis for those who have history of recurrent post catheter change infections. The antibiotic choice is as follows: 1st Line: Gentamicin 2mg/kg IV as a single dose. Check for history of Gentamicinresistant organisms before prescribing. Nottingham Antibiotic Guidelines Committee Page 5 of 12

6 2nd Line: Treat according to previous sensitivities, where possible use PO Nitrofurantoin M/R 100mg BD give two doses only (one dose several hours before catheter change and second dose 12 hours after the first dose) Not suitable for patients with CrCl < 45mL/min. MRSA Positive patients: Patients with a catheter and a diagnosis of MRSA in their urine who are at risk of developing a bacteraemia at catheter change because they have traumatic catheter changes or who have had infections following catheter change previously. Gentamicin 2mg/kg IV single dose prior to catheter change. A minority of MRSA strains locally are resistant to Gentamicin so please review the susceptibility results and seek advice if required. Recurrent Urinary Tract Infections Patients with recurrent UTIs may be more likely to have resistant organisms due to repeated exposure to antibiotics. In patients known to have recurrent UTIs, a pretreatment MSU should be sent and previous microbiology results reviewed prior to prescribing. Assessment for possible underlying urinary tract abnormalities should be considered and Urology referral made if appropriate. Prophylaxis for recurrent urinary tract infections should not be routinely started. If considering prophylaxis then discussion with Microbiology and/or Urology is required, with regards to choice of agent, monitoring and follow-up. Upper Urinary Tract Infections: Pyelonephritis and Sepsis of Urinary Tract origin Defined as: Patients with pyelonephritis: usually have loin pain, kidney tenderness and signs of sepsis. Patients with lower urinary tract symptoms and signs of sepsis. Patients with known or possible structural or functional abnormalities of the urinary tract and signs of sepsis. Assess patient according to the NUH Sepsis guidelines a.aspx. Ensure two sets of blood cultures and a urine sample are sent (clearly labelled with the type of specimen e.g. MSU, CSU, nephrostomy urine) previous culture results and assess risk of Multiresistant Gram-negative Bacilli (MRGNB) prior to prescribing antibiotic: amnegative.aspx Nottingham Antibiotic Guidelines Committee Page 6 of 12

7 If no risk factors for Multiresistant Gram-negative Bacilli (MRGNB): First line: Piperacillin Tazobactam IV 4.5g tds Note this contains a penicillin If non severe penicillin allergy (e.g. no anaphylaxis, angioedema or urticarial rash in first 72 hours): Cefuroxime IV 1.5g tds. If patient is previous C.difficile positive (PCR or toxin), cefuroxime requires Microbiology approval before use If severe penicillin allergy: Ciprofloxacin IV 400mg bd if severe sepsis or unable to take orally converting as soon as possible to Ciprofloxacin PO 500mg bd. If patient is previous C.difficile positive (PCR or toxin), or MRSA colonization, ciprofloxacin requires Microbiology approval before use If the patient has severe sepsis or the blood pressure fails to respond to initial fluid bolus: Consider adding single dose Gentamicin IV 5 mg/kg (max 500mg) if normal renal function. For advice on dosing in renal impairment and for monitoring levels refer to the Trust antibiotic website OR If at risk of MRGNB: Meropenem IV 500mg qds (review antibiotics with microbiology within 48 hours) (Not to be used in severe penicillin allergy, e.g. urticarial rash within the first 72 hours, anaphylaxis or angioedema; please discuss with a Microbiologist) Further therapy need for IV antibiotics at 48 hours with microbiology results using IV-PO switch guideline on antibiotic website. If culture results available to guide therapy, a narrow spectrum agent should be used according to sensitivities. Note that nitrofurantoin should NOT be used as an oral stepdown after IV therapy for upper UTI (pyelonephritis or sepsis or urinary tract origin), as it has insufficient systemic concentrations to be used for this indication. If there are no culture results to indicate narrow spectrum therapy, convert IV Piperacillin/tazobactam to PO Ciprofloxacin 500mg BD If patient is previous C.difficile positive PCR or toxin, or MRSA colonization, ciprofloxacin requires microbiology approval before use. Total duration of IV+PO therapy: 7 days Nottingham Antibiotic Guidelines Committee Page 7 of 12

8 Multi-resistant UTI Local, national and international surveillance has identified a worrying increase in multiple resistance to antibiotics in Gram-negative bacilli; particularly gentamicin, quinolone and cephalosporin resistant E. coli. Local surveillance has identified the following risk factors for ESBL positive E. coli or multi- resistant Gram negative sepsis: Previous history of isolation of ESBL positive E coli or Multiresistant Gram negative organisms OR Recurrent urinary or biliary tract infections (>3 in last year) Sepsis despite current or recent (within the last week) treatment with broadspectrum antibiotics e.g. co-amoxiclav, cefuroxime or quinolones (ciprofloxacin, levofloxacin) Recurrent admissions with neutropaenic sepsis requiring treatment with Piperacillin-Tazobactam To enable effective management of these patients, it is therefore important that urine for MC&S is sent (and blood cultures if signs of pyelonephritis or systemic sepsis are present), and previous microbiology results reviewed. Most multi-resistant isolates including ESBL-producing strains remain sensitive to nitrofurantoin and pivmecillinam; these options should be used when possible. If these are not suitable then PO fosfomycin (unlicensed) is available on the advice of a Microbiologist (restricted agent) for the treatment of urinary tract infections: PO Fosfomycin dosing Lower UTI in women: 3g single dose Lower UTI in men, diabetics, those with a structural or functional abnormality of the urinary tract, or recent urinary surgery / instrumentation: 3g dose, followed by a further 3g dose 72 hours later Nottingham Antibiotic Guidelines Committee Page 8 of 12

9 Acute Prostatitis Acute prostatitis is caused by urinary tract pathogens. Infection may spread from the distal urethra but can also spread from the bladder, blood and lymphatic system. Acute prostatitis is an uncommon complication of UTI, urological instrumentation or catheterisation. Acute prostatitis is an acute severe systemic illness. Symptoms include: symptoms of a urinary tract infection: dysuria, frequency and urgency symptoms of prostatitis: low back pain, perineal, penile and sometimes rectal pain symptoms of bacteraemia: fever and rigors; arthralgia and myalgia; recurrent Gram negative bacteraemia of unknown focus. Signs include: an extremely tender, swollen and tense, smooth textured prostate gland which is warm to the touch Cases of suspected prostatitis should be discussed with Urology, so that appropriate imaging +/- intervention can be arranged. Ensure a urine sample is sent for MC&S (clearly-labelled with the specimen type e.g. MSU), and two sets of blood cultures are taken. First line: PO Ciprofloxacin 500mg bd for 28 days If patient is previous C.difficile positive (PCR or toxin) ciprofloxacin requires Microbiology approval before use If vomiting, concerns about absorption or if severe sepsis, give IV ciprofloxacin 400mg BD, converting to oral as soon as oral route available Second line (If ciprofloxacin unsuitable e.g. resistant organism or contra-indicated): PO Trimethoprim 200mg bd for 28 days Antibiotic choice should be reviewed at 48 hours with urine MC&S, blood cultures, and imaging results. Nottingham Antibiotic Guidelines Committee Page 9 of 12

10 MANAGEMENT OF EPIDIDYMITIS AND ORCHITIS Clinical presentation: Pain and swelling of the epididymis +/- testes (Orchitis), pyrexia, with or without urethral discharge (ENSURE TESTICULAR TORSION EXCLUDED). Sexual history: Causative agents: YES It is important to take a sexual history in ALL cases. Sexually transmitted infections (STIs) may be the underlying cause of epididymitis and orchitis, especially in younger patients (under 35 years). However, patients over 35 years of age without suggestion of sexual contact, are more likely to have infections of urological origin. Gram negative enteric organisms are more commonly the cause if recent instrumentation or catheterisation has occurred. Organisms of the urinary tract e.g. Escherichia coli. Sexually transmitted infection (STI) e.g. Chlamydia trachomatis, Neisseria gonorrhoea In non-immunised males born between mumps orchitis must be considered. Send an inside cheek/throat viral swab for mumps PCR testing. SEXUAL CONTACT? NO DAYTIME Do NOT initiate antibiotic treatment Phone GUM Health Advisors to make same day appointment (ext 55949, 56745) Write a brief referral letter to accompany the patient to GUM clinic GUM will take appropriate samples, initiate treatment and organise partner notification OUT OF HOURS 1. Sample 10ml of the first part of urine flow into a universal bottle and send to Microbiology for Chlamydia nucleic acid amplification test (NAAT) 2. Send the rest of the MSU to Microbiology for cell count, culture &sensitivity (MC&S) 3 Urethral swab for N. gonorrhoeae and put into transport medium for sending to Microbiology for Gonococcal culture + sensitivities. All overnight/weekend specimens should be refrigerated Doxycycline PO 100mg bd for days PLUS single dose IM Ceftriaxone 500mg. Severe penicillin allergy (anaphylaxis, angioedema or urticarial rash within first 72 hours or allergy to cephalosporins,- discuss treatment with Microbiology/GUM) If Microbiology results are positive for STI, refer to GUM for follow up and partner notification Check MSU result if positive to adjust antibiotics where necessary Sample MSU +/- blood cultures Ofloxacin PO 200mg BD for 14 days PLUS if severe sepsis Gentamicin 5mg/kg od (max 500mg) reduce dose if renal impairment for 48 hrs initially Adjust antibiotics according to urine or blood culture results (and previous microbiology results if urinary source) Nottingham Antibiotic Guidelines Committee Page 10 of 12

11 Equality Impact Assessment Report 1. Name of Policy or Service Response to external best practice policy 2. Responsible Manager Tim Hills Lead pharmacist antimicrobials and Infection control 3. Name of person Completing EIA Annette Clarkson 4. Date EIA Completed 04/02/15 5. Description and Aims of Policy/Service This guideline describes the antibiotic management of urinary tract infection in adults. 6. Brief Summary of Research and Relevant Data There is no research or relevant data at the present time. 7. Methods and Outcome of Consultation Consultations have been carried out with the following: Urology Consultant Mr Parkinson Antibiotic guidelines committee Comments from the above consultations have been received and incorporated where appropriate. Nottingham Antibiotic Guidelines Committee Page 11 of 12

12 8. Results of Initial Screening or Full Equality Impact Assessment: Equality Group Age Gender Race Sexual Orientation Religion or belief Disability Dignity and Human Rights Working Patterns Social Deprivation Assessment of Impact 9. Decisions and/or Recommendations (including supporting rationale) From the information contained in the procedure, and following the initial screening, it is my decision that a full assessment is not required at the present time. 10. Equality Action Plan (if required) N/A 11. Monitoring and Arrangements April 2017 Nottingham Antibiotic Guidelines Committee Page 12 of 12