TO SEND OR NOT TO SEND? THE ROLE OF URINE CULTURES IN UNCOMPLICATED UTI Patricia Moriarty, MSN, FNP-BC, APRN June 3, 2016
OBJECTIVES 1. List the indications for a urine culture. 2. Define an uncomplicated UTI 3. Define a complicated UTI 4. List three first-line antibiotic regimens for the treatment of lower UTI.
Pop Quiz: WHAT DO YOU KNOW ABOUT CYSTITIS? (Medscape 4/1/2016) Which of the following causes most uncomplicated cystitis cases? A. Proteus mirabilis B. Escherichia coli C. Klebsiella pneumonia D. Enterococcus faecalis
Pop Quiz: WHAT DO YOU KNOW ABOUT CYSTITIS? (Medscape 4/1/2016) Which of the following is the most important risk factor for cystitis in women? A. Interference with the flow of urine (eg. stone in the bladder) B. Antibiotic use C. Allergies D. Sexual activity
Pop Quiz: WHAT DO YOU KNOW ABOUT CYSTITIS? (Medscape 4/1/2016) Which of the following symptoms is suggestive of pyelonephritis rather than cystitis? A. Nausea and vomiting B. Hematuria C. Dysuria D. Flank pain
Pop Quiz: WHAT DO YOU KNOW ABOUT CYSTITIS? (Medscape 4/1/2016) Which of the following is the criterion standard for diagnosis of a UTI? A. Urine microscopy B. Dipstick testing C. Urine Culture D. Nitrate test
Pop Quiz: WHAT DO YOU KNOW ABOUT CYSTITIS? (Medscape 4/1/2016) Which of the following statements is true regarding the treatment of uncomplicated acute cystitis in women? A. Women who receive effective antibiotic treatment still typically experience severe symptoms for at least 7 days. B. Without treatment, a significant number of uncomplicated cystitis cases in women spontaneously resolve. C. The likelihood of uncomplicated acute cystitis that goes untreated progressing to pyelonephritis is high. D. The first-choice agents for treatment of uncomplicated acute cystitis are beta-lactam antibiotics.
FEMALE ANATOMY
Reason for UTI TQI Study Visits for urinary tract infections (UTIs) account for many patient visits at Student Health Services: According to ICD 9 599.0 (now ICD 10 code N39.0) (UTI), the following encounters were noted: 671 patient encounters from 8/1/2012 to 7/31/2013 (716 encounters from 8/1/2011 to 7/31/2012) 270 patient encounters from 1/1/2013 to 5/31/2013 (352 encounters from 8/1/2012 to 12/19/2012) Inconsistencies amongst providers ordering urine cultures had been originally proposed and confirmed at the 2012 audit (49% did not meet evidence based criteria for obtaining a urine culture). A follow up audit was indicated to note any change in practice after 1/2013 education and the implementation of a UTI template for SHS EMR. Per ACOG, a urine culture is not required for the initial treatment of women with a symptomatic lower urinary tract infection (UTI)..
Purpose of UTI TQI Study Whether evidence-based practice interventions regarding the ordering of urine cultures utilized at SHS changed after education and implementation of a UTI template for SHS EMR. Research reveals a urine culture is NOT indicated for the vast majority of UTIs. To identify the role of urine cultures in uncomplicated UTIs according to evidence-based practice at SHS. To identify the cost effectiveness of urine culture tests performed at SHS. urine culture: $48.00 plus urine sensitivity: $47.00 TOTAL: $95.00
UTIs According to UpToDate 2016: Urine dipstick in the absence of a urine culture is sufficient for diagnosis of uncomplicated cystitis if symptoms are consistent with a UTI unless there is reason to suspect antimicrobial resistance or other complicating features!
Co-Morbidities & Complicating Factors DM Immunosuppression Urologic Structural/Functional Abnormality Spinal Cord Injury Nephrolithiasis Recent hospitalization/catheter Symptoms for > 7 days Pregnancy Vaginitis symptoms/std concerns Pyridium use Recent UTI treatment Travel outside the U.S. in the preceding 3-6 months
Uncomplicated UTI Dysuria, urinary frequency, urgency, suprapubic pain and/or hematuria are consistent with symptoms of an uncomplicated UTI Absence of fever, chills, flank pain, CVAT, N/V or other suspicion for pyelonephritis Able to take oral medication No antimicrobial therapy for a UTI within 6 months
Urine Culture Indications If symptoms are not characteristic of an uncomplicated UTI If there are the presence of co morbidities If symptoms persist for > 7 days or recur within 6 months of antimicrobial therapy If a complicated infection is suspected such as pyelonephritis
Urine Dipsticks Leukocyte esterase may be used to detect > 10 leukocytes per high power field (sensitivity of 75-96%; specificity of 94-98%). The nitrite test is fairly sensitive and specific though it lacks adequate sensitivity for detection of other organisms so negative results should be interpreted with caution. Dipstick analysis is the least expensive and time intensive test.
Microbial Spectrum E. coli (75-95%) Enterobacteriaceae such as Proteus mirabilis and Klebsiella pneumoniae Staphylococcus saprophyticus Resistance rates > 15-20% necessitate a change in antibiotic class
E. coli Sensitivity Updated 1/22/2013 CIPROFLOXACIN 0 33 94.92 617 CEPHALOTHIN 67.08 75 139 436 SULFAMETHOXAZOLE 0 82.62 113 537 % Sensitive Intermediate Sensitivity NITROFURANTOIN 3 0 99.54 647 Resistent sensitive TETRACYCLINE 0 80.62 126 524 AMPICILLIN 60.77 40 215 395 0 100 200 300 400 500 600 700 Total Cases Treated
Klebsiella Sensitivity Updated 1/22/2013 CIPROFLOXACIN 0 0 49 100.00 CEPHALOTHIN 4 2 41 83.67 SULFAMETHOXAZOLE NITROFURANTOIN 1 4 3 9 35 43 71.43 87.76 % Sensitive Intermediate Sensitivity Resistent Sensitive TETRACYCLINE 0 7 40 81.63 AMPICILLIN 0.00 1 0 48 0 20 40 60 80 100 120 Total Cases Treated
Enterobacter aerogenes Sensitivity Updated 1/22/2013 CIPROFLOXACIN 0 0 22 100.00 CEPHALOTHIN 1 1 4.55 20 SULFAMETHOXAZOLE NITROFURANTOIN TETRACYCLINE 0 0 1 1 1 6 15 22 20 68.18 90.91 100.00 % Sensitive Intermediate Sensitivity Resistent Sensitive AMPICILLIN 0 1 4.55 21 0 20 40 60 80 100 120 Total Cases Treated
Staph. saprophyticus Sensitivity 96.49 UPDATED 1/22/2013 LEVOFLOXACIN 0 1 55 28.07 ERYTHROMYCIN 0 16 33 % SENSITIVE Intermediate Sensitivity 94.74 Resistent SULFAMETHOXAZOLE 0 2 sensitive 54 87.72 TETRACYCLINE 0 6 50 0 20 40 60 80 100 120 Total Cases Treated
Treatment Regimens For Uncomplicated Acute Bacterial Cystitis Antimicrobial Agent Dose When to avoid Nitrofurantoin SHS cost $27.00 Bactrim DS SHS cost $12.00 100mg PO BID x 5 days Suspicion for early pyelonephritis and is contraindicated when creatinine clearance is < 60mL/min One tab PO BID x 3 days Avoid if resistance rate > 20%. Avoid if use in the past 3-6 months and travel, particularly international travel. Fosfomycin Not offered at SHS Expensive No generic 3 gm single dose Avoid if there is suspicion for early pyelonephritis
Second-Line Therapy For Uncomplicated Acute Bacterial Cystitis Antimicrobial Agent Fluoroquinolones (FQ) are effective but should be reserved for more invasive infections.
Infectious Disease Society of America (IDSA) IDSA first published clinical practice guidelines for the treatment of UTI in 1999 followed by an update in 2010. Macrobid is under-prescribed, while TMP/SMX and Cipro are over-prescribed per IDSA.
TQI UTI AUDIT 2013 Findings
Was a UTI History Obtained by the Provider? 2012 74 out of 75 charts did! 98.7% 2013 80 out of 80 charts did! 100%
The following was noted: 30% 25% 20% 15% 10% 2012 2013 5% 0% No LMP noted No mention of sx duration
The following were not always routinely asked: 70% 60% 50% 40% 30% 20% 10% Last UTI HX Comorbidities Vaginitis sx Pyridium use STD concerns 0% 2013
Were there any complicating factors such as: 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Symptoms > 7 days Vaginitis type symptoms Pyridium use prior to visit On menses at time of the visit
Any Co-morbidities noted? 2% 1% 1% 0% 2012 comorbidities 2013 comorbidities
Was a Urinalysis Multistix Done? 2012 urine dip done 2013 urine dip done Yes: 93.3% No: 6.7% YES: 95% NO: 5 %
Reasons for Not Having a Urine Multistix Done: 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% 2012 why Multistix not done 2013 why multistix not done
Was a Urine Culture Done? 2012 2013 YES: 52% NO: 48% YES: 56.25% NO: 43.75%
Uncomplicated UTI & Urine Culture 50 45 40 35 30 25 20 15 10 5 0 Uncomplicated UTI Urine C & S 2012 2013
How many patients did NOT meet evidence based criteria for obtaining a urine culture?
Complicated UTI & Urine Culture 40 35 30 25 20 15 2012 2013 10 5 0 No Urine Culture Complicated UTI
Complicated UTI 8 7 6 5 4 3 2012 2013 2 1 0 UTI < 6 months Sx's > 7 days Kidney Stones
Was a Temperature taken? 2012 2013 Yes: 94.7% No: 5.3% YES: 98.7% No: 1.3%
Was an Abdominal/CVAT exam Performed? 2012 2013 Yes: 80% No: 20% Yes: 92.5% No: 7.5%
Analysis of no documentation of an abdominal and/or CVAT Exam 60% 50% 40% 30% 20% 2012 2013 10% 0% No abdominal or CVAT exam Abdominal exam only CVAT exam only
Antibiotic prescribed? 70% 60% 50% 40% 30% 20% 10% 0% 2012 2013
Urine Culture Results 60% 50% 40% 30% 20% 10% 0% 2012 2013
Bactrim Resistance in sample 70% 60% 50% 40% 30% 20% 10% 0% E. Coli Bactrim prescribed Those prescribed Bactrim with resulting resistance 2012 2013
Any follow-up needed related to the UTI? 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Yes No 2012 2013
Analysis of patients requiring follow-up: 6 5 4 3 2 1 0 2012 2013
UTI EMR Scenario for UTI
Telephone Management Strategy for Acute Uncomplicated Cystitis JAMA. 2014;312(16):1677-1684. doi:10.1001/jama.2014.12842 Example of a Telephone Management Strategy for Acute Uncomplicated Cystitis Individuals Eligible for Telephone Management Adult women with acute onset (duration, <7-10 days) of at least 1 of the following: dysuria, frequency, urgency, or gross hematuria. No flank or abdominal pain No fever (>100.5 F) Ability to urinate in past 4 hours Able to take oral medications Not pregnant a No comorbid conditions (eg, immunosuppression) a No voiding abnormalities (eg, neurogenic bladder) No history of sexually transmitted disease or new sex partner No vaginal symptoms No recent urinary tract infection (past 4-6 weeks) or urological procedure
Telephone Management Strategy for Acute Uncomplicated Cystitis JAMA. 2014;312(16):1677-1684. doi:10.1001/jama.2014.12842 Therapy Regimens Modify based on local susceptibility rates. Preferred: Fosfomycin, one 3-g dose Nitrofurantoin, 100 mg twice a day for 5 days Trimethoprim-sulfamethoxazole, 1 double-strength tablet twice daily for 3 days Alternative: Ciprofloxacin, 250 mg twice daily for 3 days
CONCLUSION Acute uncomplicated UTI in women can be diagnosed without an office visit (telephone) or a urine culture. Define an uncomplicated UTI.
Uncomplicated UTI Uncomplicated UTIs are defined as: Acute onset of dysuria, urgency, and/or frequency in a healthy pre-menopausal nonpregnant woman without known functional or anatomical abnormalities of the urinary tract! Absence of fever Absence of vaginal symptoms
Complicated UTI DM (some research questions) Immunosuppression Urologic Structural/Functional Abnormality Spinal Cord Injury Nephrolithiasis Recent hospitalization/catheter Symptoms for > 7 days Pregnancy Vaginitis symptoms/std concerns Pyridium use Recent UTI treatment Travel outside the U.S. in the preceding 3-6 months
Post Test Questions A 20-year-old woman with NKDA presents to the university student health service with a 2-day history of increasing urinary frequency along with urgency and dysuria. Her urine is reportedly blood tinged. She has no history of a prior UTI. The patient had recently become sexually active and she was using a barrier contraception with spermicide. 1. Is this a complicated or uncomplicated UTI? 2. Does this patient need a urine culture? 3. Would a telephone visit be appropriate? 4. What antibiotic should this pt receive? 5. What other questions would you ask?
Post Test Questions Now this same 20 y/o female college student returns in one month with the same urinary symptoms plus genital pain. Patient denies any other related symptoms and this patient is asking for Bactrim DS that she received one month ago because it worked. 1. Complicated or uncomplicated UTI? 2. Does this patient need a urine culture? 3. Does this patient need an exam? 4. Would you prescribe Bactrim DS because it worked last time to resolve her urinary symptoms?
UTI Differential Diagnosis? Ideas????????????
UTI Differential Diagnosis (Some) Herpes simplex (HSV) N. gonorrhoeae Chlamydia Trichomonas Vaginitis Nephrolithiasis Trauma GU tuberculosis GU neoplasm Intra-abdominal abscess Sepsis - source other than GU system
REFERENCES Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary Tract infections: epidemiology, mechanisms of infection and treatment options. National Review of Microbiology. May 2015; 13(5): 269-284. Geerlings S. Urinary tract infections: a common but fascinating infection, with still many research questions. Current Opinion in Infectious Diseases. February 2015; 28: 86-87. Grigoryan L, Gupta K. Diagnosis and Management of Urinary Tract Infections in the Outpatient Setting. JAMA. 2014;312(16):1677-1684. doi:10.1001/jama.2014.12842 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 Disease Society of America and the European Society For Microbiology and Infectious disease. Clin Infect Dis. 2011; 52:e103-120. Hooten TM, Gupta K. Acute uncomplicated cystitis and pyelonephritis in women. 2016 UpToDate. Kim M, Lloyd A, Condren M, Miller MJ. Beyond antibiotic selection: concordance with the IDSa guidelines for uncomplicated urinary tract infections. Infection. 2015; 43:89-84. Slekovec C, Leroy J, Vernaz-Hegi N, et al. Impact of a region wide antimicrobial stewardship guideline on urinary tract infection prescription patterns. Int J Clin Pharm. 2012; 34:325-329. Stapleton AE. Urine culture in uncomplicated UTI: Interpretation and significance. Curr Infect Dis Rep. 2016; 18:15.
QUESTIONS?? Contact: Patricia Moriarty APRN patricia.moriarty@uconn.edu