1. CG Health Project, UTI Guidance

2. Guideline for the Diagnosis and Management of Adults in LTC with UTI 4 Key concepts to optimize management of UTI in LTC patients: Most UTIs present with fever and/or symptoms localizing to the urinary tract. Antibiotics are not recommended to treat colonization of the urinary tract (asymptomatic bacteriuria), except in pregnancy and invasive genitourinary procedures.

3. Guideline for the Diagnosis and Management of Adults in LTC with UTI Urinalysis and urine culture have poor test characteristics in older patients and patients with indwelling urinary catheters—they should not be ordered unless symptoms are present. Alteration in mental status (delirium) is neither sensitive nor specific for UTI. Thus delirium without other localizing symptoms is unlikely to be a UTI.

4. Guideline for the Diagnosis and Management of Adults in LTC with UTI Localizing UTI symptoms Fever, rigorsUrgency Acute hematuriaFrequency Flank painDysuria Suprapubic pain Costovertebral angle pain or tenderness Pelvic discomfort

5. Guideline for the Diagnosis and Management of Adults in LTC with UTI When you suspect a UTI, answer these two questions: Does this patient have any localizing UTI symptoms? Does a non-UTI diagnosis likely account for the symptoms?

6. Guideline for the Diagnosis and Management of Adults in LTC with UTI Does this patient have any localizing UTI symptoms? – No Do not send UA or urine culture. – Yes Continue to next question.

7. Guideline for the Diagnosis and Management of Adults in LTC with UTI Does a non-UTI diagnosis likely account for the symptoms? – Yes Work up other cause. – No Continue to next question.

8. Guideline for the Diagnosis and Management of Adults in LTC with UTI 1. Send urine culture. 2. Consider empiric antibiotics for UTI. 3. Review urine culture results at 48-72 hours and narrow or stop antibiotics as appropriate.

9. Guideline for the Diagnosis and Management of Adults in LTC with UTI This is intended as a guide for evidence- based decision-making and should augment not replace clinical judgment.

10. Guideline for the Diagnosis and Management of Adults in LTC with UTI Key concepts to optimize antibiotic use when managing UTI in LTC patients: 1) Obtain urine culture prior to initiating antimicrobial therapy. 2) Fluoroquinolones and Trimethoprim-sulfamethoxazole are not routinely recommended as empiric therapy due to increasing bacterial resistance to these agents. 3) For patients with an appropriate clinical response, the recommended treatment duration for complicated cystitis, pyelonephritis, or CAUTI is 5-7 days.

11. Guideline for the Diagnosis and Management of Adults in LTC with UTI Fluoroquinolones and Trimethoprim-sulfamethoxazole are not routinely recommended as empiric therapy due to increasing bacterial resistance to these agents. If we look at the 5 lab (CG area labs) antibiograms for E. coli: Only 1 of 5 has SMZ/TMP treating above 80% (75-83%). Only 2 of 5 have fluoroquinolones treating above 80% (67- 83%).

12. Guideline for the Diagnosis and Management of Adults in LTC with UTI Guideline applicable to patients with: uncomplicated cystitis, complicated cystitis, pyelonephritis, catheter- associated UTI (CAUTI). NOT applicable to: prostatitis, pregnancy, bacteremia, renal transplant, persistent urinary tract obstruction, renal/perinephric abscess, percutaneous nephrostomy tubes, and other clinical scenarios requiring specialized management.

13. Guideline for the Diagnosis and Management of Adults in LTC with UTI Uncomplicated cystitis, defined as a bladder infection in a LTC female without evidence of upper urinary tract involvement, obstruction, anatomic abnormalities, or recent instrumentation.

14. Guideline for the Diagnosis and Management of Adults in LTC with UTI Common pathogens: E. coli, Klebsiella sp., Proteus sp, S. saphrophyticus Antibiotics for empiric use, should show less that 20% resistance. Out of 228 CG cultures, the study identified 83 E. coli, 29 Proteus mirabilis, 24 Klebsiella sp., 14 Pseudomonas aeruginosa and the rest <3. Also remember to look at patient’s pathogen history.

15. Guideline for the Diagnosis and Management of Adults in LTC with UTI Initial antibiotic selection (empiric) Nitrofurantoin 100mg PO BID x 5 days ( GFR>60; for GFR 40 to 60, 7days therapy safe and efficacious*) (E. coli, 93-97%, Proteus sp. 0%) OR Cephalexin 500 mg PO BID x 5 days (E. coli, 87-96%, Proteus sp. 77-100%) OR Trimethoprim-sulfamethoxazole DS 1 tab PO BID x 3 days (check your local antimicrobial susceptibilities for resistance) (E. coli, 75-83%,1 of 5, Proteus sp. 64-85%) OR Fosfomycin 3gm PO x1 * Oplinger M, Andrews CO.. Nitrofurantoin contraindication in patients with a creatinine clearance below 60mL/min: looking for the evidence. Ann Pharmacother 2013;47:106–11

16. Guideline for the Diagnosis and Management of Adults in LTC with UTI Treatment duration: as noted in initial antibiotic selection box (previous slide) 1-5 days, depending on agent.

17. Guideline for the Diagnosis and Management of Adults in LTC with UTI Complicated cystitis, defined as any bladder infection not meeting all criteria for uncomplicated cystitis (including any male) OR pyelonephritis OR catheter- associated UTI* AND Low Risk for Antibiotic-Resistant Organism * If Foley catheter in place, remove or change catheter

18. Guideline for the Diagnosis and Management of Adults in LTC with UTI Common pathogens: E. coli, Enterococcus sp., Klebsiella sp., other gram-negative bacilli Empiric therapy depends on local antimicrobial susceptibilities and formulary. Options may include: Ceftriaxone IV/IM (E. coli, 97-99%, Proteus sp.97-100%) If severe PCN allergy: ciprofloxacin IV/PO OR levofloxacin IV/PO ( Only 2 of 5 facilities have fluoroquinolones treating above 80% (67-83%), look to your local antibiogram for guidance). Antibiotic Timeout. Empiric therapy should be narrowed or stopped at 48-72 hours depending on culture results.

19. Guideline for the Diagnosis and Management of Adults in LTC with UTI Transition to oral therapy: Target antibiotic selection to microbiologic data when available. For empiric therapy, consider: If ceftriaxone used : cephalexin, oral 2 nd - or 3 rd -generation cephalosporin OR Fosfomycin (3 doses) (only if no pyelonephritis) OR If severe PCN allergy: ciprofloxacin OR levofloxacin

20. Guideline for the Diagnosis and Management of Adults in LTC with UTI Treatment duration for patients with an appropriate clinical response: 5-7 days Use clinical judgment for days of therapy or consider hospitalization for patients that are slow to respond.

21. Guideline for the Diagnosis and Management of Adults in LTC with UTI Complicated cystitis OR pyelonephritis OR catheter-associated UTI* AND High Risk for Antibiotic-Resistant Organism (prior colonization/infection with an antibiotic-resistant organism) Patients with sepsis, hemodynamic instability, or shock should be transferred to hospital for care. * If Foley catheter in place, remove or change catheter

22. Guideline for the Diagnosis and Management of Adults in LTC with UTI Common pathogens: E. coli, Pseudomonas aeruginosa, Enterobacter sp., Enterococcus sp., other gram-negative bacilli Empiric therapy depends on local antimicrobial susceptibilities and formulary. Options may include: Cefepime or Ceftazidime IV (E. coli and Proteus sp., 97-99%) Piperacillin-Tazobactam IV (E. coli and Proteus sp., 97-100%) Carbapenem IV (if suspicion for extended-spectrum beta-lactamase (ESBL)- producing organism) (E. coli and Proteus sp., 100%) If severe PCN allergy: ciprofloxacin OR levofloxacin IV Antibiotic Timeout. Empiric therapy should be narrowed or stopped at 48-72 hours depending on culture results.

23. Guideline for the Diagnosis and Management of Adults in LTC with UTI Transition to oral therapy: Target antibiotic selection to microbiologic data if available. For empiric therapy, consider: Ciprofloxacin OR levofloxacin OR Fosfomycin (3 doses only if no Pyelonephritis) Treatment duration for patients with an Appropriate clinical response : 5-7 days, Use clinical judgment for days of therapy or consider hospitalization for patients that are slow to respond.

24. Guideline for the Diagnosis and Management of Adults in LTC with UTI This is intended as a guide for evidence-based decision-making and should not replace clinical judgment. Patient’s clinical characteristics, local antimicrobial susceptibility patterns, allergies, and formulary must be considered in treatment decisions.

25. CDC Get Smart for Healthcare Antibiotic overuse contributes to the growing problems of Clostridium difficile infection and antibiotic resistance in healthcare facilities. Targeting antibiotic use through stewardship interventions and programs improves patient outcomes, reduces antimicrobial resistance, and saves money. Interventions to improve antibiotic selection can be implemented in any healthcare setting, from the smallest to the largest, and can be applied to communities. Improving antibiotic selection is a medication-safety and patient-safety issue.

26. Guideline for the Diagnosis and Management of Adults in LTC with UTI Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter–Associated Asymptomatic Bacteriuria. JAMA Intern Med. 2015;175(7):1120-1127. doi:10.1001/jamainternmed.2015.1878. Loeb, Mark, David W. Bentley, Suzanne Bradley, Kent Crossley, Richard Garibaldi, Nelson Gantz, Allison McGeer, et al.. 2001. “Development of Minimum Criteria for the Initiation of Antibiotics in Residents of Long‐term–care Facilities: Results of a Consensus Conference”. Infection Control and Hospital Epidemiology 22 (2). [Cambridge University Press, Society for Healthcare Epidemiology of America]: 120–24. doi:10.1086/501875.\ Nace DA, Drinka PJ, Crnich CJ. Clinical uncertainties in the approach to long term care residents with possible urinary tract infection. J Am Med Dir Assoc. 2014;15:133–139. doi: 10.1016/j.jamda.2013.11.009. Rowe TA, Juthani-Mehta M. Diagnosis and Management of Urinary Tract Infection in Older Adults. Infectious disease clinics of North America. 2014;28(1):75-89. doi:10.1016/j.idc.2013.10.004. Beveridge LA, Davey PG, Phillips G, McMurdo ME. Optimal management of urinary tract infections in older people. Clinical Interventions in Aging. 2011;6:173-180. doi:10.2147/CIA.S13423. Bains A, Buna D, Hoag NA. A retrospective review assessing the efficacy and safety of nitrofurantoin in renal impairment. Can Pharm J. 2009;142:248-252. Oplinger M, Andrews CO.. Nitrofurantoin contraindication in patients with a creatinine clearance below 60mL/min: looking for the evidence. Ann Pharmacother 2013;47:106–11 Stone, N. D., Ashraf, M. S., Calder, J., Crnich, C. J., Crossley, K., Drinka, P. J.,... & MacCannell, T. (2012). Surveillance definitions of infections in long- term care facilities: revisiting the McGeer criteria. Infection Control & Hospital Epidemiology, 33(10), 965-977. Hooton, T. M., Bradley, S. F., Cardenas, D. D., Colgan, R., Geerlings, S. E., Rice, J. C.,... & Nicolle, L. E. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical infectious diseases, 50(5), 625-663. Gupta, K., Hooton, T. M., Naber, K. G., Wullt, B., Colgan, R., Miller, L. G.,... & Soper, D. E. (2011). 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. Clinical infectious diseases, 52(5), e103-e120. McKenzie, Robin et al. Bacteriuria in Individuals Who Become Delirious The American Journal of Medicine, Volume 127, Issue 4, 255 - 257 Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults Clin Infect Dis. (2005) 40 (5): 643-654 doi:10.1086/427507.\ We will include a copy of these papers in your facility packages.

27. Thanks! Marc Meyer BPharm, RPh, CIC 970-564-2190 mmeyer@swhealth.org