Burning Issues with UTIs
Meghan Brett, MD
Division of ID
Hospital Epidemiologist
Medical Director, Antimicrobial Stewardship
Objectives
• Distinguish between asymptomatic bacteriuria (ASB) and different
types of active UTIs (complicated vs. uncomplicated)
• Describe in which patients ASB should be treated
• Learn how to diagnose a catheter-associated UTIs (CAUTIs)
• Describe how to determine empiric treatment and how long
uncomplicated UTIs should be treated
• Know how to access and use various antibiograms and other
resources
What’s the Burden of UTIs?
• 50% of women will have a UTI in their lifetime
– Up to 25% may have a second UTI within 6 months
• Visits related to UTI
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3 million ED visits in 2010
Most common primary diagnosis for U.S. women visiting EDs
100,000 hospitalizations in U.S.
0.9% of all ambulatory visits
• Half of all UTIs were among patients age 18 to 44 years
• Pts visiting the ED have higher acuity than those pts
presenting to primary care
– 400,000 (13%) were for pyelo (13 visits/10,000 people)
– In general population: 1 case/28 cases of cystitis
Who is Most Affected by UTIs?
• Annual Incidence of UTIs
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Young, sexually active women: 2 – 4%
Women > 70 yrs: 5 – 10%
Women > 80 yrs: 50%
Institutionalized Women: 40%
Adult men (childhood through middle age): < 1%
Men > 65 yrs: 1 – 3%
Men > 80 yrs: 10%
Institutionalized Men: 25%
• CAUTIs: ~1 million/year
What Are Take Home Points?
• Assemble the whole clinical picture (i.e., limiting
reflexive Rx of positive Urine Cx)
• Determine the syndrome
• Distinguish between complicated vs.
uncomplicated UTIs
• Choose appropriate empiric antibiotics based on
likely bacterial etiologies and their resistance
• Adjust antibiotics based on culture results
• Decide about length of therapy
Questions (1st Set)
• How do you define asymptomatic bacteriuria ASB?
• How do you differentiate between asymptomatic bacteriuria and
UTI?
• Which groups need to be treated for ASB?
• What criteria do you use to define uncomplicated vs. complicated
UTIs?
• Why does distinguishing uncomplicated vs. complicated help?
• What kinds of questions would you ask to distinguish between
uncomplicated and complicated?
Asymptomatic Bacteriuria
• Asx women: 2 consecutive voided urine
specimens with isolation of same bacterial strain
in quantitative counts ≥ 105 cfu/mL
• Men: single, clean-catch voided specimen with 1
bacterial species isolated in quantitative counts ≥
105 cfu/mL
• Women or men: single catheterized specimen
with 1 bacterial species isolated in quantitative
count ≥ 102 cfu/mL
Infectious Diseases Society of America (IDSA), ASB guidelines 2005
ASB
• Evidence that screening and treatment does
not lead to improved clinical outcomes
• More likely, unnecessary antibiotics may cause
harm
– Adverse effects
– C difficile infection
– Antibiotic resistance
– Wasted expense
UTI Signs/Sx
Clinical Presentation –
Distinguishing ASB vx. UTI
• Lower tract signs
– Dysuria
– Frequent urination
– Urgent urination
• DDX:
– STIs
– Vaginitis
– Exposure to chemical or allergic irritants
Clinical Presentation –
Distinguishing ASB vx. UTI
• Upper tract:
– Fevers, chills
– Nausea
– Flank pain
– Often also with dysuria/frequency/urgency
Which Groups Require Rx for ASB?
• Definitive:
– Pregnant Women
– Anyone undergoing TURP or Urologic procedures
during which mucosal bleeding is anticipated
• Maybe:
– Renal transplant patients
– Neutropenic patients
Infectious Diseases Society of America (IDSA), ASB guidelines 2005
Uncomplicated vs. Complicated
• Uncomplicated – premenopausal women
– No structural or functional abnormalities in urinary
tract
– Not pregnant
• Complicated –
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Structural abnormalities (e.g., nephrolithiasis)
Functional abnormalities (e.g., ureteral reflux)
Compromised hosts (e.g., pregnant, diabetic)
UTIs in boys/men: until structural/functional ruled out
IDSA, Uncomplicated UTI Guidelines 2011
Dielubanza EJ. ID Clin N Am 2014.
Why Distinguish Between
Uncomplicated vs. Complicated?
• Guidelines for uncomplicated but none for
complicated UTIs
• More important than upper tract/lower tract
• Complicated
– May need further evaluation (diagnostics, urology
consult)
– Increased morbidity and mortality
– May encounter more drug resistance (IV ABX)
– Duration of therapy will likely be longer
• Assess conversion from uncomplicated to
complicated (may indicated underlying issues)
Questions to Distinguish
Uncomplicated from Complicated
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Pregnancy status
History of kidney stones
Structural/functional GU abnormalities
Pelvic surgery
DM
Neurologic disorders
Recent ABX use
Recent hospitalization
Recent GU instrumentation
Questions (2nd Set)
• What’s the best way to obtain a urine sample for
diagnosing a UTI?
• What are indications for having a Foley catheter?
• What tests do you review on a urinalysis to make
you consider a UTI? ASB?
• How do you diagnose a CAUTI?
Key Issue – Urine Sample Collection
• Clean-catch, mid-stream = best
• In/Out catheterization
• DO NOT insert Foley catheters for sake of
urine collection (unless otherwise indicated)
Indications for Foley Catheters
• Patients with hemodynamic instability (e.g., on
pressors) who require urine output monitoring
• Urinary obstruction/retention
• Sacral or perineal wounds in patients with
incontinence
• Genitourinary surgery/Placed by a Urologist
• Requires prolonged immobilization (unstable
spine)
• End of life care
CDC (HICPAC) CAUTI Prevention Guidelines, 2009
http://www.cdc.gov/HAI/ca_uti/uti.html
Review of UA for Evidence of Infection
• Check squamous cells first… if > 20, likely a
contaminated sample
• Nitrites
– Produced by many Gram-negatives
– Requires hours for conversion of nitrate  nitrite
– Not by Gram-positives, candida species
• WBCs
– > 10 per high powered field
• Leukocyte esterase
– Enzyme found in neutrophils
– If present, indicates neutrophil activity
Caveats
• Pyuria in ASB does not need to be treated
• Urine samples that sit will have alterations in
UA results
– Samples analyzed within 2 hours or refrigerated to
limit false positive and false negative results
Questions (3rd Set)
• How do you select an antibiotic for empiric treatment
treatment?
• When do you change from empiric to directed antibiotic
therapy?
• How long do you treat uncomplicated cystitis?
Uncomplicated pyelonephritis?
• How do you treat CAUTIs? For how long?
• Do you test urine for cure? Why?
Treatment of UTIs – What Bugs?
• Enteric flora colonizing perineum and urethra
• E. coli
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80% of first infection in women, men, children
50% of nosocomial UTIs
Most common for acute uncomplicated cystitis
Many episodes of complicated UTIs and pyelo
• Staphylococcus saprophyticus
– 11% of UTIs (sexually active, younger women)
• Remaining
– GNRs (Klebiella, Proteus mirabilis)  increasingly MDROs
– Gram-positive cocci (entercoccus and GBS)
What’s First Line Therapy (Empiric
Treatment)? – Uncomplicated Only!
• Antimicrobial Stewardship Clinical Pathway
(with a focus on inpatients)
Change from Empiric to Directed?
• When you have culture results
• Look at susceptibility interpretations
• Determine what has good urine/kidney
penetration
• Lowest MIC ≠ Best ABX selection
• Questions? Call Antimicrobial Stewardship!
(on amion.com)
How Long to Treat?
• It depends!
• Uncomplicated UTIs
– Cystitis 
• Nitrofurantoin or Bactrim  3 days
• 20% resistance in isolates is an indication not to use this for
empiric coverage
• Note: nitrofurantoin should not be used in patients with
Creatinine clearance < 50 (does not reach bladder)
– Pyelonephritis 
• FQ  5 – 7 days
• Beta-lactams  10 – 14 days
• Bactrim  14 days
How Long to Treat CAUTIs?
• 7 days of treatment for patients with CAUTI
who have prompt resolution of symptoms
• 10 – 14 days in patients with delayed response
to treatment
• 3 day regimen may be considered for women
≤ 65 yrs who develop CAUTI without upper
tract sx after a catheter has been removed
Test of Cure?
• Nope (please don’t)
Other Notes
• Complicated including CAUTIs
– Polymicrobial for longer-term (>30d) indwelling
catheters
– More drug resistant (ESBLs, P. aeruginosa, or
enterococcus faecium)
• S. aureus – what to do?
Treatment of CAUTIs
• Algorithm to be developed
Greatest Overuse of Antibiotics
It’s ASB
patient’s positive urine cx
Unintended Consequences of ABX
• Drug reactions
• C difficile infections
• Selection for drug resistance
• Stay tuned… impact to the microbiome
Resources
ASP – Inpt Antibiograms and Clinical Pathways
• https://hospitals.health.unm.edu/intranet/Ind
ex.cfm
• https://hospitals.health.unm.edu/intranet/ant
imicrobial/pathways.shtml
Tricore – Outpatient Antibiograms
• http://www.tricore.org/HealthcareProfessionals/Test-Information/Antibiograms