TO TREAT OR NOT TO TREAT
THAT IS THE QUESTION
Dr. Ruth Kandel
Director, Infection Control
Hebrew SeniorLife
Objectives
• Define whether to screen for or treat
asymptomatic bacteriuria in an elderly
population
• Review complications of antibiotic use
• Define symptomatic urinary tract infections
• Review challenges of diagnosis in the elderly
2
Clinical Infectious Disease 2005;40:643-654
3
What is Asymptomatic
Bacteriuria?
Asymptomatic Bacteriuria (ASB)
• Laboratory diagnosis
• Positive urine culture
– Colony count significant (> 10⁵ cfu/mL)
• Absence of symptoms
Clinical Infectious Disease 2010;50:625-663
5
Pyuria
• Pyuria (> 10 WBC / high-power field) is evidence of
inflammation in the genitourinary tract
• Pyuria is commonly found with ASB
• Elderly institutionalized residents 90%
• Short-term (< 30 days) catheters 30-75% (Arch IM 2000;160:673-82)
• Long-term catheters 50-100% (Am J Infect Control 1985;13:154-60)
(Infect Dis Clin North Am 1997;11:647-62)
6
Treatment for ASB Indicated
• Pregnant women
– Increased risk for adverse outcomes
• Urologic interventions
• TURP
• Any urologic procedure with potential mucosal
bleeding
7
Treatment for ASB Not Indicated
•
•
•
•
•
•
Premenopausal, non-pregnant women
Diabetic women
Older persons living in the community
Elderly living in long term care facilities
Persons with spinal cord injury
Catheterized patients
CID2005;40:643-654
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Prevalence of ASB
POPULATION
Prevalence %
•
Healthy premenopausal women
1-5
•
•
Postmenopausal women
(50 to 70 years of age)3
2.8-8.6
•
Older community-dwelling patients
0.7 to 1.0
– Women (older than 70 years)
– Men
•
Older long-term care residents
– Women
– Men
•
10.8-16
3.6-19
25-50
15-40
Patients with an indwelling catheter
– Short-term
– Long-term
9-23
100
CID2005;40:643-654
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No Benefit Treating ASB in the Elderly
• Large long-term studies of ASB in pre and
postmenopausal women
– NO ADVERSE OUTCOMES in women not treated
• Randomized studies (treatment vs. no
treatment) in elderly LTC residents
– NO BENEFIT to treatment
– No decreased rate of symptoms
– No improved survival
CID2005;40:643-654
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Prospective Randomized Studies
Treatment vs. No Treatment ASB
Authors
Subjects
Intervention
Outcome
Nicolle LE, et al.
NEJM
1983;309:1420-5
Men, NH,
median age 80
Treated 16
Not treated 20
Duration 2 years
No difference
mortality or
infectious morbidity
2 groups
Nicolle LE, et al.
Am J Med
1987;83:27-33
Women, NH,
median age 83
Treated 26
Not treated 24
Duration 1 year
No difference
mortality/GU
morbidity. Increase
drug reactions and
AB resistance
treated group.
Abrutyn E, et al.
Ann Intern Med
1994;120:827-33
Women,
ambulatory and NH
Mean age 82
Treated 192
Not treated 166
Duration 8 years
No survival benefit
from treatment
Ouslander JG
Ann Intern Med
1995;122:749-54
Women and men
NH
Mean age 85
Treated 33
Not treated 38
Duration 4 weeks
No difference
chronic urinary
incontinence
11
Cohort Studies
Authors
Subjects
Observation
Outcome
JAGS
1990;38:1209-14
Men, Ambulatory,
> 65 years
29 Subjects
No adverse
outcomes
attributed to no
treatment
Duration 1-4.5
years
NEJM
1986;314:1152-6
Population based
Swedish men and
women
Duration 5 years
No association
between
bacteriuria and
survival
Gerontology
1986;32:167-71
Population based
Finnish men and
women > 85 years
Duration 5 years
No association
between
bacteriuria and
survival
12
Proportion of Women with Diabetes Who Remained Free of Symptomatic Urinary Tract Infection, According to
Whether They Received Antimicrobial Therapy or Placebo at Enrollment.
Harding GK et al. N Engl J Med 2002;347:1576-1583.
13
IDSA Recommendations
• Routine screening for and treatment of ASB in
older individuals in the community is not
recommended.
• Screening for and treatment of ASB in elderly
residents in LTCFs is not recommended.
CID2005;40:643-654
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Any
Problems
Just
Treating
Anyway?
16
CDC Website
17
Antibiotic misuse adversely
impacts patients - resistance
•
Getting an antibiotic increases a patient’s
chance of becoming colonized or infected
with a resistant organism.
Antibiotic Resistance
CDC Website
19
Antibiotic Resistance
CDC Website
20
Antibiotic resistance increases
mortality
Mortality associated with carbapenem resistant
(CR) vs susceptible (CS) Klebsiella
pneumoniae (KP)
60
p<0.001
Percent of subjects
50
p<0.001
40
30
20
10
0
Overall Mortality
OR 3.71 (1.97-7.01)
Attributable
Mortality
OR 4.5 (2.16-9.35)
Patel G et al. Infect Control Hosp Epidemiol 2008;29:1099-1106
CRKP
CSKP
Mortality of resistant (MRSA) vs.
susceptible (MSSA) S. aureus
•
•
Mortality risk associated with MRSA
bacteremia, relative to MSSA bacteremia:
OR: 1.93; p < 0.001.1
Mortality of MRSA infections was higher than
MSSA: relative risk [RR]: 1.7; 95% confidence
interval: 1.3–2.4).2
1. Clin. Infect. Dis.36(1),53–59 (2003).
2. Infect. Control Hosp. Epidemiol.28(3),273–279 (2007).
CDC: Get Smart About Antibiotics
24
CDC: Get Smart About Antibiotics
• Antibiotic resistance is one of the world’s most
pressing public threats.
• Antibiotic resistance in long-term care
increases risk
– Hospitalization
– Death
– Cost of treatments
25
Antibiotic misuse adversely
impacts patients- resistance
•
Increasing use of antibiotics increases the
prevalence of resistant bacteria in hospitals.
Reservoir for Spread of Antibiotic
Resistant Pathogens
Clinical Infections
Colonized
(asymptomatic)
Patients
27
Antibiotic‐Resistant Bacteria Travels
Journal of the American Geriatrics Society
pages 242-246, 12 JUL 2002
http://onlinelibrary.wiley.com/doi/10.1046/j.1532-5415.50.7s.5.x/full#f1
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And Another Reason Not To Treat
Clostridium Difficile Infection
30
Clostridium difficile infection (CDI) cases by location and type of
exposures — United States, Emerging Infections Program, 2010
MMWR March 9, 2012
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Rates of Clostridium difficile Infection Among Hospitalized
Patients Aged ≥65 Years
CDC September 2, 2011 / 60(34);1171
32
Background: Impact
Age-Adjusted Death Rate* for
Enterocolitis Due to C. difficile, 1999–2006
2.5
Male
Female
White
Black
Entire US population
Rate
2.0
1.5
1.0
0.5
0
1999 2000 2001 2002 2003 2004 2005 2006
*Per 100,000 US standard population
Year
Heron et al. Natl Vital Stat Rep 2009;57(14).
http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf
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Deaths from Gastroenteritis Double
C. difficile and norovirus are the leading causes
• Adults over 65 years old accounted for 83 percent of
deaths.
• Clostridium difficile and norovirus most common
infectious causes.
• Clostridium difficile
– Accounted for two-thirds of the deaths.
– Presumed cause is spread of a hypervirulent, resistant
strain of C. difficile.
CDC March 14, 2012 Press Release
34
Background: Epidemiology
Risk Factors
•
•
•
•
•
•
•
Antimicrobial exposure
Main modifiable risk
Acquisition of C. difficile
factors
Advanced age
Underlying illness
Immunosuppression
Tube feeds
Gastric acid suppression FDA Drug Safety Communication:
Clostridium difficile infection can be associated with stomach acid drugs known as
proton pump inhibitors (PPIs) February 2012
35
When to Treat
Urinary Tract Infections
Long Term Care
Challenges
• Comorbid illnesses may result in symptoms
similar to UTIs.
• Cognitive impairment may make reporting of
symptoms difficult.
• Older individuals can have atypical
presentations for infections.
• There is a lack of evidenced based guidelines
for symptomatic UTIs.
37
Criteria for Surveillance, Diagnosis and
Treatment
• Based on consensus group recommendations
• Modified by
– Recent clinical practice guidelines
– Current research
38
Criteria for Surveillance, Diagnosis and
Treatment
Consensus group recommendations
• McGeer criteria developed for surveillance
and outcome assessments
– Used by Centers for Medicare and Medicaid
Services
• Loeb criteria recommends minimal set of criteria
necessary to initiate antibiotic therapy for UTI
– Similar to IDSA Guidelines
39
McGeer Criteria
No Indwelling Catheter
Chronic Indwelling Catheter
• At least three of the
following
• At least two of the following
– Fever* or chills
– New or increased dysuria,
frequency or urgency
– New flank or suprapubic pain
or tenderness
– Change in character of urine
– Worsening of mental or
functional status
– Fever* or chills
– New flank or suprapubic pain
or tenderness
– Change in character of urine
– Worsening of mental or
functional status
*Fever > 100.4° F
Am J Infect Control
1991;19:1-7
40
Loeb Minimal Criteria
Initiating Antibiotics
No Indwelling Catheter
• Acute dysuria Or
• Fever* + new or worsening
(must have at least one of
following)
–
–
–
–
–
Urgency
Frequency
Suprapubic pain
Gross hematuria
Costovertebral angle
tenderness
– Urinary incontinence
Chronic Indwelling Catheter
Must have at least one of the
following
• Fever*
•
•
•
New costovertebral angle
tenderness
Rigors (shaking chills)
New onset delirium
*Fever > 100° or 2.4° F above
baseline
ICHE 2001;22:120-124
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Criteria for Surveillance, Diagnosis and
Treatment
Clinical Practice Guidelines
• Infectious Disease Society of America (IDSA)
Clinical Practice Guidelines Fever and Infection
Long-Term Care Facilities 2008 CID 2009;48:149-171
• IDSA Clinical Practice Guidelines CatheterAssociated Urinary Tract Infections Adults
2009 CID 2010;50:625-663
• IDSA Guidelines Asymptomatic Bacteriuria CID
2005;40:643-654
42
Criteria for Surveillance, Diagnosis and Treatment
Current Research
Diagnostic algorithm for ordering urine cultures for NH residents in intervention arm
Loeb M et al. BMJ 2005;331:669
©2005 by British Medical Journal Publishing Group
43
Treatment algorithm for prescribing antimicrobials to NH residents in intervention arm
Loeb M et al. BMJ 2005;331:669
44
©2005 by British Medical Journal Publishing Group
Monthly rates of antimicrobial prescriptions for urinary indications in intervention and usual
care nursing homes.
Loeb M et al. BMJ 2005;331:669
45
©2005 by British Medical Journal Publishing Group
Collecting Urine Samples
• Mid-stream or clean catch specimen for cooperative and
functionally capable individuals. However, often necessary
– For males to use freshly applied, clean condom (external)
catheter and monitor bag frequently
– For females to perform an in-and-out catheterization
• Residents with long-term indwelling catheters
– Change catheter prior to collection (sterile technique/equip.)
• Resident with short-term catheterization (< 30 days)
– Obtain by sampling through the catheter port using aseptic
technique
– If port not present may puncture the catheter tubing with a
needle and syringe
– If catheter in place > 2 weeks at onset of infection, replace
CID 2009;48:149-171
CID 2010;50:625-663
46
Role of Urine Analysis and Dipstick Testing in the Evaluation of
Urinary Tract Infection in Nursing Home Residents
•
Negative urine analysis for WBCs and negative dipsticks tests for leukocyte esterase and nitrites do
not support UTI BUT cannot completely rule it out
–
–
Leukocyte esterase (LE)
• Enzyme found in white blood cells (WBCs)
Nitrites
• Certain bacteria reduce urinary nitrates to nitrites
– Pyuria
•
> 10 WBC / high-power field
Squamous cells
Increased number suggests contamination
Infect Control Hosp Epidemiol 2007;28:889-891
Am Fam Phys 2005;71:1153-1162
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Urine Culture
• A urine culture should always be obtained
when evaluating SYMPTOMATIC infections.
• Urine cultures will assist in appropriate
antibiotic selection.
• A negative urine culture obtained prior to
initiation of antibiotics excludes routine
bacterial urinary infection
48
At least one of the following that are
new or increased
□ Fever (> 100°F or 2.4°F >
baseline)
□ Costovertebral angle tenderness
□ Rigors (shaking chills)
□ Delirium
□ Flank pain* or pelvic discomfort*
□ Acute hematuria*
□ Malaise or lethargy with no other
cause*
*CID 2010;50:625-663
Acute dysuria alone OR
Fever (> 100°F or 2.4°F > baseline) AND
at least one of the following that is new or
increased
□ Urgency
□ Frequency
□ Suprapubic pain □ Gross hematuria
□ Costovertebral angle tenderness
□ Urinary incontinence
□ Change in mental status*
□ Rigors (shaking chills)*
If accompanied only by fever, rule out other
causes
*CID 2012;54:973-978 BMJ 2005;331:669
49
Key Points
• Routine screening for and treatment of ASB is not
recommended
– In older individuals in the community
– In elderly residents in LTCFs
• Get Smart About Antibiotics
– Antibiotic resistance is one of the world’s most pressing public
threats.
– Clostridium difficile infections are on the rise and are associated
with increased mortality especially among the elderly
• Treat only symptomatic urinary tract infections in the
elderly
– Refer to clinical guidelines to assist in making a diagnosis
50