Syndrome - Prince Edward Island

Health PEI: Provincial Antibiotic Advisory Team Urinary Tract Infection Empiric Treatment Guidelines
Syndrome
Urinary Tract
Infection
(Antibiotics are
listed in the
numerical order of
preference.)
(Tailoring of
treatment after
susceptibilities are
known is highly
recommended.)
Prevention
Cranberry juice?,
Estrogenized vaginal
mucosa, controlled
diabetes and stones.
Remove indwelling Foley
Catheter
Major Hurdles
True symptoms?, previous
Antibiotics past 90 days
(esp. same class),
Pregnancy, travel outside
of Canada.
Considerations
prostatitis, vaginitis, PID,
urethritis as mimics.
Tuberculosis as culture
negative disease.
Non-SIRS / Pre-SIRS
FEMALE CYSTITIS
(<6d Symptoms)
1. Nitrofur. x 5d (if CrCl > 60
mL/min)*
2. TMP/SMX x 3d
3. Cefixime x 5-7d
4. Amox/Clav x 5-7d
MALE CYSTITIS and EARLY
MALE or FEMALE
PYELONEPHRITIS
1. Cipro x7d
2. TMP/SMX x10-14d
3. Cefixime x 14d
4. Amox/Clav TID x14d
IF in ER or on a unit:
Add Ceftriaxone 1g or Tobra
5mg/kg x1 for pyelonephritis
Septic Shock (Pressors)
Severe Sepsis(1 of 7+)
SIRS / Sepsis (2 of 4)
Refractory Septic Sh.
Mottled, anuria,
>38.3<36.0; HR>90;
(More Pressors)
Lactate>2, Plt<100,
RR>20 or PaCO2<32;
DIC, ARDS, fastΔLOC…
WBC <4 >12 or Bands
In Absence of Indwelling Foley Catheter or Urinary Stent
1. Amp & Tobra
2. Ceftazidime
3. See Early Pyelo for
non-admission Tx.
Pip/Tazo & Cipro
If penicillin allergy:
Mero & Cipro
Mero & Tobra
Or
Mero & Cipro
(Renal Sparing)
In Presence of Indwelling Foley Catheter or Urinary Stent
(Catheter should be removed or changed)
As above and add Vanco
Mero, Vanco,
1. Pip/Tazo
(or Linezolid if VRE is a
&Fluconazole
2. Meropenem
concern)
If previous culture (90d) Add Cipro or Tobra if
Add Fluconazole or
growth of previous P.
or stat gram points to
Amphotericin-B
aeruginosa(90d).
yeast, Enterococcus or
MRSA -add therapy.
RE: Penicillin allergy: Avoid pip/tazo, but meropenem is reasonable to give in severe sepsis or greater even with history of anaphylaxis. Consult Inf. Dis. if in doubt.
*Nitrofurantoin should not be used with abnormal kidney function (CrCl < 60 mL/min) and is discouraged for long term prophylaxis in the elderly(potential for pulmonary
toxicity, inadequate concentrations in the urine in pt with CrCl< 60 mL/min). If financially feasible, Macrobid twice daily versus nitrofurantoin four times daily formulations is
strongly preferred for patient adherence.
Logic for guidelines:
1. The oral antibiotic that urinary isolates of E. coli in PEI have the highest susceptibility to is nitrofurantoin. As per the Health PEI Antibiogram 2013, the local susceptibilities of
urine isolates of E. coli to select antibiotics are as follows: nitrofurantoin 95%, TMP/SMX 83%, cefixime 93%, amoxicillin/clavulanate 88%, ciprofloxacin 85%. Cephalexin data
(59%) is difficult to interpret due to changes in internationally set breakpoints for susceptibility. Yet cephalexin does concentrate in the urine, which would increase its
effectiveness beyond 59%.
2. Avoid collateral damage: nitrofurantoin does not have a serious effect on other bacteria outside the urinary tract, TMP/SMX has lower C. difficle risk than levofloxacin,
ciprofloxacin, or amoxicillin/clavulanate.
3. Nitrofurantoin should NOT be used for pyelonephritis or secondary bacteremia due to inadequate tissue and serum concentrations.
4. A recent article reviewed the literature on nitrofurantoin use in renal dysfunction. The authors of this article suggest that nitrofurantoin is effective and safe to use for shortterm treatment (≤ 1 week) in patients with a CrCl > 40 mL/min. (Oplinger M and Andrews CO 2013 Nitrofurantoin Contraindication in Patients with a Creatinine Clearance
Below 60 mL/min: Looking for the Evidence. The Annals of Pharmacotherapy 47: 106.)
Approved: May, 2013
This document is designed to aid Prince Edward Island hospital and community practitioners in the appropriate utilization of antimicrobials.
It does not serve as a substitute for clinical judgment or consultation with Infectious Disease experts.
Next Review: May, 2015
Health PEI: Provincial Antibiotic Advisory Team Urinary Tract Infection Empiric Treatment Guidelines
Logic for guidelines (continued):
5. Resistance to levofloxacin and ciprofloxacin is greater than 10% which necessitates conservation (limit use in non-serious infections or prophylaxis) and supplementation
(addition of a second agent is recommended for the treatment of serious infections). IDSA guidelines recommend, for treatment of pyelonephritis, when there is >10%
fluoroquinolone resistance, an initial one-time IV/IM dose of a long-acting antimicrobial (such as ceftriaxone or an aminoglycoside) be given. Furthermore, fluoroquinolone
toxicity is an increasing concern such as retinal detachment, ligament tears in the elderly or on steroids, and QT-interval prolongation (especially in patients with other risk
factors). Moxifloxacin should never be used to treat a UTI because it does not concentrate in the urine. The PAAT discussed adding levofloxacin high dose (750 mg po daily)
x5 days in addition to having an option for ciprofloxacin 500 mg po bid x 7days for the treatment of early pyelonephritis. Due to the Special Authorization criteria for
levofloxacin on the PEI Pharmacare Formulary and lack of clarity on using levofloxacin high dose x 5 days for this indication, we have decided not to include levofloxacin high
dose as an option at this time.
6. Enterococcus has relatively low virulence. Enterococcal UTIs are most often nosocomial and/or associated with obstruction, urinary catheterization or instrumentation. In
patients with long-term catheterization, urine cultures obtained before and after the catheter was replaced showed that the mean concentration of Enterococci were >10fold higher in the indwelling catheter than they were in the replacement catheter.
7. Gentamicin vs tobramycin: gentamicin is considered more nephrotoxic than tobramycin and tobramycin has a greater spectrum of activity for empiric treatment of UTIs.
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Epp A. Larochelle A. et al 2010 SOGC Clinical Practice Guidelines Recurrent Urinary Tract Infection. JOGC. 250:1082.
Gupta, K. et al 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. CID 52:e103
Hooton TM et al. 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 CID 50:625
Blondel-Hill E. and Fryters S. Bugs & Drugs 2012.
Capital Health (QE2) Antimicrobial Handbook – 2012
Vancouver Island Health Authority (VIHA) Cowichan District Hospital. Antimicrobial Empiric Prescribing Guidelines – Adults. 2011 (Edition 2)
The Ottawa Hospital (TOH) Guidelines for Empiric Antibiotic Therapy (2012)
Drugs for Urinary Tract Infections. The Medical Letter on Drugs and Therapeutics. 2012. 54:57
Health PEI Antibiogram 2013.
Etminan M. et al 2012 Oral Fluoroquinolones and the Risk of Retinal Detachment. JAMA 307: 1414
Khaliq Y. and Zhanel G. 2003 Fluoroquinolone-Associated Tendinopathy: A Critical Review of the Literature. CID 36: 1404
The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. 2012 American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older
Adults. J Am Geriatr Soc. 60: 616.
Oplinger M and Andrews CO 2013 Nitrofurantoin Contraindication in Patients with a Creatinine Clearance Below 60 mL/min: Looking for the Evidence. The Annals of Pharmacotherapy 47:
106
www.azcert.org , accessed Feb 4, 2013.
Bains A. et al. 2009 A retrospective review assessing the efficacy and safety of nitrofurantoin in renal impairment. CPJ 142: 248.
Murray BE. 2012 Treatment of enterococcal infections. UpToDate (accessed Feb 4, 2013)
Solensky R. 2012 Penicillin-allergic patients: Use of cephalosporins, carbapenems, and monobactams. UpToDate (accessed Jan 3, 2013)
Romano A. et al. 2007 Brief Communication: Tolerability of Meropenem in Patients with IgE-Medicated Hypersensitivity to Penicillins. Annals of Internal Medicine 146:266.
Atanasković-Marković M. et al. 2008. Tolerability of Meropenem in Children with IgE-mediated Hypersensitivity to Penicillins. Allergy 63:237.
Decker BS. Molitoris BA. 2012 Pathogenesis and prevention of aminoglycosides nephrotoxicity and ototoxicity. UpToDate (accessed Feb 4, 2013).
Health PEI Physician Reviewers: Dr. Lenley Adams, Dr. Scott Campbell, Dr. Greg German, Dr. Kate Ellis-Ghiz, Dr. Gil Grimes, Dr. Michael Irvine, Dr. Ian Reid, Dr. John Sampson
Approved: May, 2013
This document is designed to aid Prince Edward Island hospital and community practitioners in the appropriate utilization of antimicrobials.
It does not serve as a substitute for clinical judgment or consultation with Infectious Disease experts.
Next Review: May, 2015
Provincial Drugs & Therapeutics Committee
16 Garfield Street
PO Box 2000, Charlottetown
Prince Edward Island
Canada C1A 7N8
www.healthpei.ca
16, rue Garfield
C.P. 2000, Charlottetown
Île-du-Prince-Édouard
Canada C1A 7N8
www.healthpei.ca
From: Provincial Drugs and Therapeutics Committee
To: All Island Physicians, Nurse Practitioners, and Pharmacists
Date: May 24, 2013
RE: Provincial Urinary Tract Infection Empiric Treatment Guidelines and Health PEI Antibiogram
Consideration of local susceptibly patterns is crucial to empirically treating infections and reducing the spread
of antibiotic resistance. Our Island wide Health PEI Antibiogram 2013, based on 2012 data, is attached and
available at www.healthpei.ca/antibiogram. This data is from all community and hospital specimens received,
removing duplicated specimens for better quality.
Dr. Greg German, Medical Microbiologist, gave grand round presentations at QEH and PCH in the Fall
introducing the antibiogram as it pertains to UTIs and how it may affect your practice. The Provincial Antibiotic
Advisory Team (PAAT), of which Dr. German is co-chair, has developed the enclosed UTI Empiric Treatment
Guidelines which were adapted and approved by a well-represented committee of Physician Reviewers. The
guidelines are based on local susceptibilities and are in keeping with national and international guidelines.
Individual medication recommendations do not necessarily take into account coverage by PEI Pharmacare or
private drug plans. The guidelines were developed with the desire to appropriately and safely treat urinary
tract infections while reducing collateral damage and attempting to save fluoroquinolones for more serious
infections.
The layout of the guidelines includes preventative and diagnostics tips, followed by a list of empiric treatment
options spanning the continuum of patients’ illness from generally well to septic shock. This standardization
should allow for a rapid, consistent, and collaborative approach for almost all patients on the Island. It is
important to note that these guidelines were not designed for special populations such as paediatrics,
pregnancy or patients with severe renal impairment. The guidelines are further categorized by the following:
in patients who are non-SIRS or pre-SIRS, empiric antibiotic treatment differs for female cystitis (< 6 days of
symptoms) versus male cystitis/early male or female pyelonephritis. For patients anywhere across the
spectrum from generally well to refractory septic shock, the suggested treatment options differ for those with
or without an indwelling Foley catheter or urinary stent.
Provincial Drugs & Therapeutics Committee
The new guidelines will potentially change routine practices. For example:
1) Nitrofurantoin is suggested as the first option for female cystitis (if no contraindication for use).
Fluoroquinolones are not listed as one of the top four agents for the treatment of female cystitis. It is
encouraged that fluoroquinolones be reserved for more serious infections.
2) Due to the level of ciprofloxacin resistance (E. coli resistance to ciprofloxacin is 15%), an initial onetime IV dose of a long-acting parenteral antimicrobial (such as ceftriaxone or a consolidated 24h dose
of an aminoglycoside) as a second agent is recommended when possible, when treating early
pyelonephritis.
3) Ampicillin and tobramycin are recommended as first line therapy in patients with SIRS or sepsis
without an indwelling Foley catheter or urinary stent. It is recommended to step-down from ampicillin
and tobramycin as early as possible to avoid aminoglycoside toxicities.
4) For SIRS or sepsis patients with an indwelling Foley catheter or urinary stent, the use of a stat urine
Gram stain to check for yeast, MRSA or Enterococcus is recommended.
5) The cross reactivity of truly penicillin-allergic patients with meropenem is less than 1%. Meropenem is
a reasonable choice to give to serious penicillin-allergic patients in severe disease.
The Urinary Tract Infection Empiric Treatment Guidelines is the first of a series of guidelines the Provincial
Antibiotic Advisory Team is working on developing. Guidelines for Clostridium difficile and skin and soft tissue
infections are to come out in the next few months.
For any questions about the Health PEI Antibiogram 2013, please contact Greg German (894-2515;
[email protected]). For questions on the Provincial UTI Empiric Treatment Guidelines, you can contact the
PAAT co-chairs Greg German or Jennifer Boswell (antimicrobial pharmacist; 894-2587; [email protected]).
2
Vancomycin IV
60
68
100
97
94
100
88
84
100
57
57
85
76
53
66
99
54
PR
PR
42
PR
PR
PR
100
100
100
100
100
~60
PR
79
91
100
100
100
100
100
~26
PR
65
69
100
85^
85^
85
100
~60
~70
79
~90
100
32
91
97
97
132
PR
57
Enterococcus
48
54
Group A Strep
Sample
of 75
Sample
of 100
112
*MRSA Rate: 7.4% of Blood Cultures; 18% of Wounds (QEH and PCH Emerg.)
~National data as local data is unavailable. PR: Predictably Resistant
‡S. pneumoniae and Levofloxacin (99%), in vitro testing not reliable for other GPC.
^85% at regular dose, 100% at high dose in non-Central Nervous System Infections.
Tobramycin
86 PR PR PR 100 95 96 Piperacillin+Tazo
100 100 100 100 100 100 100 Meropenem
94
100 100 100 100 100 100 99 92
PR 100 100 88 91 99 100
PR
96
76 PR PR PR 100 96 93
95
Cefazolin
Ertapenem
PR PR PR PR 100 96 93
PR
Ceftazidime
PR PR PR PR 84 89 89
Ceftriaxone
Ciprofloxacin
100 95 81 100 100 98 78
261
89
Pseudomonas
aeruginosa
PR
7
Co-trimoxazole
Acinetobacter
PR 100 100 94 96 100 99 78
22
Cefixime
Serratia
PR PR PR PR 100 96 90
16
PR
Citrobacter
Cefprozil
49
PR PR PR PR 100 94 86
Enterobacter
PR
11
Cephalexin
Proteus
mirabilis
PR PR PR PR 100 86 59
76
PR
Klebsiella
PR
182
PR PR PR PR 100 PR 54 AmpIV /AmoxPO
PR PR PR PR 100 95 83 Amox +Clav. Acid
E. coli
ALL Gram
Negative
ISOLATES
PR
(Except URINE)
Total (12 Months)
*Nitrofurantoin activity limited to bladder (uncomplicated UTIs only)
PR: Predictably Resistant ; ^Urine inc. levels = likely higher %
Vancomycin IV or Linezolid PO / IV
Clindamycin
100 100
Tobramycin
Erythromycin
98
96
PR 100 97 100 97
PR
Meropenem
98 100 100 97 100 100
PR
58
97 Piperacillin+Tazo
90
97
96 100 PR
PR
58
Ertapenem
99 100 100
PR 100 91
PR
PR
Ceftazidime
97
PR
95
99
96
94
PR
PR
Ceftriaxone
98
PR
95
98
96
PR
PR
PR
Ciprofloxacin
98
99
PR
Streptococcus
pneumoniae‡
99 100 97
97
82 to 93*
1260
Group B Strep
85
85
76^ 99
97
PR
97
99
93
PR
PR
PR
Cefixime
Cephalexin
94 59^
93
PR
82
PR
PR
PR
88 Amox + Clav. Acid
96
PR
98
99
PR
PR
58
60 AmpIV / AmoxPO
90
PR PR
PR
PR
PR
58
Co-trimoxazole
83
93 100 96
92
Total (7 months)
Nitrofurantoin*
95
36
72
25
Co-trimoxazole
Staph. aureus
MSSA & MRSA
Staphylococcus
lugdunensis (SL)
Coagulase Neg.
Staph (Except SL)
352
Cefuroxime or
Ceftriaxone
Doxycylcine
(Tetracycline)
(Except URINE)
147
Cephalexin or
Cefazolin
Cocci
“GPC”
87
Amox+Clav. Acid
Gram Positive
124
PR 90^ PR
Enterococcus
92
PR
Proteus mirabilis
(Not P. vulgaris)
Pseudomonas
aeruginosa
Staphylococcus
saphrophyticus
63
95 100 PR
Enterobacter
333
Amp IV or Amox
Klebsiella
pneumoniae
Klebsiella
oxytoca
2221
(12 Months)
E. coli
Total Number
URINE
Isolates
Health PEI ANTIBIOGRAM 2013
(Island-wide Antibiotic Susceptibility Results of Non-duplicative Isolates)
Medical Microbiologist:
Dr. Greg German
Secretary: # 894-2439
QEH Switchboard for
Direct line or Page
Head Microbiology Technologists:
Andrea Dowling
QEH Laboratory # 894-2312
Becky Moore
PCH Laboratory # 438-4287
Anaerobic susceptibilities*
Predictably Susceptible:
Amoxicillin+Clavulanic Acid, Pipercillin+Tazobactam, Ertapenem, and Meropenem;
Also Predictably Susceptible:
Metronidazole (Yet Actinomyces or Propionibacterium are intrinsically resistant)
Double anaerobic coverage when already on one of above antibiotics is discouraged.
NOT-Predictably Susceptible: Moxifloxacin, Doxycycline, Cefoxitin or Clindamycin
Note: Most beta-lactamase negative oral anaerobes are susceptible to Amoxicillin.
*Bugs and Drugs (Canada) 2012; Susceptibilities available on a case by case basis.
www.healthpei.ca/antibiogram