psmid urosurgical infections
TRANSCRIPT
Urosurgical Infections
Arthur Dessi Roman, MD, MTM, FPCP,
DPSMID
27 November 2014, Crowne Plaza
Philippine Society for Microbiology and Infectious Diseases36th Annual Convention
Relationship Between Urosurgical Conditions and
Infection1. GU abnormalities predispose to infection
Provide nidus for infections
Obstruction urine stasis.
As little as ___ mL of residual urine has been calculated to be significant.
O'Grady & Cattell, 1966; O'Grady et ai, 1973
Relationship Between Urosurgical Conditions and
Infection1. GU abnormalities predispose to infection
Provide nidus for infections
Obstruction urine stasis.
Relationship Between Urosurgical Conditions and
Infection
Urease splits urea to ammonia and carbonic acid
Ammonia raises urinary pH
Growth of struvite stones (carbonate apatite, Mg ammonium phosphate
2. Growth of urinary tract calculi and proliferation of bacteria are synergistic
Uy NT, Lapitan MCM, Gatchalian ER. The epidemiology of urinary stones in a tertiary government hospital. Phil J Urol 2008; 18(2): 31-37.
Relationship Between Urosurgical Conditions and
Infection3. Instrumentation and manipulation (e.g.
catheterization)
1 out 5 admissions are catheterized
70% develop bacteremia at the rate of 3-10%/day
Bacteremia is universal by 30 days
Relationship Between Urosurgical Conditions and
Infection
4. Infection predisposes to post-operative complications
Plaza and Lapitan. Predictors of Postoperative Complications of Transurethral Resection of the Prostate in a Resource-Poor Setting* . Philippine Journal of Urology December 2012; 22: 2
Pre-operative UTI
4XPost-operative complications
Relationship Between Urosurgical Conditions and
Infection
5. Surgery is the modality of choice in certain infection (e.g. renal abscess >5 cm)
Relationship Between Urosurgical Conditions and
Infection
5. Surgery is the modality of choice in certain infection (e.g. renal abscess >5 cm)
Survey says…What is the most common urologic diagnosis that
warrants surgical intervention?
PyonephritisAbscess, all forms
Relationship Between Urosurgical Conditions and
Infection
5. Surgery is the modality of choice in certain infection (e.g. renal abscess >5 cm)
Survey says…What is the most common surgery done for which
infection is the indication?
Urinary diversion (e.g. nephrostomy)
Scope of
Urosurgical infections
Antimicrobial prophylaxis
Screening for asymptomatic bacteriuria
Infections in the pre-, peri- and post-kidney transplant patients and donor organ infections
Management of complicated UTIs secondary to the Presence of
structural abnormalities causing urinary stasis and obstruction of the
genitourinary tract
Management of complicated UTIs secondary to Functional abnormalities that affect normal urine outflow
Management of complicated UTIs associated with Iatrogenic
urosurgical conditions
Infections for which urosurgery is indicated
Strength of Recommendation and Quality of Evidence
Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schunemann HJ, GRADE Working Group. GRADE: an emerging consensuson rating quality of evidence and strength of recommendations. BMJ 2008;336: 924-926Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, Schünemann HJ and for the GRADE Working Group. Going from evidence torecommendations. BMJ 2008; 336: 1049-51
Scope of the Lecture
• Renal abscess
• Recommendations for Empiric Antimicrobial Treatment
• Screening for asymptomatic bacteriuria
• Antimicrobial pre-operative antimicrobial prophylaxis in urology
Scope of the Lecture
• Renal abscess
• Recommendations for Empiric Antimicrobial Treatment
• Screening for asymptomatic bacteriuria
• Antimicrobial pre-operative antimicrobial prophylaxis in urology
What is a renal abscess?
• collection of pus within the kidney that may extend into the retroperitoneum.
What is a renal abscess?
• Tissue necrosis of the lobules walled off inside a cavity
• Incidence density among diabetics: 1.1 to 4 cases per 10,000 person years
• Case fatality rate: 39-50% 3-6%
– better imaging modalities and better antibiotics
Lin HS 2008, Meng MV 2002, Coelho 2007, Lee 2008, Ko M-C 2011
S/Sx of renal abscess similar with other cUTI syndromes
• Fever (75-93% )
• CVA tenderness (75%)
• Lumbar pain (36-64.5%)
• Nausea and vomiting (30%)
• Dysuria (8.9-12%)
• Anorexia (6-37%)
Deyoe 1990, Coelho 2007, Lee 2008, Lim 2011, Rai 2007
When to suspect renal abscess?
Diabetic patients presenting with hypotension and renal impairment
Strong level of recommendation, low quality of evidence
Patients suspected to have upper UTI who remain febrile and hypotensive 72 hours after initial intravenous antibiotic
administration.
When to suspect renal abscess?
Diabetic patients presenting with hypotension and renal impairment
DM is the most common predisposing factor
DM (p=0.016, OR 5.8)Hypotension (p=0.044, OR 4.7)
renal impairment (P = 0.001, OR 13.4) and
Lee BE 2008, Coelho 2007, Rai RS 2007, Lee SH 2010, Lin HS 2008Lim SK and Ng FC. Acute pyelonephritis and renal abscesses in adults--correlating clinical parameters with radiological (computer tomography) severity. Ann Acad Med Singapore 2011; 40:407-13.Mowat AG 1971, Bybee JD 1964 , Repine JE 1980
defective chemotaxis, phagocytosisand bactericidal activity of phagocytes in DM patients
When to suspect renal abscess?
Diabetic patients presenting with hypotension and renal impairment
Strong level of recommendation, low quality of evidence
Patients suspected to have upper UTI who remain febrile and hypotensive 72 hours after initial intravenous antibiotic
administration.
When to suspect renal abscess?
Patients suspected to have upper UTI who remain febrile and hypotensive 72 hours after initial intravenous antibiotic
administration.
Only 13% of cUTI patients will have fever beyond 72 hours post treatment
Behr MA, Drummond R, Libman MD, Delaney JS, Dylewski JS. Fever duration in hospitalized acute pyelonephritis patients. Am J Med. 1996 Sep; 101(3):277-80.Yen DH, Hu SC, Tsai J, Kao WF, et al. Renal abscess: early diagnosis and treatment. Am J Emerg Med. 1999 Mar;17(2):192-7
A protracted UTI course despite initiation of antibiotic was associated with renal abscess
Recommendations: Renal abscess diagnostics
• Imaging: UTZ or CT-scan (higher sensitivity)
• Cultures
– Urine (41-43% positivity rate)
– blood culture (31-40%)
– Abscess aspirate (59%)- if drainage performed
• blood or urine culture may parallel the bacteriology of the abscess
Strong level of recommendation, Low quality of evidence
Capitan Manjon C, Tejido Sanchez A, Piedra Lara JD, Martinez Silva V, Cruceyra Betriu G, Rosino Sanchez A, Garcia Penalver C, LeivaGalvis O. Retroperitoneal abscesses: analysis of a series of 65 cases. Scand J Urol Nephrol. 2003;37:139–144.Yen DH, Hu SC, Tsai J, Kao WF, et al. Renal abscess: early diagnosis and treatment. Am J Emerg Med. 1999 Mar;17(2):192-7.
Renal abscess: Management Algorithm
Do Imaging: CT scan (preferable) or
ultrasound
YES
Continue antibiotics
NO
Pt suspected with upper UTI PLUS:
DM + Hypotension/ Renal impairment
OR Failure to respond to IV
antibiotics with 72 hours
Renal abscess: Management Algorithm
Renal abscess >
5 cms?
If UTZ is negative consider doing a CT scan.
If CT scan is negative, renal abscess is unlikely.
Continue antibiotics for a minimum of 4weeks, antibiotics can be discontinued upon resolution of abscess on repeat CT scan
Refer to Urology for drainage of abscess, antibiotics is continued for a minimum of 4 weeks in a setting of
proper drainage
YES
NORenal abscess present?
NO
What empiric antibiotic to start?
Microbiology of Renal Abscess
• E. coli, Klebsiella sp., and Proteus spp.
• Similar with complicated UTI pathogens, may include drug-resistant pathogens (e.g. ESBL, Pseudomonas, Staphylococcus aureus)
• Recommendations for empiric antibiotics the same for renal abscess and severe complicated UTIs
Yen 1999, Lee 2008, Deyoe 1990, Lin 2008, Saiki 1982
Scope of the Lecture
• Renal abscess
• Recommendations for Empiric Antimicrobial Treatment
• Screening for asymptomatic bacteriuria
• Antimicrobial pre-operative antimicrobial prophylaxis in urology
Reasons for Antibiotic RecommendationAntimicrobial Agent ARSP 2013* ARSP2012** cUTI study 2013+
N %R N %R
All cultures,
N=178
(n, %R)
ESBL-producing,
N=48
(n, %R)
Amikacin
Ampicillin
Ceftazidime
Ceftriaxone
Cefuroxime axetil
Ciprofloxacin
Co-amoxiclav
Ertapenem
Gentamicin
Imipenem
Levofloxacin
Meropenem
Nitrofurantoin
Piperacillin-tazobactam
Tigecycline
TMP-SMX
1,835
1,670
-
1,683
871
1,635
1,974
1,059
-
-
-
-
1,622
1,835
-
1,465
6%
85%
-
36%
40%
46%
23%
2%
-
-
-
-
6%
6%
-
69%
1,253
-
-
1,326
443
1,362
1,397
1.452
-
-
-
-
1,264
-
-
1,239
5.2%
-
-
30.8%
34.2%
42.1%
27.1%
2%
-
-
-
-
8.3%
-
-
68.9%
3 (2.1%)
125 (80.7%)
51 (31.7%)
49 (32.2%)
62 (41.6%)++
-
63 (42.6%)
0
47 (29.2%)
3 (2.1%)
80 (48.2%)
1 (0.7%)
32 (24.2%)
30 (24.2%)
5 (4.6%)
95 (59.4%)
0
48 (100%)
44 (91.7%)
47 (97.9%)
48 (100%)++
-
38 (79.2)
0
24 (50.0%)
0
43 (93.8)
0
12 (34.3%)
16 (45.7%)
5 (15.2%)
40 (83.3%)
Antimicrobial Resistance Surveillance Reference Laboratory, Antimicrobial Resistance Surveillance Program Annual Report, 2013: Manila, Philippines.Henson, K.R., et al., Prevalence and risk factors for extended-spectrum beta-lactamase-producing organisms among patients with complicated urinary tract infections in a developing country, in 53rd Interscience Conference on Antimicrobial Agents and Chemotherapy2013: Denver, CO, USA.
The global phenomenon of rising antimicrobial resistance has been
observed in the region
ESBL (extended spectrum beta-lactamase)
- ESBL-rate in the Asia-Pacific region: 28.2%
- Tertiary hospital in Manila in 2007: 37%
- Private tertiary hospital in Pasig in 2011: 29%
KPC (K. pneumoniae carbapenemase) production
Fluoroquinolone and TMP-SMX resistance
Multidrug-resistance Henson, K.R., et al., Prevalence and risk factors for extended-spectrum beta-lactamase-producing organisms among patients with complicated urinary tract infections in a developing country, in 53rd Interscience Conference on Antimicrobial Agents and Chemotherapy2013: Denver, CO, USA.Zamora, R.P., et al., Clinical and molecular profile, risk factors and outcome of beta-lactamase-producing Enterobacteriaceae infections in a government university hospital, in 2013 ID Week2013 October 2-6: San Francisco, CA, USA
Risks for Antibiotic Resistance
ESBL-producing organisms
Prolonged stay in a hospital or healthcare facility
Recent use of antibiotics* (fluoroquinolones, cephalosporins, B-lactams)
Recent hospitalization (past 3 months)
Recent travel to ESBL-highly endemic areas (Asia, The Middle East or Africa) in the past 6 weeks
Presence of Diabetes mellitus and/or other co-morbidities (e.g. neutropenia)
Urinary catheterization, surgery or instrumentation and use of other invasive devices
Recent episode of UTI, recurrent UTI
Structural or anatomical abnormality of the genitourinary tract, including prostatic disease
Mechanical ventilation
Pseudomonas (including multi-drug resistant Pseudomonas)
Use of antibiotics in the past 2 months* (ciprofloxacin, BLICs)
Recent episode of UTI
Previous urinary tract surgery, catheterization
Underlying urinary tract pathology (e.g. pathological VCUG results)
Recent stay in another healthcare unit/facility
Empiric antibiotic options for complicated UTI
ANTIBIOTICRecommended Dose
and DurationComments
Amikacin (First line) 15 mg/kg q24h Be cautious in giving aminoglycosides in patients with
renal insufficiency
Ertapenem 1g IV q24h1 For patients with no risk for Pseudomonas or
Enterococcus
Anti-Pseudomonal carbapenems For patients with risk for Pseudomonas infection
For ESBL-producing EnterobacteriaceaeDoripenem2
Imipenem-cilastin3
Meropenem4
500 mg q8h
500 mg q6h
1 g q8h
Vancomycin 1g IV q 12 For suspected staphylococcal infections5
Colistin (Colistimethate sodium) For multidrug-resistant Enterobacteriaceae, Klebsiella
pneumonia carbapenemase-producing (KPC) bacteria,
Multi-drug resistant (MDR) Pseudomonas sp. or MDR
Acinetobacter sp.
Colomycin6 31,250–62,500 IU/kg per
day, divided in 2-4 equal
doses
(240-480 mg/kg/day)
Coly-Mycin Double the dose of
colomycin (400-800
mg/kg/day)
Empiric antibiotic options for complicated UTI
ANTIBIOTICRecommended Dose
and DurationComments
Tigecycline 100 mg IV loading dose then
50 mg IV q12
For vancomycin-resistant Enterococci
For ESBL-producing Enterobacteriaceae (except
Pseudomonas sp.
Ampicillin 1-2 g IV q6-8h For susceptible enterococcal infections
Cefepime 1-2 g IV q8-12h For Pseudomonas or Acinetobacter sp. infections
Ceftazidime 1-2 g IV q8h+
Piperacillin-
Tazobactam
4.5 g IV q24
Levofloxacin 750 mg q24h For mild infections with no history of previous third
generation cephalosporin or fluoroquinolone use
Fluconazole For fungal infections (see Section on Urinary
Candidiasis and Candida Urinary Tract Infections for
dosing regimens)
Amphotericin B ±
5-flucytosine
Duration of Treatment
• In general, at least 7-14 days of therapy is recommended. Treatment duration may be extended depending on the clinical situation.
Strong recommendation, Moderate quality of evidence
• Antibiotics are modified according to the results of the urine culture and sensitivity tests. Patients started with parenteral regimen may be switched to oral therapy upon clinical improvement.
Strong recommendation, Moderate quality of evidence
Scope of the Lecture
• Renal abscess
• Recommendations for Empiric Antimicrobial Treatment
• Screening for asymptomatic bacteriuria
• Antimicrobial pre-operative antimicrobial prophylaxis in urology
Recommendation
Screening and treatment for ASB is recommended in patients who will undergo
genitourinary manipulation or instrumentation.
Strong recommendation, Grade of evidence vary per procedure
Philippine Society for Microbiology and Infectious Diseases36th Annual Convention
Definitions: Asymptomatic Bacteriuria
Significant bacteriuria without symptoms
Pyuria ≠ symptomatic infection
Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis 2005; 40:643-54
Definitions: Significant Bacteriuria
Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis 2005; 40:643-54
Men Women Both
Specimen Single, clean-catch voided urine
specimen
Two (2) consecutive , clean catch voided urine specimens
taken > 24 h apart
Single catheterized urine specimen with
Microbiologic criteria
Isolation of 1 bacterial species
Isolation of the same bacterial strain
Isolation of 1 bacterial species
Quantitativecount
≥105 cfu/mL 105 cfu/mL. ≥ 100 cfu/mL
GRADE Strong recommendationLow quality of evidence
Strong recommendationHigh quality of evidence
Strong recommendationHigh quality of evidence
Rationale
Grabe M. Antimicrobial agents in transurethral prostatic resection. J Urol 1987; 138:245–52.Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis 2005; 40:643-54.
• Bacteremia occurs in up to 60% of bacteriuricpatients who undergo TURP
– sepsis in 6%–10% of patients
• 1 Retrospective and 4 RCT: antibiotics prevent complications in bacteriuric men undergoing TURP
Recommendation
Grabe M. Antimicrobial agents in transurethral prostatic resection. J Urol 1987; 138:245–52.Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis 2005; 40:643-54.
Take cultures 72 hours prior to the procedure.
Initiate antibiotics the night before or immediately before the procedure
Catheter removed:Stop antibiotics after
procedure
Catheter remains:Continue antibiotics until
catheter is removed
Strong recommendation, Low quality of evidence
Urine culture beyond reach?
Norman DC, Yamamura R. Yoshikawa TT. Pyuria: Its predictive value of asymptomatic bacteriuria in ambulatory elderly men. J Urol 1996; 135:520-2
significant pyuria (>10 wbc/hpf)
OR
positive gram stain of unspun urine (>2 microorganisms/oif)
Strong Recommendation, Low quality of evidence
Two consecutive unspun midstream urine samples
Urine culture and sensitivity testing are not necessary when urinalysis is negative for pyuria or urine gram stain
Strong Recommendation, Moderate quality of evidence
Digressing a bit…
Spot QuizIn what other condition is screening and
treatment for ASB recommended?
Scope of the Lecture
• Renal abscess
• Recommendations for Empiric Antimicrobial Treatment
• Screening for asymptomatic bacteriuria
• Antimicrobial pre-operative antimicrobial prophylaxis in urology
Who should receive antimicrobial prophylaxis?
Patient group Strength of
Recommendation
Quality of evidence
Trans-rectal or trans-perineal prostate biopsy Strong High
TURP Strong High
Clean, contaminated, open or laparoscopic urological surgeries• Pelvio-ureteric junction repair• Nephron- sparing tumor resection• Total prostatectomy, bladder surgery, partial cystectomy• Urine diversion, orthotopic bladder replacement• Ileal conduit
Strong Low
Complicated endourological surgery, nephrostomy tube
insertion, ureteroscopy of proximal or impacted stone,
percutaneous stone extraction
Strong Low
Risk Factors for Infectious Complications
• Old age
• Nutritional deficiency
• Impaired immune response
• DM
• Smoking
• Extreme weight
• Co-existing infection at a remote site
• Long pre-operative hospital stay or recent hospitalization
• History of recurrent urogenital infections
• Surgery involving bowel segment
• Long term drainage
• Urinary obstruction and urinary stone
Who should receive antimicrobial prophylaxis?
Who should receive antimicrobial prophylaxis?
Who should receive antimicrobial prophylaxis?
Who should receive antimicrobial prophylaxis?
Who should receive antimicrobial prophylaxis?
Who should receive antimicrobial prophylaxis?
Who should receive antimicrobial prophylaxis?
Who should receive antimicrobial prophylaxis?
Who should receive antimicrobial prophylaxis?
Duration of treatment
• The duration of peri-operative prophylaxis should be kept to a minimum.
• The decision to continue and/or to shift antibiotics and the duration after the procedure will depend on the best clinical judgement of the physician.
Strong recommendation, low quality of evidence
In summary…
• Suspect renal abscess in patients with a protracted course of UTI especially diabetics. Treatment is antibiotics and surgery (for size >5 cms).
• Amikacin and ertapenem are good empiric antibiotic options.
• Always assess for the presence of risk factors for antimicrobial-resistant organisms when deciding for empiric antibiotic.
• Screen and treat for ASB in patient who will undergo urologic surgery.
• Initiate antibiotic prophylaxis in high-risk urologic procedures and if risk factors for infectious complications are present.
UTI Task ForceChair: Mediadora C. Saniel, MD
Co Chair: Marissa M. Alejandria, MD
Cluster Heads, Complicated UTI
Arthur Dessi E. Roman, MD
Allan Raymond S. Tenorio , MD
Members:
Rufino T. Agudera, MD
Anne Margaret J. Ang, MD
Regina P. Berba, MD
Jill R. Itable, MD
Marie Carmela M. Lapitan. MD
Maria Nicolette M. Mariano, MD
Katha W. Ngo-Sanchez. MD
Oliver S. Sanchez, MD
Thank you!