URIs and UTIs

1. URIs and UTIs Meghan Brett, MD UNMH Hospital Epidemiologist Medical Director, Antimicrobial Stewardship Associate Professor, Infectious Diseases 10.31.18

2. Planned Topics • Flu • URIs • UTIs

3. Background on Influenza

4. Neuraminidase Viral RNA Hemagglutinin

5. Influenza Epidemiology • Season: October – March • 31 seasons between 1976 and 2007 • Estimated numbers of influenza deaths?1 • 3,000 - 49,000 people • Typically, ~90% of deaths occur in pts ≥ 65 yrs • Estimated impact of Influenza in 20032 • 24.7 million cases with 31.4 outpatient visits • 334,185 hospitalizations, 3.1 million hospital days • 41,000 deaths 1 CDC MMWR 2010; 59: 1057-1062. 2 Molinari NAM et al. Vaccine 2007; 25: 5086–5096.

6. Current Influenza Activity

7. Current Flu Activity • 3 cases of influenza in Quay county in the past month • No evidence for sustained influenza transmission at the moment • http://www.tricore.org/infectious_disease_report

8. New Mexico Department of HealthInfluenza & Respiratory Disease Report, 2018-2019 • Summary of Activity: Week 41 • October 7th - 13th, 2018 • New Mexico influenza-like illness (ILI) activity is currently 0.8% of patient visits • US ILI is 1.4% • The national ILI baseline is 2.2% • Influenza activity is below the NM ILI baseline of 2.4% in all five health regions • No influenza outbreaks were reported this week

9. Regional Influenza-Like Illness (ILI) Activity, 2018-2019 NW NE Metro SE SW Outbreak: An influenza outbreak is defined as at least two cases of ILI in a specific area with at least one laboratory confirmed case. PCR Testing: Polymerase Chain Reaction (PCR) tests can identify the presence of influenza viral RNA in respiratory specimens. PCR testing is performed at various laboratories across New Mexico. 3

10. Influenza Vaccination

11. Current Recommendations for Influenza Vax from ACIP • Anyone ≥6 months of age • No vaccine is currently preferred over another • Vaccine should be given throughout the flu season • It’s OK to get your flu shot now • NO NEED FOR A SECOND FLU VACCINE FOR ADULTS DURING THE FLU SEASON

12. Why Should Anyone who Works in Healthcare Get the Flu Vaccine? • Limit the amount of time that you’re sick • Flu vaccine prevents or limits duration of illness • Prevent transmission of influenza to others • Protect your patients, your family, and your co-workers • Recommended by CDC especially for HCPs • Supported by TJC, ANA, ACIP, APIC, SHEA, IDSA, and many others

13. Influenza Testing

14. Testing for Flu from TriCore • Respiratory Viral Swab • Pink culture media (refrigerated) with E-Swab • May be requested from Lab • Instructions on obtaining swab on TriCore’s website • Two available testing methods • RESPAN • FLURSV • FAQ regarding testing to be put on IPCD’s and ASP’s websites in the near future (draft handed out)

15. Isolation Precautions • Guidance on Infection Prevention and Control’s Website (UNMH Intranet) • Contact and Droplet • Peds (< 12 yrs) • Adults (> 12 yrs) • Immunocompromised • Instructions about when to start and when to stop isolation

16. Influenza Treatment

17. Antiviral Medications • Oseltamivir (oral, 2 weeks and older [FDA]) • Zanamivir (inhaled) • Peramivir IV (non-formulary, $$$$, ≥18 yrs, single dose) • UNMH Guidelines  Antimicrobial Stewardship Website (Intranet) Key points: • Best if treated within 48hrs of symptom onset • For hospitalized patients, reasonable to start after this timeframe • Don’t wait for testing results if flu is clinically suspected • Renally adjust

18. Antibiotics… then Antibiotic Resistance Burgess DS, Rapp RP. Am J Health-Syst Pharm 2008.

19. Antibiotic Resistance – So What? • Impact on patient outcomes • Incorrect empiric antibiotics increases patient mortality • Higher mortality among patients with antibiotic-resistant infections • Big issues with alternative antibiotics • Broader antibiotics may be needed for simpler infections • Use of less effective, second-line antibiotics for resistant organisms • More toxic and less-well characterized antibiotics used to treat patients • Large impact on Healthcare • Higher cost of care and potentially longer lengths of stay: $20 billion excess direct costs annually and $35 billion in lost productivity

20. Rethink Our Relationship with Antibiotics • Antibiotics are not benign: short-term and long-term consequences • Antibiotics are “Drugs of Fear” • Deescalation is standard of care • For many infections, trend is that “less is more” • Patient education may help to reset expectations

21. Impact of Antibiotics on Our Gut Jernberg C et al. Microbiology 2010

22. Health Consequences of Microbiome Disruption Across a Lifetime Langdon A, Crook N, Dantas G. Genome Medicine 2016.

23. What are the most common infections treated with ABX in the outpatient setting? • Upper respiratory infections • Positive urine cultures (? Urinary tract infections)

24. National Data about ABX Prescribing in Ambulatory Settings

25. Appropriate vs. Inappropriate ABX by Conditions

26. Appropriate vs. Inappropriate ABX by Conditions

27. National Data about ABX Prescribing in Ambulatory Settings

29. URTIs

31. Principles of Appropriate ABX Use for Nonspecific URIs in Adults • Immunocompetent adults without complicating comorbid conditions (e.g., lung disease or heart disease) • Acute rhinopharyngitis: • Viral in origin • Acute infection • Sinus, pharyngeal, and lower airway sx: present but not prominent • Purulent secretions from nares or throat predict neither bacterial infection nor response to ABX treatment Gonzales R et al. Ann Intern Med 2001; 134: 490-4.

32. Basics of Nonspecific URIs • Most resolve spontaneously • Duration: 1 – 2 weeks • Small % complicated by bacterial rhinosinusitis or pneumonia • Rhinosinusitis (2%): obstruction of sinus ostia • Pnuemonia: effects of flu on host immunity • May have sinus involvement (seen on CT scan within 2 – 4d of sx onset)

33. Pathogens involved in non-specific URIs • Rhinoviruses • With ache and fatigue: influenza and parainfluenza • Adenovirus • Respiratory syncytial virus (RSV)

34. Treatment of NS URIs • Supportive: • Drink more water/fluids • Nasal saline spray to relieve congestion • Ice chips, sore throat spray or lozenges • Honey to relieve cough • Specific medications: acetaminophen or ibuprofen http://www.cdc.gov/getsmart/community/downloads/16_270228-b-oneill_non-antibiotic_perscription_pads_508.pdf

35. ABX for NS URIs? Most RCTs for treatment of URIs have been performed in children (7) which did not affect resolution of illness [95% CI, 0.7 - 1.28] • Early ABX does not prevent pneumonia or acute otitis media 3 among adults showed no benefit of treating URIs with ABX • Do not address subsequent complications

36. Viral vs. ABRS • Distinguishing acute bacterial rhinosinusitis (ABRS) from viral (any 1 of 3) • Onset with persistentsx/signs consistent with acute rhinosinusitis lasting for >= 10d without evidence for improvement • Onset with severesx/signs of high fever (39C) and purulent nasal drainage or facial pain for 3 – 4 consecutive days • Onset with worsening sx/signs with new onset fever, headache, or increase in nasal d/c following typical viral URI (5-6d) and were initially improving

37. Resources • CDC Get Smart • https://www.cdc.gov/getsmart/index.html • Adult Treatment Recommendations • https://www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/adult-treatment-rec.html • Pediatric Treatment Recommendations • https://www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/pediatric-treatment-rec.html • Continuing Education about ABX use in Ambulatory settings • https://www.cdc.gov/getsmart/community/for-hcp/continuing-education.html

38. UTIs

39. UTI Signs/Sx

41. ASB • Evidence that screening and treatment does not lead to improved clinical outcomes • May actually lead to an increased number of infections among some patient populations • More likely, unnecessary antibiotics may cause harm • Adverse effects • C difficileinfection • Antibiotic resistance • Wasted expense

42. 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

43. Uncomplicated vs. Complicated UTIs • Uncomplicated – premenopausal women • No structural or functional abnormalities in urinary tract • Not pregnant • Complicated – • 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 DielubanzaEJ. ID Clin N Am 2014.

44. 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)

45. 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 • No test alone is sufficient to dx a UTI • Neg LCE and Neg nitrites had NPV of 88% (preg women, elderly, family med, and urology pts)

46. 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

47. Treatment of UTIs – What Bugs? • Enteric flora colonizing perineum and urethra • E. coli • 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)

48. 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

49. Test of Cure? • Nope (please don’t) • Would follow symptoms

50. Take Home Points • Antimicrobial resistance continues to grow • Antibiotics are not as benign as previously thought • We can do better with our antibiotic use! • Use resources to help guide you and discussions with your patients