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Antibiotics in Urology

Antibiotics in Urology. Claire Kingston Pharmacist SVUH Jan 31 st 2014. Introduction – Urinary tract Infection (UTI). 2 nd most common clinical indication for empirical antimicrobial treatment

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Antibiotics in Urology

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  1. Antibiotics in Urology Claire Kingston Pharmacist SVUH Jan 31st 2014

  2. Introduction – Urinary tract Infection (UTI) • 2nd most common clinical indication for empirical antimicrobial treatment • Inappropriate and unnecessary use of antibiotics associated with problems such as Clostridium difficile infection (CDI), MRSA, VRE • Evidence-based antibiotic guidelines are key to improving prescribing, reducing resistance & optimising patient outcomes • Antimicrobial Prescribing in Primary Care (2011) now available on http://www.antibioticprescibing.ie/

  3. Principles of antimicrobial treatment – empirical prescribing • Treat patient not result • Ensure provisional clinical diagnosis documented & specimens taken before start of therapy. • Broad spectrum empirical therapy for severe infections, then de-escalate once causative organism identified. • Check C/I, allergies, interactions, adverse effects. • IV route initially if severe infection, or unable to tolerate oral drugs. Review Rx after 48 hours .

  4. Principles of antimicrobial treatment • Local policies often limit drugs use based on economics & local resistance • Sample should be taken for C+S testing before starting therapy - will identify the causative pathogen & its susceptibility pattern. • Dose may vary depending on age, weight, hepatic & renal function, severity of infection • Route may depend on severity on infection • Duration depends on infection & response

  5. DAY 1 START SMART… FOCUS THEN… • Do not start antibiotics if no clinical evidence of bacterial infection • Obtain cultures first • c) EMPIRIC TREATMENT BASED ON ANTIMICROBIAL GUIDELINES or BASED ON MICROBIOLOGY ADVICE • STOP ANTIBIOTICS • CONTINUE ANTIBIOTICS/ PLAN TREATMENT/ COURSE • CHANGE ANTIBIOTICS/ PLAN/TREATMENT COURSE • SWITCH TO PO IF APPROPRIATE • CONSIDER OPAT IF APPROPRIATE • STOP ANTIBIOTICS • CONTINUE ANTIBIOTICS/ PLAN TREATMENT/ COURSE • CHANGE ANTIBIOTICS/ PLAN/TREATMENT COURSE • SWITCH TO PO IF APPROPRIATE • CONSIDER OPAT IF APPROPRIATE DAY 2 …. ONWARDS REVIEWTREATMENT REVIEWTREATMENT ALWAYS DOCUMENT INDICATION FOR THE ANTIMICROBIAL AND TREATMENT PLAN IN THE MEDICAL NOTES Adapated from ARHAI Antimicrobial Stewardship Guidance Nov 2011

  6. Classification of antibiotics:-β-lactams • Penicillins • Benzylpenicillin, phenoxymethylphenicillin • Penicillinase-resistant, e.g. flucloxacillin • Broad-spectrum, e.g. amoxycillin, co-amoxiclav • Antipseudomonal, e.g.Tazocin, Timentin  • Cephalosporins e.g. cephalexin, ceftriaxone • Carbapenems – e.g. ertapenem, meropenem • Meropenem used for complicated UTIs & severe hospital infxns. • Ertapenem – seizure potential. Resistance • Other beta-lactams – e.g. aztreonam

  7. Penicillins – Hypersenstivity • Allergies in 1-10% patients, anaphylaxis in 0.05% • Greater risk if history of atopic allergy • If history of anaphylaxis, urticaria or rash immediately after penicillin – do not give penicillins or cephalosporins • If history of minor rash (non-pruritic, small area) more than 72 hours after drug – may not be allergic • 0.5-0.65% penicillin-sensitive patients will also be allergic to cephalosporins • Aztreonam less likely to cause hypersensitivity.

  8. Classification of antibiotics (contd) • Aminoglycosides – e.g.gentamicin • Glycopepdidases – e.g. teicoplanin, vancomycin • Macrolides – e.g. clarithromycin • Quinolones – e.g. ciprofloxacin - Ensure adequate fluid intake (risk of crystalliuria) - May impair performance of skilled tasks - Caution if history of seizures - Photosensitivity reactions - Prolongs QT interval - Give > 1 hour before ( or > 4 hours after) Mg, iron, dairy products

  9. Aminoglycoside once-daily dosinge.g. gentamicin • Total dose should be specified on Rx. Use accurate weight. • If patient is obese use dosing weight calculator to calculate dose (www.UptoDate.com) • Usual dose 5mg/kg/day (normal renal function) or 2mg/kg/day if serum creatinine >120 umol/L or GFR <80ml/min • Take level before 2nd or 3rd dose and 18-24 hours after last dose (= trough). • Give (ideally) at 6pm to facilitate morning assay • Check levels 2-3 times weekly in patients < 50 years and every 2nd day if > 50 years. If renal function abnormal, do daily levels. • Target level < 1mg/l

  10. Classification of antibiotics (contd) • Trimethoprim - synergistic with sulfamethoxazole (cotrimoxazole) - serum creatinine may rise due to competition for renal excretion - may cause hyperkalaemia in severe renal impairment - Stevens Johnson’s syndrome & blood dyscrasias rare • Tetracyclines – e.g. doxycycline, (Tigecycline) • Nitrofurantoin - can cause peripheral neuropathy - avoid in GFR < 20mls/min as inadequate urine conc & toxicity (blood dyscrasias, neuropathy) - pulmonary reactions (e.g.pulmonary fibrosis) reported • Others – e.g. daptomycin, linezolid, sodium fusidate, colistin, metronidazole, clindamycin, rifaximin

  11. Extended Spectrum B-lactamases (ESBLs) • Enzymes produced by some bacteria that provide resistance to extended spectrum (3rd generation) cephalosporins, & monobactams (aztreonam). Don’t affect carbapenems. • Beta-lactamase provides antibiotic resistance by breaking the antibiotic’s structure. • Gram-negative enteric bacteria, in particular K pneumoniae and E coli, are involved • ESBLs are multi-resistant but remain sensitive to nitrofurantoin

  12. Classification of urinary & male genital tract infections • Uncomplicated lower UTI (cystitis) • Uncomplicated pyelonephritis • Complicated UTI +/- pyelonephritis • Urosepsis • Urethritis • Prostatits, epididymitis, orchitis

  13. Significant bacteriuria in adults • 1. ≥ 103 uropathogens/mL of midstream urine in acute uncomplicated cystitis in female. • 2. ≥ 104 uropathogens/mL of midstream urine in acute uncomplicated pyelonephritis in female. • 3. ≥ 105 uropathogens/mL in midstream urine of women or 104 uropathogens/mL of midstream urine in men (or in straight catheter urine in women) with complicated UTI. • 4. In a suprapubic bladder puncture specimen, any count of bacteria is relevant. • 5. Asymptomatic bacteriuria = two positive urine cultures taken ≥ 24 hours apart containing ≥ 105 uropathogens/ml of the same bacterial strain.

  14. Acute, uncomplicated UTIs • Includes acute cystitis & acute pyelonephritis • Mostly in women without structural & functional abnormalities within the urinary tract, kidney diseases or co-morbidity • E.coli responsible for 70-95% cases, S. saprophyticus in 5-10% cases

  15. Treatment for Acute Uncomplicated Cystitis • Nitrofurantoin 50-100mg QDS for 3 - 7 days – low resistance & S/E, high efficacy. Activity effected by urinary pH - avoid alkalinising agents if on. • Trimethoprim 200mg BD for 3 days or Trimethoprim-sulfamethoxazole 160/800mg BD for 3 days (if resistance rate < 20%). • -lactams (e.g. co-amoxiclav, cephalexin), – inferior efficacy & increased adverse effects. Only use if others can’t be used – used based on local resistance rates. Amoxicillin/ampicillin should not be used (resistance/poor efficacy). • Fluoroquinolones (e.g. ciprofloxacin) – efficacious but high S/E – not recommended routinely. Reserve for resistant infections with limited option & confirmed by C + S results. • Fosfomycin 3g stat – minimal resistance & S/E but may be less efficacious –microbiology advice.

  16. Prophylaxis with probiotics / cranberry • Probiotics: • Oral probiotics – may restore vaginal lactobacilli, compete with urogenital pathogens & prevent vaginosis • Intravaginal probiotics once/twice weekly – L. rhamnosus GR-1 & L. reuteri RC-14 • Cranberry: • Some evidence (min 36mg proanthocyanidin A) may reduce rate of lower UTIs is women, but small number of weak clinical studies. Can increase INR.

  17. UTIs in men • Acute, uncomplicated UTIs in young men:need at least 7 days treatment • Most men with febrile UTI have concomitant prostate infection ( PSA & prostate volume). If so  2 weeks treatment ( up to 3 weeks) is recommended preferably with a fluoroquinolone.

  18. Complicated UTIs due to urological disorders • Infection associated with a condition such as a structural or functional abnormality of genitourinary tract, or underlying disease that interferes with host defences • Broad range of bacteria responsible – larger spectrum &  resistance than uncomplicated UTIs • Enterobacteriacae predominate, E. coli most common pathogen. Pseudomonas, serratia & + cocci (e.g. staphylococci & enterococci) also involved • Proteus & pseudomonas particularly common with urinary stones • Need 7-14 days treatment

  19. Treatment for Acute Pyelonephritis If no healthcare contact or antibiotic therapy in past 6 months: • Ciprofloxacin 500mg BD for 7 days (+/- 400mg IV stat) for mild-moderate infection if resistance < 10%. Can be +/- gentamicin. • Trimethoprim 200mg BD for 14 days or Trimethoprim-sulfamethoxazole 160/800mg BD if sensitivities allow. • Oral -lactams less effective. Co-amoxiclav 500/125mg TDS for 14 days may be option.

  20. Treatment for Acute Pyelonephritis If healthcare contact or antibiotic therapy in past 6 months: • Piperacillin-tazobactam 4.5g 8 hourly IV (Aztreonam 2g 8 hourly IV if penicillin rash or anaphylaxis) PLUS • Gentamicin once daily IV • Usually 14 day treatment

  21. Catheter associated UTIs (CAUTIs) • Most are derived from the patient’s own colonic flora • Duration of catheterisation is most important risk factor (> 30 days) • While catheter in place, treatment of asymptomatic catheter-asociated bacteriuria is not recommended. • Routine urine cultures in asymptomatic catheterised patients not recommended • Urine (& in septic patients, also blood cultures) should be taken before antimicrobial therapy is started to guide therapy • 7 days course of antibiotic reasonable.

  22. Change or removal of urinary catheter • Ciprofloxacin 500mg PO 1 hour prior to removal OR ciprofloxacin 400mg IV immediately prior to removal OR gentamicin 2mg/kg IV immediately prior to removal

  23. Transrectal prostate biopsy • Ciprofloxacin 750mg PO AND amikacin 500mg IM one hour pre-procedure. • Give second dose of Ciprofloxacin 750mg 12 hours post-procedure • Check recent urine culture results and modify as necessary

  24. References • BNF, 66th edition (2013) • European Society of Urology Guidelines (2013) • SIGN 88 – Management of suspected bacterial urinary tract infection in adults (2012)

  25. QUIZ!

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