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When to Test and When to Treat… High Yield Clinical Concepts: Asymptomatic Bacteriuria

This article discusses the background and importance of antimicrobial stewardship, focusing on asymptomatic bacteriuria. It includes case discussions and highlights the factors to consider when deciding to treat or not. The text language is English.

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When to Test and When to Treat… High Yield Clinical Concepts: Asymptomatic Bacteriuria

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  1. When to Test and When to Treat…High Yield Clinical Concepts:Asymptomatic Bacteriuria Robert Redwood MD, MPH Emergency & Preventive Medicine Physician April 12, 2018. WHA Journal Club #1

  2. Conflict of Interest Disclosure Robert Redwood MD, MPH has no real or apparent financial relationships to report.

  3. Aims and Outline • Background on Antimicrobial Stewardship • Deep dive on Asymptomatic Bacteriuria • Case Discussions: To treat or not to treat?

  4. Treat or not? CASE #1 • 43yoF with old spinal cord injury and indwelling catheter p/w vomiting, but no other symptoms, UA strongly positive.

  5. What is asymptomatic bacteriuria? • An “asymptomatic urinary tract infection” • an isolation of bacteria in an appropriately collected urine sample from an individual without signs or symptoms referable to a urinary infection Nicolle LE et al. Clin Infect Dis.2005;40(5):643-654.

  6. Epidemiology of asymptomatic bacteriuria • Health women: 2-5% • Pregnant women: 2-11% • Diabetic women: 7-9% • Elderly: nursing home: 5-50% • Varies widely because prevalence of ASB corresponds to level of functional impairment • Spinal cord injury: 50% • Long-term catheter: 100% • 80% discordance between recommended practices and actual practices Nicolle LE et al. Clin Infect Dis.2005;40(5):643-654.

  7. Why is it important to stop treating asymptomatic bacteriuria? • 35% of US Ecoli strains are resistant to ciprofloxacin • CDiff more than doubled from 65.6 to 156.3 per 100,000 population from 1991 to 2003 • 1 in 8 will have antibiotic associated diarrhea • 0.3% rate of antibiotic related ADEs J Pharm Pract. 2013 Oct; 26(5): 464–475. BMC Infect Dis. 2015; 15: 545.

  8. Treat or not? CASE #2 • Healthy 33yoF G1P0 is in OB clinic for 8wk US w/o symptoms, second urine culture grows E.Coli.

  9. Core Principles of AMS • Antimicrobials exert selective pressure on pathogens • Top 3: Meat industry, vets, human medicine • Worldwide: 700,000 annual deaths attributable to nosocomial-resistant organisms • US: 2,049,442 illnesses and 23,000 deaths / yr • Sequelae of AMR costs the US $21-$34 billion with 8 million additional patient-days in the hospital • Right dx, right drug, right dose, right duration

  10. Oh…and there’s this • 1980’s: 16 new abx • 1990’s: 10 new abx • 2000’s: 5 new abx • 2008-2012: 1 new abx • Only 5 of 572 pharmaceutical companies have active antibacterial discovery programs http://www.who.int/bulletin/volumes/89/2/11-030211/en/

  11. Oh…and then there’s this Superbug resistant to every antibiotic available in US kills Nevada woman January 13, 2017 “It was tested against everything that’s available in the United States… and was not effective” Dr Alexander Kallen, a medical officer with the CDC who first reported the discovery of the superbug http://www.pbs.org/newshour/rundown/superbug-resistant-every-available-antibiotic-u-s-kills-nevada-woman/

  12. Treat or not? CASE #3 • 21yoF is suicidal with strongly positive UA on psych clearance labs. No symptoms. Accepting MD requests abx prior to acceptance.

  13. Brief history of how we got to where we are today? • Quantitative urine culture for the microbiological diagnosis of UTI (1957) • Pregnant women with ASB frequently went on to develop pyelonephritis • Treatment of ASB started in this group and was extrapolated to other groups without clear evidence

  14. The three times it ok to screen for and treat asymptomatic bacteriuria • Once in early pregnancy • only treat if two positive cultures • Pre-urologic procedure (usually TURP) • Post-renal transplant • Although growing body of evidence against this Infect Dis Clin North Am. 2003 Jun;17(2):367-94

  15. Treat or not? CASE #4 • 65yoF w/o symptoms grows pseudomonas on pre-op screening urine culture before TKA.

  16. The low-hanging fruit: Clinical scenarios where asymptomatic bacteriuria is commonly treated (incorrectly) • Catheter myths: Foul smelling, dark, or sediment in foley catheter bag • Convenience screening (“The patient peed doc, should I send a UA?” • Contaminated sample incorrectly treated empirically or incorrectly sent for culture • “Positive UA” on medical clearance for psych or jail (ED) • Blaming altered mental status on ASB (ED, ICU, LTCF)

  17. Treat or not? CASE #5 • 11yoF with periumbilicalabd pain has 4+ WBCs on UA w/o bacteriuria. No other urinary symptoms.

  18. How to stop treating asymptomatic bacteriuria in 6 easy steps • Recognize the problem • Recognize high-risk populations • Do not screen for ASB • Recognize when a UA or Ucx is being sent for the wrong reasons • Diagnose UTIs with sophistication • Free-text the REAL diagnosis

  19. Treat or not? CASE #6 • 89yoF presents to the ED with no urinary symptoms and AMS. Cath UA strongly positive.

  20. 1. Recognize the problem Up to 80% of ASB patients are given antibiotics (against IDSA guidelines) Nicolle LE et al. Clin Infect Dis.2005;40(5):643-654.

  21. 2. Recognize populations with high likelihood of having ASB • Indwelling catheter • Spinal cord injury • Urologic procedure • Long term care resident • Diabetic female • Pregnant female

  22. 3. Do not screen for asymptomatic bacteriuria • Each and every time you send a UA, have a good reason for doing so • RN initiated UA protocols should emphasize symptoms • Beware order sets • Beware reflex culture orders on a urinalysis order • If a UA was ordered to evaluate for non-infectious symptoms (i.e. proteinuria) and it appears to a “UTI”, do not act on results and do not send it for culture

  23. 4. Recognize when a UA or Ucx is being sent for the wrong reasons • Foley catheter without flank pain, fever, or sepsis • Foul smelling urine = UTI • Dark urine = UTI • Foul smelling urine or change in urine appearance does not correlate with infection. It is usually related to hydration status. • Screening, reflex orders, convenience, incidental J Emerg Med. 2016;51(1):25-30. 

  24. 5. Diagnose UTIs with sophistication • Urinary symptoms = UTI. • Between 34% and 50% of women presenting with urinary symptoms do not have a UTI. Concentrated urine causes dysuria mimicking a UTI. • WBCs = UTI. • Pyuria is inflammation within the genitourinary tract and is measured as WBCs in the urine. It is a common accompaniment of asymptomatic bacteriuria and should not influence decisions about antimicrobial therapy. • Leukocyte esterase and/or nitrites = UTI. • Not so fast, leukocyte esterase suggests pyuria and nitrites suggest bacteria--either of these could be present in asymptomatic bacteriuria, so clinical context (i.e. symptoms) really matters. J Emerg Med. 2016;51(1):25-30. 

  25. 5. Diagnose UTIs with sophistication (cont.) • Positive culture always means UTI. • A good specimen has <5 epithelial cells per low-power field. A "positive" culture is meaningless if the sample was contaminated. • UTI is a common cause of altered mental status in the elderly. • Actually it is an uncommon cause and this type of anchoring bias can work against us in terms of uncovering the true cause of our patient's altered mental status. Before you think UTI, think of more common (and also more subtle) etiologies like medication reactions, sundowning, dehydration or sensory impairment. • Once resistant, always resistant. • Previous resistance does not predict future resistance; however, previous susceptibility is likely to predict future susceptibility. J Emerg Med. 2016;51(1):25-30. 

  26. 6. Free-text the REAL diagnosis • Being precise is a tenet of good medical practice • EHRs sometimes lead to oversimplification • If Asymptomatic Bacteriuria is not on the diagnosis menu, add it

  27. Theory vs. Reality:Treating probable asymptomatic bacteriuria • If you have a diagnostic uncertainty and choose to treat probable ASB… • Consider watch and wait prescription • If possible, wait for culture results, then call patient to RE-confirm symptoms • If admitting, consider 24 hour “tincture of time” • Choose nitrofurantoin, bactrim, or 1st gen cephalosporin if appropriate • Inform patient of your uncertainty and risks / benefits

  28. Treat or not? CASE #7 • 35yoF presents to the clinic with dysuria and frequency for 1d. UA is strongly positive, but >5 squamous epithelial cells/hpf.

  29. Not all bugs are bad bugs “Transient bacteriuria is common in healthy young women” Clin Infect Dis (2005) 40 (5): 643-654. N Engl J Med , 2000, vol. 343 (pg. 992-7) J Infect Dis , 1982, vol. 146 (pg. 579-83) JAMA , 1980, vol. 243 (pg. 134-9)

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