Transcript When To Test When to Treat

TO TREAT OR NOT TO TREAT
THAT IS THE QUESTION
Dr. Ruth Kandel
Director, Infection Control
Hebrew SeniorLife
Objectives
• Define whether to screen for or treat
asymptomatic bacteriuria in an elderly
population
• Review complications of antibiotic use
• Define symptomatic urinary tract infections
• Review challenges of diagnosis in the elderly
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Clinical Infectious Disease 2005;40:643-654
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What is Asymptomatic
Bacteriuria?
Asymptomatic Bacteriuria (ASB)
• Laboratory diagnosis
• Positive urine culture
– Colony count significant (> 10⁵ cfu/mL)
• Absence of symptoms
Clinical Infectious Disease 2010;50:625-663
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Pyuria
• Pyuria (> 10 WBC / high-power field) is evidence of
inflammation in the genitourinary tract
• Pyuria is commonly found with ASB
• Elderly institutionalized residents 90%
• Short-term (< 30 days) catheters 30-75% (Arch IM 2000;160:673-82)
• Long-term catheters 50-100% (Am J Infect Control 1985;13:154-60)
(Infect Dis Clin North Am 1997;11:647-62)
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Treatment for ASB Indicated
• Pregnant women
– Increased risk for adverse outcomes
• Urologic interventions
• TURP
• Any urologic procedure with potential mucosal
bleeding
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Treatment for ASB Not Indicated
•
•
•
•
•
•
Premenopausal, non-pregnant women
Diabetic women
Older persons living in the community
Elderly living in long term care facilities
Persons with spinal cord injury
Catheterized patients
CID2005;40:643-654
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Prevalence of ASB
POPULATION
Prevalence %
•
Healthy premenopausal women
1-5
•
•
Postmenopausal women
(50 to 70 years of age)3
2.8-8.6
•
Older community-dwelling patients
0.7 to 1.0
– Women (older than 70 years)
– Men
•
Older long-term care residents
– Women
– Men
•
10.8-16
3.6-19
25-50
15-40
Patients with an indwelling catheter
– Short-term
– Long-term
9-23
100
CID2005;40:643-654
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No Benefit Treating ASB in the Elderly
• Large long-term studies of ASB in pre and
postmenopausal women
– NO ADVERSE OUTCOMES in women not treated
• Randomized studies (treatment vs. no
treatment) in elderly LTC residents
– NO BENEFIT to treatment
– No decreased rate of symptoms
– No improved survival
CID2005;40:643-654
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Prospective Randomized Studies
Treatment vs. No Treatment ASB
Authors
Subjects
Intervention
Outcome
Nicolle LE, et al.
NEJM
1983;309:1420-5
Men, NH,
median age 80
Treated 16
Not treated 20
Duration 2 years
No difference
mortality or
infectious morbidity
2 groups
Nicolle LE, et al.
Am J Med
1987;83:27-33
Women, NH,
median age 83
Treated 26
Not treated 24
Duration 1 year
No difference
mortality/GU
morbidity. Increase
drug reactions and
AB resistance
treated group.
Abrutyn E, et al.
Ann Intern Med
1994;120:827-33
Women,
ambulatory and NH
Mean age 82
Treated 192
Not treated 166
Duration 8 years
No survival benefit
from treatment
Ouslander JG
Ann Intern Med
1995;122:749-54
Women and men
NH
Mean age 85
Treated 33
Not treated 38
Duration 4 weeks
No difference
chronic urinary
incontinence
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Cohort Studies
Authors
Subjects
Observation
Outcome
JAGS
1990;38:1209-14
Men, Ambulatory,
> 65 years
29 Subjects
No adverse
outcomes
attributed to no
treatment
Duration 1-4.5
years
NEJM
1986;314:1152-6
Population based
Swedish men and
women
Duration 5 years
No association
between
bacteriuria and
survival
Gerontology
1986;32:167-71
Population based
Finnish men and
women > 85 years
Duration 5 years
No association
between
bacteriuria and
survival
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Proportion of Women with Diabetes Who Remained Free of Symptomatic Urinary Tract Infection, According to
Whether They Received Antimicrobial Therapy or Placebo at Enrollment.
Harding GK et al. N Engl J Med 2002;347:1576-1583.
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IDSA Recommendations
• Routine screening for and treatment of ASB in
older individuals in the community is not
recommended.
• Screening for and treatment of ASB in elderly
residents in LTCFs is not recommended.
CID2005;40:643-654
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Any
Problems
Just
Treating
Anyway?
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CDC Website
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Antibiotic misuse adversely
impacts patients - resistance
•
Getting an antibiotic increases a patient’s
chance of becoming colonized or infected
with a resistant organism.
Antibiotic Resistance
CDC Website
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Antibiotic Resistance
CDC Website
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Antibiotic resistance increases
mortality
Mortality associated with carbapenem resistant
(CR) vs susceptible (CS) Klebsiella
pneumoniae (KP)
60
p<0.001
Percent of subjects
50
p<0.001
40
30
20
10
0
Overall Mortality
OR 3.71 (1.97-7.01)
Attributable
Mortality
OR 4.5 (2.16-9.35)
Patel G et al. Infect Control Hosp Epidemiol 2008;29:1099-1106
CRKP
CSKP
Mortality of resistant (MRSA) vs.
susceptible (MSSA) S. aureus
•
•
Mortality risk associated with MRSA
bacteremia, relative to MSSA bacteremia:
OR: 1.93; p < 0.001.1
Mortality of MRSA infections was higher than
MSSA: relative risk [RR]: 1.7; 95% confidence
interval: 1.3–2.4).2
1. Clin. Infect. Dis.36(1),53–59 (2003).
2. Infect. Control Hosp. Epidemiol.28(3),273–279 (2007).
CDC: Get Smart About Antibiotics
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CDC: Get Smart About Antibiotics
• Antibiotic resistance is one of the world’s most
pressing public threats.
• Antibiotic resistance in long-term care
increases risk
– Hospitalization
– Death
– Cost of treatments
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Antibiotic misuse adversely
impacts patients- resistance
•
Increasing use of antibiotics increases the
prevalence of resistant bacteria in hospitals.
Reservoir for Spread of Antibiotic
Resistant Pathogens
Clinical Infections
Colonized
(asymptomatic)
Patients
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Antibiotic‐Resistant Bacteria Travels
Journal of the American Geriatrics Society
pages 242-246, 12 JUL 2002
http://onlinelibrary.wiley.com/doi/10.1046/j.1532-5415.50.7s.5.x/full#f1
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And Another Reason Not To Treat
Clostridium Difficile Infection
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Clostridium difficile infection (CDI) cases by location and type of
exposures — United States, Emerging Infections Program, 2010
MMWR March 9, 2012
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Rates of Clostridium difficile Infection Among Hospitalized
Patients Aged ≥65 Years
CDC September 2, 2011 / 60(34);1171
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Background: Impact
Age-Adjusted Death Rate* for
Enterocolitis Due to C. difficile, 1999–2006
2.5
Male
Female
White
Black
Entire US population
Rate
2.0
1.5
1.0
0.5
0
1999 2000 2001 2002 2003 2004 2005 2006
*Per 100,000 US standard population
Year
Heron et al. Natl Vital Stat Rep 2009;57(14).
http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf
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Deaths from Gastroenteritis Double
C. difficile and norovirus are the leading causes
• Adults over 65 years old accounted for 83 percent of
deaths.
• Clostridium difficile and norovirus most common
infectious causes.
• Clostridium difficile
– Accounted for two-thirds of the deaths.
– Presumed cause is spread of a hypervirulent, resistant
strain of C. difficile.
CDC March 14, 2012 Press Release
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Background: Epidemiology
Risk Factors
•
•
•
•
•
•
•
Antimicrobial exposure
Main modifiable risk
Acquisition of C. difficile
factors
Advanced age
Underlying illness
Immunosuppression
Tube feeds
Gastric acid suppression FDA Drug Safety Communication:
Clostridium difficile infection can be associated with stomach acid drugs known as
proton pump inhibitors (PPIs) February 2012
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When to Treat
Urinary Tract Infections
Long Term Care
Challenges
• Comorbid illnesses may result in symptoms
similar to UTIs.
• Cognitive impairment may make reporting of
symptoms difficult.
• Older individuals can have atypical
presentations for infections.
• There is a lack of evidenced based guidelines
for symptomatic UTIs.
37
Criteria for Surveillance, Diagnosis and
Treatment
• Based on consensus group recommendations
• Modified by
– Recent clinical practice guidelines
– Current research
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Criteria for Surveillance, Diagnosis and
Treatment
Consensus group recommendations
• McGeer criteria developed for surveillance
and outcome assessments
– Used by Centers for Medicare and Medicaid
Services
• Loeb criteria recommends minimal set of criteria
necessary to initiate antibiotic therapy for UTI
– Similar to IDSA Guidelines
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McGeer Criteria
No Indwelling Catheter
Chronic Indwelling Catheter
• At least three of the
following
• At least two of the following
– Fever* or chills
– New or increased dysuria,
frequency or urgency
– New flank or suprapubic pain
or tenderness
– Change in character of urine
– Worsening of mental or
functional status
– Fever* or chills
– New flank or suprapubic pain
or tenderness
– Change in character of urine
– Worsening of mental or
functional status
*Fever > 100.4° F
Am J Infect Control
1991;19:1-7
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Loeb Minimal Criteria
Initiating Antibiotics
No Indwelling Catheter
• Acute dysuria Or
• Fever* + new or worsening
(must have at least one of
following)
–
–
–
–
–
Urgency
Frequency
Suprapubic pain
Gross hematuria
Costovertebral angle
tenderness
– Urinary incontinence
Chronic Indwelling Catheter
Must have at least one of the
following
• Fever*
•
•
•
New costovertebral angle
tenderness
Rigors (shaking chills)
New onset delirium
*Fever > 100° or 2.4° F above
baseline
ICHE 2001;22:120-124
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Criteria for Surveillance, Diagnosis and
Treatment
Clinical Practice Guidelines
• Infectious Disease Society of America (IDSA)
Clinical Practice Guidelines Fever and Infection
Long-Term Care Facilities 2008 CID 2009;48:149-171
• IDSA Clinical Practice Guidelines CatheterAssociated Urinary Tract Infections Adults
2009 CID 2010;50:625-663
• IDSA Guidelines Asymptomatic Bacteriuria CID
2005;40:643-654
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Criteria for Surveillance, Diagnosis and Treatment
Current Research
Diagnostic algorithm for ordering urine cultures for NH residents in intervention arm
Loeb M et al. BMJ 2005;331:669
©2005 by British Medical Journal Publishing Group
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Treatment algorithm for prescribing antimicrobials to NH residents in intervention arm
Loeb M et al. BMJ 2005;331:669
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©2005 by British Medical Journal Publishing Group
Monthly rates of antimicrobial prescriptions for urinary indications in intervention and usual
care nursing homes.
Loeb M et al. BMJ 2005;331:669
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©2005 by British Medical Journal Publishing Group
Collecting Urine Samples
• Mid-stream or clean catch specimen for cooperative and
functionally capable individuals. However, often necessary
– For males to use freshly applied, clean condom (external)
catheter and monitor bag frequently
– For females to perform an in-and-out catheterization
• Residents with long-term indwelling catheters
– Change catheter prior to collection (sterile technique/equip.)
• Resident with short-term catheterization (< 30 days)
– Obtain by sampling through the catheter port using aseptic
technique
– If port not present may puncture the catheter tubing with a
needle and syringe
– If catheter in place > 2 weeks at onset of infection, replace
CID 2009;48:149-171
CID 2010;50:625-663
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Role of Urine Analysis and Dipstick Testing in the Evaluation of
Urinary Tract Infection in Nursing Home Residents
•
Negative urine analysis for WBCs and negative dipsticks tests for leukocyte esterase and nitrites do
not support UTI BUT cannot completely rule it out
–
–
Leukocyte esterase (LE)
• Enzyme found in white blood cells (WBCs)
Nitrites
• Certain bacteria reduce urinary nitrates to nitrites
– Pyuria
•
> 10 WBC / high-power field
Squamous cells
Increased number suggests contamination
Infect Control Hosp Epidemiol 2007;28:889-891
Am Fam Phys 2005;71:1153-1162
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Urine Culture
• A urine culture should always be obtained
when evaluating SYMPTOMATIC infections.
• Urine cultures will assist in appropriate
antibiotic selection.
• A negative urine culture obtained prior to
initiation of antibiotics excludes routine
bacterial urinary infection
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At least one of the following that are
new or increased
□ Fever (> 100°F or 2.4°F >
baseline)
□ Costovertebral angle tenderness
□ Rigors (shaking chills)
□ Delirium
□ Flank pain* or pelvic discomfort*
□ Acute hematuria*
□ Malaise or lethargy with no other
cause*
*CID 2010;50:625-663
Acute dysuria alone OR
Fever (> 100°F or 2.4°F > baseline) AND
at least one of the following that is new or
increased
□ Urgency
□ Frequency
□ Suprapubic pain □ Gross hematuria
□ Costovertebral angle tenderness
□ Urinary incontinence
□ Change in mental status*
□ Rigors (shaking chills)*
If accompanied only by fever, rule out other
causes
*CID 2012;54:973-978 BMJ 2005;331:669
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Key Points
• Routine screening for and treatment of ASB is not
recommended
– In older individuals in the community
– In elderly residents in LTCFs
• Get Smart About Antibiotics
– Antibiotic resistance is one of the world’s most pressing public
threats.
– Clostridium difficile infections are on the rise and are associated
with increased mortality especially among the elderly
• Treat only symptomatic urinary tract infections in the
elderly
– Refer to clinical guidelines to assist in making a diagnosis
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