Stanford Antimicrobial Safety and Sustainability Program ...

Stanford Antimicrobial Safety and Sustainability Program Originally Developed: 11/14/2017 Revised:03/18/2021

SHC Clinical Pathway: Inpatient Management of Urinary Tract Infections ? Adult Patients I. Background: We have adapted national guidelines to assist in the management of adult with UTIs in the inpatient

setting. II. Exclusion: Prostatitis and acute pyelonephritis complicated by an abscess or nephrolithiasis is outside of the scope of

this guideline. Please consider an infectious disease (ID) or urology consult as appropriate. III. Procedures/Guidelines:

1) Definitions: i. Acute uncomplicated UTI: occur in otherwise healthy, non-pregnant, pre-menopausal women with normal urinary tract anatomy. ii. Acute complicated UTI: occur in those with risk factors that increase the risk of failing therapy including urinary tract obstruction, functional or anatomic abnormality of the urinary tract, renal failure, diabetes mellitus, immunosuppression, hospital-acquired infection, and renal transplant. iii. Acute uncomplicated pyelonephritis: upper tract infection in otherwise healthy, non-pregnant, pre-menopausal women with normal urinary tract anatomy.

iv. Acute complicated pyelonephritis: upper tract infection that is complicated by an abscess, nephrolithiasis, papillary necrosis, or emphysematous pyelonephritis

2) Symptoms: i. Cystitis: dysuria, urinary frequency, urinary urgency, suprapubic pain, hematuria ii. Pyelonephritis: fever (>38oC), chills, flank pain, costovertebral angle tenderness, and nausea/vomiting

3) Diagnosis: A positive urine culture may confirm a UTI, but it may also reflect asymptomatic bacteriuria or a urine sample that was contaminated by bacteria during collection. Urine cultures are most useful if they are only obtained for patients with high clinical suspicion of UTI. They should not be obtained for asymptomatic patients with dirtyappearing or smelly urine samples. For patients with an indwelling urinary catheter, samples should be obtained from newly placed catheter (eg within 5 days) or straight catherization.

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Stanford Antimicrobial Safety and Sustainability Program Originally Developed: 11/14/2017 Revised:03/18/2021

Table 1. 2020 SHC data for E.coli isolated from urine cultures ? inpatient setting and emergency department (ED)

Species

No. of isolates

Ampicillin

Amoxicillin/ clavulanate

Cefazolin

Ceftriaxone

Nitrofurantoin

TMP/SMX

Cirpofloxacin

Levofloxacin

Inpatient

349

45.2% (332)

75.7% (333)

74.9% (343)

79.5% (332)

94% (349)

69.3% (332)

63.6% (332)

58.9% (333)

Emergency department

1063

50.7% (992)

81.8% (992)

84.3% (1058)

86.6% (992)

96.6% (1063)

71.3% (990)

72.6% (991)

68% (992)

4) Antibiotic selection: i. Empiric antibiotic selection is directed at E. coli (the most common uropathogen) and should take into consideration local resistance patterns (Table 1), recent exposure to antibiotics, and recent history of multidrug resistant organisms (MDROs). 1. If a MDRO is identified or the patient has a history of UTIs secondary to MDROs, see the MDROdirected antibiotic selection table below (section 5).

Clinical Syndrome

Treatment Options*

Duration**

Comments

Asymptomatic bacteriuria (ASB)

Pregnant patients:

?

1st line: cephalexin 500 mg PO QID for 7 days (if active

based on urine culture)

?

2nd line: Macrobid 100 mg PO BID for 5 days (if active

based on urine culture)

?

3rd line: fosfomycin 3g PO once (restricted) (if active based on urine culture)

Prior to urologic procedures:

?

1nd line: cefazolin 2 gram IV/IM once 30-60 minutes prior to the procedure

2nd line: ciprofloxacin 400 mg IV once 30-60 minutes

prior to the procedure

?

Fluoroquinolones and doxycycline are contraindicated throughout pregnancy. TMP/SMX is contraindicated during the first 8 weeks of pregnancy. Interpretive criteria for fosfomycin susceptibility can only be provided for E. coli or E. faecalis, as CLSI has not established clinical breakpoints for other organisms.

Treatment of ASB is indicated prior to urologic surgeries that break the mucosal barrier (i.e. TURP, ureteroscopy including lithotripsy, percutaneous stone surgery).10 Treatment is not recommended for urologic procedures that do not break the mucosal barrier (i.e. catheter exchange, cystoscopy, etc.).10

Kidney transplant patients (within 30 days of transplantation only):

? Macrobid should be avoided if CrCl < 30 mL/min.

? Interpretive criteria for fosfomycin susceptibility can only be provided

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Clinical Syndrome

Stanford Antimicrobial Safety and Sustainability Program Originally Developed: 11/14/2017 Revised:03/18/2021

Beyond the intial 30 days post kidney transplant, there is evidence to recommend against treatment

of ASB.10

1st line: cephalexin 500 mg PO BID for 5 days (if active based on urine culture)

2nd line: Macrobid 100 mg PO BID for 5 days (if active based on urine culture)

3rd line: ciprofloxacin 250 mg PO BID for 3 days (if active based on urine culture)

4th line: fosfomycin 3g PO once (restricted) (if active based on urine culture)

for E. coli or E. faecalis, as CLSI has not established clinical breakpoints for other organisms.

Treatment Options*

Duration**

Comments

Macrobid 100 mg PO BID

(preferred based on local resistance rates, tolerability, and low cost)

5 days

? Often has acitivity against MDROs, such as ESBLs and VRE.

? Avoid in elderly women with CrCl ................
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