TO TREAT OR NOT TO TREATTHAT IS THE QUESTION

Dr. Ruth KandelDirector, 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

2

Clinical Infectious Disease 2005;40:643-654

3

What is Asymptomatic Bacteriuria?

Asymptomatic Bacteriuria (ASB)

5

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% (Infect Dis Clin North Am 1997;11:647-62)

• 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)

6

Treatment for ASB Indicated

• Pregnant women– Increased risk for adverse outcomes

• Urologic interventions• TURP• Any urologic procedure with potential mucosal

bleeding

7

Treatment for ASB Not Indicated

8

Prevalence of ASB

9

No Benefit Treating ASB in the Elderly

10

Prospective Randomized StudiesTreatment vs. No Treatment ASB

Authors Subjects Intervention Outcome

Nicolle LE, et al. NEJM 1983;309:1420-5

Men, NH, median age 80

Treated 16Not treated 20Duration 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 26Not treated 24Duration 1 year

No difference mortality/GU morbidity. Increase drug reactions and AB resistance treated group.

Abrutyn E, et al.Ann Intern Med1994;120:827-33

Women, ambulatory and NHMean age 82

Treated 192Not treated 166Duration 8 years

No survival benefit from treatment

Ouslander JGAnn Intern Med1995;122:749-54

Women and menNHMean age 85

Treated 33Not treated 38Duration 4 weeks

No difference chronic urinary incontinence

11

Cohort Studies

Authors Subjects Observation Outcome

JAGS 1990;38:1209-14

Men, Ambulatory, > 65 years

29 Subjects

Duration 1-4.5 years

No adverse outcomes attributed to no treatment

NEJM 1986;314:1152-6

Population based Swedish men and women

Duration 5 years No association between bacteriuria and survival

Gerontology1986;32:167-71

Population based Finnish men and women > 85 years

Duration 5 years No association between bacteriuria and survival

12

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.

13

IDSA Recommendations

14

Any Problems

Just Treating Anyway?

16

CDC Website17

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

19

Antibiotic Resistance

20

Antibiotic resistance increases mortality

Mortality associated with carbapenem resistant (CR) vs susceptible (CS)

Klebsiella pneumoniae (KP)

0

10

20

30

40

50

60

Overall Mortality Attributable Mortality

Pe

rce

nt o

f s

ub

jec

ts

CRKP

CSKP

Patel G et al. Infect Control Hosp Epidemiol 2008;29:1099-1106

OR 3.71 (1.97-7.01)

OR 4.5 (2.16-9.35)

p<0.001

p<0.001

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

24

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

25

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

27

Antibiotic Resistant Bacteria Travels‐

Journal of the American Geriatrics Societypages 242-246, 12 JUL 2002 http://onlinelibrary.wiley.com/doi/10.1046/j.1532-5415.50.7s.5.x/full#f1

28

And Another Reason Not To Treat

Clostridium Difficile Infection

30

Clostridium difficile infection (CDI) cases by location and type of exposures — United States, Emerging Infections Program, 2010

MMWR March 9, 2012

31

Rates of Clostridium difficile Infection Among Hospitalized Patients Aged ≥65 Years

CDC September 2, 2011 / 60(34);1171

32

Heron et al. Natl Vital Stat Rep 2009;57(14). http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf

Background: ImpactAge-Adjusted Death Rate* for

Enterocolitis Due to C. difficile, 1999–2006

*Per 100,000 US standard population

0

0.5

1.0

1.5

2.0

2.5

1999 2003

Rate

2000 20042001 20052002 2006Year

MaleFemaleWhiteBlackEntire US population

33

Deaths from Gastroenteritis DoubleC. difficile and norovirus are the leading causes

34

Background: Epidemiology

Risk Factors

• Antimicrobial exposure• Acquisition of C. difficile • 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

Main modifiable risk factors

35

When to TreatUrinary 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

38

Criteria for Surveillance, Diagnosis and Treatment

39

McGeer CriteriaNo Indwelling Catheter

• At least three 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

Chronic Indwelling Catheter

• At least two of the following– 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

40

Loeb Minimal CriteriaInitiating 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 CatheterMust 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 baselineICHE 2001;22:120-124

41

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 Catheter-Associated Urinary Tract Infections Adults 2009 CID 2010;50:625-663

• IDSA Guidelines Asymptomatic Bacteriuria CID 2005;40:643-654

42

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 Group43

Treatment algorithm for prescribing antimicrobials to NH residents in intervention arm

Loeb M et al. BMJ 2005;331:669

©2005 by British Medical Journal Publishing Group44

Monthly rates of antimicrobial prescriptions for urinary indications in intervention and usual care nursing homes.

Loeb M et al. BMJ 2005;331:669

©2005 by British Medical Journal Publishing Group45

Collecting Urine Samples

46

Role of Urine Analysis and Dipstick Testing in the Evaluation of Urinary Tract Infection in Nursing Home Residents

47

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

48

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 ORFever (> 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

49

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

50