NCUTI & Urosepsis guidelines

Dr. mahmood Almahjoob

MICU-TMC. TRIPOLI . LIBYIA

INTRODUCTION

• NCUTI among the most prevalent NCI

• Nosocomial bacteriuria develops in up to 25% of patients requiring a urinary catheter for > 7 days

• The prevalence of hospital-acquired UTIs in the PEP study was 10% and urosepsis accounted for 12% of all episodes.

Nosocomial infections

MICROBIOLOGICAL DATA• Gram-negative bacilli E.COLI account for majority of the cases

 while Gram-positive organisms are involved less frequently ,

• with E. coli being the commonest bacterium isolated in both catheterized and non-catheterized patients

• Organisms isolated from patients with complicated urinary infection and urosepsis tend to be more resistant

Etiologic agents

RISK FACTORS Of NCUTI elderly patients

diabetics

immuno-suppressed patients.

Structural and functional abnormalities of the genitourinary tract

Indwelling urinary catheters

Classification of UTI

UncomplicatedUTI >>>healthy individual

Complicated UTI >>> functional or strucutional u t abnormality

Urosepsis Special male genitourinary tract

infection eg epidedymitis prostatitis

EVALUATION• History is crucial in the evaluation of any UTI It

should include any previous history of infections, antibiotic use,

timeline of symptoms. If possible, any laboratory results associated with previous

infections, including culture results should be obtained.

• The physician should promptly look for evidence of sepsis in sever form of UTI

• A thorough physical examination (including a pelvic examination and digital rectal examination to exclude acute prostatitis) should also be performed.

INVISTIGATIONURINE FOR dipstick , R/E&CULTURE IS

CRUCIAL ROUTINE BLOOD TEST +CRP

BLOOD CUTURE LOCALIZING UNDERLYING URINARY TRACT

ABNORMALITY ULTRA SOUND CT&MRI Urine sample should be taken from sample port not from drainage bag

urine should be transported to lab &processed within 10minute presence or high acount of pyuria not indicate diagnosis if culture shows less than 10 3 cfu/ml gram stain of centrifuged urine is reliable in detection of infected organism

Diagnosis

• CA-UTI in patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization is defined by – the presence of symptoms or signs compatible with UTI

– no other identified source of infection

– >103 colony forming units (cfu)/mL of 1 bacterial species in a single catheter urine specimen or in a midstream voided urine specimen from a patient whose urethral, suprapubic, or condom catheter has been removed within the previous 48 h

Diagnosis

• CA-ASB in patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization is defined

– >105 cfu/mL of 1 bacterial species in a single catheter urine specimen

– patient without symptoms compatible with UTI• CA-ASB in a man with a condom catheter is

defined – >105 cfu/mL of 1 bacterial species in a single urine

specimen from a freshly applied condom catheter– patient without symptoms compatible with UTI

Diagnosis

• In the catheterized patient, pyuria is not diagnostic of CA-bacteriuria or CA-UTI– The presence, absence, or degree of pyuria should

not be used to differentiate CA-ASB from CA-UTI– Pyuria accompanying CA-ASB should not be

interpreted as an indication for antimicrobial treatment

TREATMENT GENERALSUPPORTIVE MANAGEMENT

• ANTIMICROBIAL THERAPY Antimicrobial Selection should be depend on:

.Local(hospital /ward) pattern of microorganism isolation and antibiotic resistance Wherever possible, antimicrobial therapy should be delayed pending results of urine culture and organism susceptibility, unless sever form or impeding sepsis indicated empirical regimes. Where empirical therapy is initiated, the antimicrobial choice should be reassessed once culture results become available, usually within 48 h to 72hr 

Antibiotic regime for NCUTI

Urinary tract infections Possible antibiotic

uncomplicated cystitis- Nitrofurntion 100mg orally for 3daysBactrim DS orally twice daily for 3 day

Ciprofloxacin 250mg orally twice daily for 3 days or Levofloxacin 250mg orally once daily for 3 days or augamantine

uncomplicatepyelonephritisI

complicated cystitis or pyelonephritisl

,Ciprofloxacin 200-400mg IV every 12 hour orLevofloxacin  250 to 500mg IV once

or aminoglycosideas 2line amikacinor gentamicin,

intravenous regimen such as a fluoroquinolone, amino glycoside (with or without an extended-spectrum cephalosporin, an extended-spectrum penicillin, or a carbapenem for7-14d 

hospital-acquired urosepsis

regime Dose

antipseudomonal third-generation cephalosporin

cefepime, ceftazidime

1–2 g every 8–12 h

2 g every 8 h

Or piperacillin/beta- lactamase inhibitorimipenem or meropenem(tazocine)

or carbamide merepnem

4.5 g every 6 h

500 mg every 6 h

plus

aminoglycoside (amikacin, (gentamicin

ا

7 mg/kg per d†Amikacin 20 mg/kg per dt

community-acquired primary urosepsis

regime dose

Or

3rd generation cephalosporin eg:Ceftriaxone 1to2g daily

+ pipracillin (beta-l actamase inhibitor (tazocin

4.5 g every 6 h

or

afluoroquinolone levofloxcine,ciproflaxcine

750 mg every d

400 mg every 8 hA combination therapy with an aminoglycoside or a carbapenem may

be essential in areas with high rate of fluoroquinolone resistance.

IMPORTANT NOTES Most patients require treatment for about 14-21 days

Successful antimicrobial therapy will usually ameliorate symptoms promptly,

Patients who fail to respond in this time frame should be reassessed to exclude

urinary obstruction or abscess (which may require drainage),

to exclude resistance of the infecting organism consider an alternate diagnosis

Catheters should be replaced before initiating antimicrobial therapy for the treatment of a symptomatic episode.

REFRENCES •Nottingham Antimicrobial Guidelines Committee April 2011 Review April 2012

•European Prevalence of Infection in Intensive care Study. EPIC International Advisory Committee

•European Society of Infections in Urology. Hospital acquired urinary tract infections in and use of antibiotics. Data from the PEP and PEAP-studies .

•SENTRY Antimicrobial Surveillance Program (2000 Diagn Microbiol Infect ) .)

•The European and Asian guidelines on management and prevention of catheter- urinary tract infections associated

•Surviving Sepsis Guidelines

•TMC infectious control

TMC GUIDELINE FOR NCUTI

always consider local pattren of microrganisms resistence ,avilblity of antibiotic ,host factor

always consider delyed anti biotic as much as patient clinical satuation tolarate to direct antibiotic according to result of culture& sensitvity