Urinary Tract Infection(UTI) دکتر مجاهدی. Urinary Tract Infections Dr MOjahedi.
CLASSIFICATION OF URINARY TRACT INFECTIONS AND …
Transcript of CLASSIFICATION OF URINARY TRACT INFECTIONS AND …
CLASSIFICATION OF URINARY TRACT
INFECTIONS AND SURGICAL FIELD
CONTAMINATION CATEGORIES AS A BASIS
FOR TREATMENT AND PROPHLAXIS
Magnus Grabe, M.D., Ph.D.
Associate Professor of Urology
University of Lund
Sweden
ESU AMU UTI Apr 2016/MG
University of Lund – since 1666
ESU AMU UTI Apr 2016/MG
University hospital - Malmö 2013
ESU AMU UTI Apr 2016/MG
Scania: South Swedish Province
ESU AMU UTI Apr 2016/MG
Winter
ESU AMU UTI Apr 2016/MG
Layout
• The European Association of Urology (EAU)
Guidelines on Urological Infections (versions
2015 and 2016)
• Principle of classification of Urinary tract
infections
• Surgical field contamination categories as a
model for peri-operative antimicrobial prophylaxis
• Antimicrobial (= antibiotic) stewardship
• Conclusions and take home message
ESU AMU UTI Apr 2016/MG
EAU Guidelines 2015
ESU AMU UTI Apr 2016/MG
www.uroweb.org/guidelines
Non-oncology/urological infections/archive: 2015
Main types of infections associated with
urological care
ESU AMU UTI Apr 2016/MG
Wound infections
Surgical site
infeciton (SSI)
Urinary tract
infection
Male accesory
gland infection
(MAGI)
Systemic and
Other organ
infection
Female
resproductive
organ infection
Classification of Urogenital infections
Urinary tract infection
(UTI)
Male accessory gland
infection (MAGI)
Uro-Genital infections (UGI)
Female
reproductive
organs
infection
EAU guidelines
Grabe et al. EAU guidelines 2012-2015 ESU AMU UTI Apr 2016/MG
PRINCIPLES OF A MODERN
CLASSIFICATION OF UTI
European Section of Infection in Urology
ESIU
European Association of Urology
EAU
ESU AMU UTI Apr 2016/MG
What we have
ICD 10
N30.9 Cystitis
N10
N11.9
Pyelonephritis
N39 UTI unspecified
A41.9 Sepsis, unspecified
N41.9 Prostatitis
• CDC 1988
• CDC update 2008
• IDSA 1992
• ESCMID 1993
ESU AMU UTI Apr 2016/MG
ESU AMU UTI Apr 2016/MG
European Association
of Urology and
International
Consultation on
Urological Diseases
• 16 sections, divided in several chapters
• 991 pages
• Each section chaired by one expert coordinating an international effort
• Evidence based review of the literature
• Totally 3628 references
T N M like
classification
A UTI severity
score
What we would like to have
ESU AMU UTI Apr 2016/MG
What is important for a UTI in Urology?
• Clinical criteria
• Presentation - localisation
• Severity
• Risk factors
• Endogenous
• Exogenous
• Urological circumstances
• Pathogens
• Pathogen (type, virulence)
• Antibiotic sensitivity
• Circumstances of UTI
acquisition
• Community
• Hospital environment
• Long term residential
• Therapeutic options
ESU AMU UTI Apr 2016/MG
STEP ONE (1) The Localisation
Symptoms
Presentation
ESU AMU UTI Apr 2016/MG
Localisation of infection of the UT
Localisation Symptoms giving the localisation Acronym
Urine (only) No
Source level unknown
ABU
Bladder Lower Urinary Tract symptoms
Cystitis
CY
Kidney Upper Urinary tract symptoms
Pyelonephritis, Pyonephrosis
“Febrile” UTI (Avoid “pyelitis”)
PN
Systemic Sepsis
“Urosepsis”
US
Male genital
infection
Prostatitis
Epididymitis
ESU AMU UTI Apr 2016/MG
Classification of clinical presentation
Clinical
diagnosis
Clinical symptoms
Grade of
severity
Acronym
Cystitis Dysuria, frequency, urgency,
suprapubic pain, etc… 1 CY-1
Mild,moderate
pyelonephritis
“Febrile UTI”
Fever (>38oC), abdominal or flank pain
Unspecific febrile symptoms with or
without symptoms of CY
2 PN-2
Severe
pyelonephritis
“Febrile UTI”
As PN-2 with nausea and vomiting 3 PN-3
UroSepsis
SIRS
Any signs of Systemic Inflammatory
Response Syndrome (SIRS) +/- PN/CY 4 US-4*
Severe Sepsis US-4 + hypo-tension and -perfusion 5 US-5*
Sepsis with
organ failure
US-5 + organ failure not responding
supportive therapy 6 US-6*
Adapted from Bjerklund Johansen, 2010
ESU AMU UTI Apr 2016/MG
* Sepsis – 2/2001
New classification of Sepsis (Sepsis-3/2016)
ESU AMU UTI Apr 2016/MG
JAMA, 2016:315(8)
Feb 23
New classification of Sepsis (Sepsis-3/2016)
ESU AMU UTI Apr 2016/MG
JAMA, 2016:315 (8);Feb 23
New classification of Sepsis (Sepsis-3): SOFA score
ESU AMU UTI Apr 2016/MG
JAMA, 2016:315 (8);Feb 23
Local symptoms Dysuria, frequency,
urgency, pain or
bladder tenderness
General symptoms Fever, Flank pain
Nausea, vomiting
Systemic response SIRS Fever, shivering
Circulatory failure
US-6 ABU CY-1 PN-2 PN-3
Febrile UTI
US-5
Symptoms
Clinical
diagnosis
Treatment
Medical
and
Surgical
US-4
+
Organ failure Single-, multiple-
Organ failure
No
symp
toms
Severity
Investigat-
ions
Risk factors
* Two exceptions: pregnancy and prior to urological procedure
Grabe et al. EAU guidelines 2012-2015 ESU AMU UTI Apr 2016/MG
STEP TWO (2)
The degree of severity
A continuum
ESU AMU UTI Apr 2016/MG
Local symptoms Dysuria, frequency,
urgency, pain or
bladder tenderness
General symptoms Fever, Flank pain
Nausea, vomiting
Systemic response SIRS Fever, shivering
Circulatory failure
US-6 ABU CY-1 PN-2 PN-3
Febrile UTI
US-5
Symptoms
Clinical
diagnosis
Treatment
Medical
and
Surgical
US-4
Gradient of severity
+
Organ failure Single-, multiple-
Organ failure
No
symp
toms
Severity
Investigat-
ions
Risk factors
* Two exceptions: pregnancy and prior to urological procedure
Grabe et al. EAU guidelines 2012-2015 ESU AMU UTI Apr 2016/MG
STEP THREE (3)
Risk Factor assessment
Grouping the Risk Factors
ESU AMU UTI Apr 2016/MG
Local symptoms Dysuria, frequency,
urgency, pain or
bladder tenderness
General symptoms Fever, Flank pain
Nausea, vomiting
Dipstick
(MSU Culture + S
as required)
Dipstick
MSU Culture + S
Renal US or I.V. Pyelogram /renal CT
Systemic response SIRS Fever, shivering
Circulatory failure
Dipstick
MSU Culture + S and Blood culture
Renal US and/or Renal and abdominal CT
US-6 ABU CY-1 PN-2 PN-3
Febrile UTI
US-5
Symptoms
Clinical
diagnosis
Treatment
Medical
and
Surgical
US-4
Risk factor assessment according to ORENUC (Table 2.1)
Gradient of severity
+
Organ failure Single-, multiple-
Organ failure
No
symp
toms
Severity
Investigat-
ions
Risk factors
* Two exceptions: pregnancy and prior to urological procedure
Uncomplicated UTI Complicated UTI
Grabe et al. EAU guidelines 2012-2015 ESU AMU UTI Apr 2016/MG
ORENUC Risk Factors
O R E N U C
No RF of
recur-
rence
Extra-
genital
Nephro-
pathic
Urolog-
ical
Cathe-
ter
related
ESU AMU UTI Apr 2016/MG
Host Risk Factors in UTI (EAU Guidelines 2011-2015)
Type Category of risk factor Examples of risk factors
O No known/associated RF Healthy premenopausal women
R RF of recurrent UTI, but no risk of severe
outcome
Sexual behaviour and contraceptive devices
Hormonal deficiency in post menopause
Secretory type of certain blood groups
Controlled diabetes mellitus
E Extra-urogenital RF, with risk of more severe
outcome
Pregnancy
Male gender
Badly controlled diabetes mellitus
Relevant immunosuppression*
Connective tissue diseases*
Prematurity, new-born
N Nephropathic disease, with risk of more
severe outcome
Relevant renal insufficiency*
Polycystic nephropathy
U Urological RF, with risk of more severe
outcome, which can be resolved during
therapy
Ureteral obstruction (i.e. stone, stricture)
Transient short-term urinary tract catheter
Asymptomatic Bacteriuria**
Controlled neurogenic bladder dysfunction
Urological surgery
C Permanent urinary Catheter and non
resolvable urological RF, with risk of more
severe outcome
Long-term urinary tract catheter treatment
Non resolvable urinary obstruction
Badly controlled neurogenic bladder dysfunction
ESU AMU UTI Apr 2016/MG
Bjerklund-Johansen et al. Urological infections. EAU-ICDU, 2010 * Not well defined
STEP FOUR (4)
Pathogen and its sensitivity
ESU AMU UTI Apr 2016/MG
Theurapeutic options
Microorganism Sensitivity
ESU AMU UTI Apr 2016/MG
Susceptibility Level
Susceptible a
Reduced
susceptibility
b
Multiresistant c
THE FINAL CODE Clinical presentation
Severity
Risk factors
Pathogen and sensitivity
Therapeutic options
ESU AMU UTI Apr 2016/MG
Additive factors for UTI severity assessment
Clinical presentation
UR: Urethritis
CY: Cystitis
PN: Pyelonephritis
US: Urosepsis
MA: Male genital glands
Grade of severity
1: Low, cystitis
2: PN, moderate
3: PN, severe, established
4: US: SIRS
5: US: Organ dysfunction
6: US: Organ failure
Risk factors ORENUC
O: No RF
R: Recurrent UTI RF
E: Extra urogenital RF
N: Nephropathic RF
U: Urological RF
C: Catheter RF
Pathogens
Species
Susceptibility grade
• Susceptible
• Reduced susceptibility
• Multi-resistant
ESIU, MG, 2010
ESU AMU UTI Apr 2016/MG
Grabe et al. EAU Guidelines on
Urological infections 2011-2015
Treatment:
Medical
Surgical?
PN-3,U:E.COLI (S)
US-5,E:PROTEUS (A)
CY-1,O:E.coli (s)
CY-1,R:E.coli (s)
ESU AMU UTI Apr 2016/MG
Not validated but a
practical tool
Local symptoms Dysuria, frequency,
urgency, pain or
bladder tenderness
General symptoms Fever, Flank pain
Nausea, vomiting
Dipstick
(MSU Culture + S
as required)
Empirical
3-5 days
Dipstick
MSU Culture + S
Renal US or I.V. Pyelogram /renal CT
Empirical + directed
7-14 days
Systemic response SIRS Fever, shivering
Circulatory failure
Dipstick
MSU Culture + S and Blood culture
Renal US and/or Renal and abdominal CT
US-6
Empirical + directed
7-14 days Consider combine 2 antibiotics
ABU CY-1 PN-2 PN-3
Febrile UTI
US-5
Symptoms
Clinical
diagnosis
Treatment
Medical
and
Surgical
NO* Empirical + directed
10-14 days Combine 2 antibiotics
US-4
Risk factor assessment according to ORENUC (Table 2.1)
Gradient of severity
+
Organ failure Single-, multiple-
Organ failure
No
symp
toms
Severity
Investigat-
ions
Risk factors
* Two exceptions: pregnancy and prior to urological procedure
Uncomplicated UTI Complicated UTI
Grabe et al. EAU guidelines 2012-2015 ESU AMU UTI Apr 2016/MG
Local symptoms Dysuria, frequency,
urgency, pain or
bladder tenderness
General symptoms Fever, Flank pain
Nausea, vomiting
Dipstick
(MSU Culture + S
as required)
Empirical
3-5 days
Dipstick
MSU Culture + S
Renal US or I.V. Pyelogram /renal CT
Empirical + directed
7-14 days
Systemic response SIRS Fever, shivering
Circulatory failure
Dipstick
MSU Culture + S and Blood culture
Renal US and/or Renal and abdominal CT
US-6
Empirical + directed
7-14 days Consider combine 2 antibiotics
ABU CY-1 PN-2 PN-3
Febrile UTI
US-5
Symptoms
Clinical
diagnosis
Treatment
Medical
and
Surgical
NO* Empirical + directed
10-14 days Combine 2 antibiotics
US-4
Risk factor assessment according to ORENUC (Table 2.1)
Gradient of severity
+
Organ failure Single-, multiple-
Organ failure
No
symp
toms
Drainage/surgery as required
Severity
Investigat-
ions
Risk factors
* Two exceptions: pregnancy and prior to urological procedure
Uncomplicated UTI Complicated UTI
Grabe et al. EAU guidelines 2012-2015 ESU AMU UTI Apr 2016/MG
SURGICAL FIELD
CONTAMINATION LEVEL
ESU AMU UTI Apr 2016/MG
CLASSIFICATION OF UROLOGICAL
PROCEDURES IN RELATION TO
LEVEL OF CONTAMINATION
Based on CDC Guidelines on prevention of SSI Mangram et al. Infect Control Hosp Epidemiol 1999;20:250-78
Adapted for urological procedures by EAU
Section on infections in Urology (ESIU)
Urological Infections 2011-2015
ESU AMU UTI Apr 2016/MG
Grabe et al. World J Urol 2011
Surgical field contamination: General
Surgical
contamination
Description Principle of
antimicrobial
prophylaxis
Clean (I)
Clean-contaminated
(II)
Contaminated
(III)
Dirty (IV)
ESU AMU UTI Apr 2016/MG
Mangram et al, 1999
Surgical field contamination: General
Surgical
contamination
Description Principle of
antimicrobial
prophylaxis
Clean (I) Urinary, genital or alimentary tracts not entered
Uninfected operative wound and no evidence of
inflammation. No break in technique.
Blunt trauma.
Clean-contaminated
(II)
Urinary, alimentary, pulmonary or genital
tracts entered with no or little (controlled)
spillage. No break in technique
Contaminated
(III)
Urinary, alimentary, pulmonary or genital
tracts entered, spillage of GI content;
inflammatory tissue; major break in technique;
Open, fresh accidental wounds
Dirty (IV) Pre-existing infection; viscera perforation
Old traumatic wound
ESU AMU UTI Apr 2016/MG
Mangram et al, 1999
Surgical field contamination: Urology
Surgical
contamination
Description Principle of
antimicrobial
prophylaxis
Clean (I) Urinary, genital or alimentary tracts not entered
Uninfected operative wound and no evidence of
inflammation. No break in technique.
Blunt trauma.
Clean-contaminated
(UT) (IIA)
Urinary or genital tracts entered with no or little
(controlled ) spillage. No break in technique
Clean-contaminated
(bowel) (IIB)
Gastrointestinal tract entered, no or little
(controlled) spillage. No break in technique
Contaminated
(III)
UT or GI tracts entered, spillage of GI content;
inflammatory tissue; major break in technique;
Open, fresh accidental wounds
Bacterial growth in urine
Dirty (IV) Pre-existing infection; viscera perforation
Old traumatic wound
ESU AMU UTI Apr 2016/MG
Grabe et al, WJU 2011
Mangram et al, 1999
Clean but entering the lower UT
Surgical field contamination: Urology
Surgical
contamination
Description Principle of
antimicrobial
prophylaxis
Clean (I) Urinary, genital or alimentary tracts not entered
Uninfected operative wound and no evidence of
inflammation. No break in technique.
Blunt trauma.
No
Clean-contaminated
(UT) (IIA)
Urinary or genital tracts entered with no or little
(controlled ) spillage. No break in technique Yes
Single dose If prolonged =
treatment Clean-contaminated
(bowel) (IIB)
Gastrointestinal tract entered, no or little
(controlled) spillage. No break in technique
Contaminated
(III)
UT or GI tracts entered, spillage of GI content;
inflammatory tissue; major break in technique;
Open, fresh accidental wounds
Bacterial growth in urine
Pre-operative
control
Dirty (IV) Pre-existing infection; viscera perforation
Old traumatic wound Treatment
ESU AMU UTI Apr 2016/MG
Grabe et al, WJU 2011
Mangram et al, 1999
Clean but entering the lower UT
Other criteria?
Event Example Decision
Breach of
protecting mucosal
layer
Cystoscopy
Endourological procedures
(e.g. URS)
Does it change?
Small rift, no change
Larger rift?
Perforation of organ Bladder wall
Ureter perforation during
stone management
Kidney pelvic wall perforation
during PCNL
Change from
prophylaxis to
treatment?
Necrotic tissue or
purulent liquide
Resection of prostate or
bladder tumour
Infected environment
ESU AMU UTI Apr 2016/MG
Lack of evidence for such decisions
Antimicrobial Stewardship (1)
• Optimise
• The outcome of prevention and treatment of infection
• Curbing overuse and misuse of antimicrobial agents
• Measure of success:
• Regulating antibiotic prescription
• Healthcare associated infection = HAI (reporting, feed-back)
• Emergence of resistant organisms, e.g. Clostridium difficile
• In urology
• Urinary tract infections (UTI)
• Male accessory glands infection (MAGI)
ESU AMU UTI Apr 2016/MG
Antimicrobial Stewardship (2)
• The most important components
• Regular training of staff in best use of antimicrobial agents
• Adherence to local, national and international guidelines
• Regular ward visits and consultation with infectious disease physicians
• Treatment outcome evaluation
• Monitoring and regular feedback to prescribers of their antimicrobial prescribing performance and local pathogen resistance profile, by
• Clinic and Ward audits
ESU AMU UTI Apr 2016/MG
Conclusions – message to take home
• Urological care is accompainied by several different forms of infections and infectious complications
• A stepwise assessment of each patient is essential for a correct management • Localisation of infection
• Careful risk factor evaluation
• Expected microorganism and resistance pattern
• Need for surgical management in addition to medical
• The surgical field contamination level is a tool to prevent infectious complications in conjunction with urological surgery
• Antibiotic stewardship programme is a tool for improving the rational and reasonable use of antibiotics
ESU AMU UTI Apr 2016/MG