UTI- Pyelonephritis Management Flashcards
What can pyelo develop to? (3)
- Bacteremia
- Sepsis
- Acute renal failure
T/F can pyelo patients be managed as outpatient
True
What is the resistance % tolerance for pyelo?
10% tolerance
T/F urine culture is not indicated for all pyelo patients diagnosed
False
What is the most common pathogen in pyelo?
What other bugs to expect (2)
E. coli still most common
Enterococcus
Pseudomonas
When would it be reasonable to cover Enterococcus and pseudomonas in pyelo? (3)
- If grown in recent culture in the last 3-6 months
- if recent broad-spectrum antibiotic use
- If ICU hospitalized
What to give patients with pyelo if they are dehydrated?
IV fluids
- improve malaise, N/V
For outpatient pyelo, which oral FQ has the most evidence? (2)
Levofloxacin and cipro (preferred)
- Resistance often over 10%
Which FQ is not used in pyelo?
Moxifloxacin
- does not penetrate bladder enough
What is usually given for empiric management in outpatients for pyelo? (2 options)
Long acting cephalosporin (ceftriaxone daily) until culture available
Can also give aminoglycoside (gentamicin) once daily
- tobramycin reserved for pseudo
Which class and route of antibiotics have less evidence in outpatient pyelo
Oral beta-lactams
What is the first line treatment for inpatient pyelo
IV 3rd gen cephalosporin (ceftriaxone)
When would you use Pip-taz in inpatient pyelo?
If suspecting pseudomonas
- (ICU admission, recent culture)
When would you use carbapenem in inpatient pyelo
If concerned for ESBL
- Recent urine culture (<3 months) positive for ESBL
- Travel to Africa, Asia in the last 3-6 months
What would you use in inpatient pyelo management if they have a type 4 beta lactam allergy?
IV Aminoglycosides
- only use when theres no other options
When can you use septra for inpatient pyelo?
For targeted therapy if susceptible (using antibiogram + culture results)
When are tetracylcines used in inpatient pyelo?
USed for multi drug resistant organisms cystitis
Which drugs are NOT used in pyelo? (2)
Nitrofurantoin
Fosfomycin
- inadequate concentrations in the kidney
What do you do once culture results are available for pyelo
It is MONObacterial
- appropriate to target therapy
Can use urine culture to predict blood culture (if bacteremia is suspected)
If a patient is not growing pseudomonas which carbapenem would you pick?
Ertapenem
Which generation do lab susceptibility test for cephalosporins? What can you infer from this results?
Test 1st gen parenteral -> Cefazolin
- can infer PARENTERAL susceptibility for 2nd and 3rd gen (Cefuroxime, cefotaxime, ceftriaxone)
T/F Cefazolin susceptibility can be inferred for Cephalexin in UTI
False
When is cephalexin susceptibility tested?
Only tested for cystitis
T/F if the bug is resistant to cefazolin (1st gen IV) it will be resistant to 3rd gen IV cephalosporin
False
- Will go on to test 3rd gen
What can we infer from cephalexin suscpetibility
Infers gram-neg susceptibility to cefprozil and cefuroxime (2nd gens)
- DOES NOT INFER SUSCEPTIBILITY TO CEFADROXIL (1st gen)
T/F labs will choose not to report data on broad spectrum agents if narrower options are available
True
What does pan-susceptibile mean
Susceptible to all agents tested by the lab
What does Pan-susceptible PsA mean?
susceptible to piperacillin (and pip-taz), ceftazidime, cipro/levofloxacin and imi/meropenem
When should you convert IV to PO (2) Which class of drugs
- tolerating oral intake (and no concerns of gut hypoperfusion) AND
- Afebrile + showing improvement for 24 hours
Can usually convert around day 3 (earlier if fever resolves faster)
Class: Beta-lactams
What if pyelo patient has bacteremia, would you extend IV duration?
If they have bacteremia, its less likely to cause seeding/serious infection (gram neg not as sticky)
- (no need for that 72 hour minimum with GAS bacteremia, for example)
Can just convert to HIGH dose oral beta lactam once criteria is met (tolerating PO and afebrile/improving for 24 hours)
Define high dose beta lactams
Cephalexin 1g TID
Amoxicillin 1g TID
What did the retrospective cohort study say for targeted enterobacterial Bacteremic UTI comparing high dose oral beta lactams and FQ or septra
As safe and effective as each other
- duration was 11 days
What is the duration of therapy for the following classes:
FQ
Septra
BL
FQ: 5-7 days
- levo 5 days
- Cipro 7 days
Septra: 7 days
- can go for 10 days
BL: 7-10 days
- including IV therapy
When would you see improvement in pyelo patients ?
Resolution?
Improvement: in 48-72 hours
Resolution: day 5
What adjustments would you make to outpatients pyelo when cultures come back?
Will not narrow therapy
- however ensure that culture results show susceptibility
What adjustments would you make to inpatients pyelo when cultures come back? (3)
- Narrow antibiotics
- Ensure adequate dosing as renal function improves
- Transition from IV BL to oral when feasible
What can you infer from this urine culture showing for a CYSTITIS patient
Cefazolin (for systemic infection): resistant
Cephalexin (for cystitis): Susceptible
Can use either agent
Cefazolin only resistant for systemic infections
you can use Cefazolin IV or Cephalexin PO
What can you infer from this urine culture showing for a PYELO patient
Cefazolin (for systemic infection): resistant
Cephalexin (for cystitis): Susceptible
CANNOT use either agent, won’t reach MIC
- need to test 2nd/3rd gen parental cephalosporin to confirm
Can consider cipro
What can you infer from this urine culture for a CYSTITIS patient
Cefazolin (for systemic infections): Susceptible
Cephalexin (for cystitis): Susceptible
Lab would still report both
Encourage the use of PO cephalexin for cystitis
