UTI- Pyelonephritis Management

Question 1

What can pyelo develop to? (3)

Answer 1

• Bacteremia
• Sepsis
• Acute renal failure

Question 2

T/F can pyelo patients be managed as outpatient

Answer 2

True

Question 3

What is the resistance % tolerance for pyelo?

Answer 3

10% tolerance

Question 4

T/F urine culture is not indicated for all pyelo patients diagnosed

Answer 4

False

Question 5

What is the most common pathogen in pyelo?
What other bugs to expect (2)

Answer 5

E. coli still most common

Enterococcus
Pseudomonas

Question 6

When would it be reasonable to cover Enterococcus and pseudomonas in pyelo? (3)

Answer 6

• If grown in recent culture in the last 3-6 months
• if recent broad-spectrum antibiotic use
• If ICU hospitalized

Question 7

What to give patients with pyelo if they are dehydrated?

Answer 7

IV fluids
- improve malaise, N/V

Question 8

For outpatient pyelo, which oral FQ has the most evidence? (2)

Answer 8

Levofloxacin and cipro (preferred)
- Resistance often over 10%

Question 9

Which FQ is not used in pyelo?

Answer 9

Moxifloxacin
- does not penetrate bladder enough

Question 10

What is usually given for empiric management in outpatients for pyelo? (2 options)

Answer 10

Long acting cephalosporin (ceftriaxone daily) until culture available

Can also give aminoglycoside (gentamicin) once daily
- tobramycin reserved for pseudo

Question 11

Which class and route of antibiotics have less evidence in outpatient pyelo

Answer 11

Oral beta-lactams

Question 12

What is the first line treatment for inpatient pyelo

Answer 12

IV 3rd gen cephalosporin (ceftriaxone)

Question 13

When would you use Pip-taz in inpatient pyelo?

Answer 13

If suspecting pseudomonas
- (ICU admission, recent culture)

Question 14

When would you use carbapenem in inpatient pyelo

Answer 14

If concerned for ESBL
- Recent urine culture (<3 months) positive for ESBL
- Travel to Africa, Asia in the last 3-6 months

Question 15

What would you use in inpatient pyelo management if they have a type 4 beta lactam allergy?

Answer 15

IV Aminoglycosides
- only use when theres no other options

Question 16

When can you use septra for inpatient pyelo?

Answer 16

For targeted therapy if susceptible (using antibiogram + culture results)

Question 17

When are tetracylcines used in inpatient pyelo?

Answer 17

USed for multi drug resistant organisms cystitis

Question 18

Which drugs are NOT used in pyelo? (2)

Answer 18

Nitrofurantoin
Fosfomycin
- inadequate concentrations in the kidney

Question 19

What do you do once culture results are available for pyelo

Answer 19

It is MONObacterial
- appropriate to target therapy

Can use urine culture to predict blood culture (if bacteremia is suspected)

Question 20

If a patient is not growing pseudomonas which carbapenem would you pick?

Answer 20

Ertapenem

Question 21

Which generation do lab susceptibility test for cephalosporins? What can you infer from this results?

Answer 21

Test 1st gen parenteral -> Cefazolin
- can infer PARENTERAL susceptibility for 2nd and 3rd gen (Cefuroxime, cefotaxime, ceftriaxone)

Question 22

T/F Cefazolin susceptibility can be inferred for Cephalexin in UTI

Answer 22

False

Question 23

When is cephalexin susceptibility tested?

Answer 23

Only tested for cystitis

Question 24

T/F if the bug is resistant to cefazolin (1st gen IV) it will be resistant to 3rd gen IV cephalosporin

Answer 24

False
- Will go on to test 3rd gen

Question 25

What can we infer from cephalexin suscpetibility

Answer 25

Infers gram-neg susceptibility to cefprozil and cefuroxime (2nd gens) - DOES NOT INFER SUSCEPTIBILITY TO CEFADROXIL (1st gen)

Question 26

T/F labs will choose not to report data on broad spectrum agents if narrower options are available

Answer 26

True

Question 27

What does pan-susceptibile mean

Answer 27

Susceptible to all agents tested by the lab

Question 28

What does Pan-susceptible PsA mean?

Answer 28

susceptible to piperacillin (and pip-taz), ceftazidime, cipro/levofloxacin and imi/meropenem

Question 29

When should you convert IV to PO (2) Which class of drugs

Answer 29

- 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

Question 30

What if pyelo patient has bacteremia, would you extend IV duration?

Answer 30

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)

Question 31

Define high dose beta lactams

Answer 31

Cephalexin 1g TID Amoxicillin 1g TID

Question 32

What did the retrospective cohort study say for targeted enterobacterial Bacteremic UTI comparing high dose oral beta lactams and FQ or septra

Answer 32

As safe and effective as each other - duration was 11 days

Question 33

What is the duration of therapy for the following classes: FQ Septra BL

Answer 33

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

Question 34

When would you see improvement in pyelo patients ? Resolution?

Answer 34

Improvement: in 48-72 hours Resolution: day 5

Question 35

What adjustments would you make to outpatients pyelo when cultures come back?

Answer 35

Will not narrow therapy - however ensure that culture results show susceptibility

Question 36

What adjustments would you make to inpatients pyelo when cultures come back? (3)

Answer 36

1. Narrow antibiotics 2. Ensure adequate dosing as renal function improves 3. Transition from IV BL to oral when feasible

Question 37

What can you infer from this urine culture showing for a CYSTITIS patient Cefazolin (for systemic infection): resistant Cephalexin (for cystitis): Susceptible

Answer 37

Can use either agent Cefazolin only resistant for systemic infections you can use Cefazolin IV or Cephalexin PO

Question 38

What can you infer from this urine culture showing for a PYELO patient Cefazolin (for systemic infection): resistant Cephalexin (for cystitis): Susceptible

Answer 38

CANNOT use either agent, won't reach MIC - need to test 2nd/3rd gen parental cephalosporin to confirm Can consider cipro

Question 39

What can you infer from this urine culture for a CYSTITIS patient Cefazolin (for systemic infections): Susceptible Cephalexin (for cystitis): Susceptible

Answer 39

Lab would still report both Encourage the use of PO cephalexin for cystitis