URIs and UTIs Meghan Brett MD UNMH Hospital

URIs and UTIs Meghan Brett, MD UNMH Hospital Epidemiologist Medical Director, Antimicrobial Stewardship Associate Professor, Infectious Diseases 10. 31. 18

Planned Topics • Flu • URIs • UTIs

Background on Influenza

Neuraminidase Viral RNA Hemagglutinin

Influenza Epidemiology • Season: October – March • 31 seasons between 1976 and 2007 • Estimated numbers of influenza deaths? 1 • 3, 000 - 49, 000 people • Typically, ~90% of deaths occur in pts ≥ 65 yrs • Estimated impact of Influenza in 20032 • 24. 7 million cases with 31. 4 outpatient visits • 334, 185 hospitalizations, 3. 1 million hospital days • 41, 000 deaths 1 CDC MMWR 2010; 59: 1057 -1062. 2 Molinari NAM et al. Vaccine 2007; 25: 5086– 5096.

Current Influenza Activity

Current Flu Activity • 3 cases of influenza in Quay county in the past month • No evidence for sustained influenza transmission at the moment • http: //www. tricore. org/infectious_disease_report

New Mexico Department of Health Influenza & Respiratory Disease Report, 2018 -2019 New Mexico Influenza Geographic Spread* No Activity Sporadic Local Regional Widespread Summary of Activity: Week 41 October 7 th - 13 th, 2018 § New Mexico influenza-like illness (ILI) activity is currently 0. 8% of patient visits § US ILI is 1. 4% § The national ILI baseline is 2. 2% § Influenza activity is below the NM ILI baseline of 2. 4% in all five health regions § No influenza outbreaks were reported this week 8

Regional Influenza-Like Illness (ILI) Activity, 2018 -2019 NM ILI Activity by Health Region, 2018 -2019 5. 0% NW 4. 0% NE Metro 3. 0% 2. 0% 1. 0% 0. 0% OCT NOV DEC JAN FEB MAR APR MAY SW SE NM Baseline Region NW NE Metro SW SE This Week Last Week 0. 5% 1. 0% 0. 9% 0. 6% 0. 7% 1. 1% 1. 5% Outbreaks +PCR testing at SLD Outbreak: An influenza outbreak is defined as at No No least two cases of ILI in a specific area with at least one laboratory confirmed case. No No PCR Testing: Polymerase Chain Reaction (PCR) No No No tests can identify the presence of influenza viral RNA in respiratory specimens. PCR testing is performed at various laboratories across New Mexico. 3

Influenza Vaccination

Current Recommendations for Influenza Vax from ACIP • Anyone ≥ 6 months of age • No vaccine is currently preferred over another • Vaccine should be given throughout the flu season • It’s OK to get your flu shot now • NO NEED FOR A SECOND FLU VACCINE FOR ADULTS DURING THE FLU SEASON

Why Should Anyone who Works in Healthcare Get the Flu Vaccine? • Limit the amount of time that you’re sick • Flu vaccine prevents or limits duration of illness • Prevent transmission of influenza to others • Protect your patients, your family, and your co-workers • Recommended by CDC especially for HCPs • Supported by TJC, ANA, ACIP, APIC, SHEA, IDSA, and many others

Influenza Testing

Testing for Flu from Tri. Core • Respiratory Viral Swab • Pink culture media (refrigerated) with E-Swab • May be requested from Lab • Instructions on obtaining swab on Tri. Core’s website • Two available testing methods • RESPAN • FLURSV • FAQ regarding testing to be put on IPCD’s and ASP’s websites in the near future (draft handed out)

Isolation Precautions • Guidance on Infection Prevention and Control’s Website (UNMH Intranet) • Contact and Droplet • Peds (< 12 yrs) • Adults (> 12 yrs) • Immunocompromised • Instructions about when to start and when to stop isolation

Influenza Treatment

Antiviral Medications • Oseltamivir (oral, 2 weeks and older [FDA]) • Zanamivir (inhaled) • Peramivir IV (non-formulary, $$$$, ≥ 18 yrs, single dose) • UNMH Guidelines Antimicrobial Stewardship Website (Intranet) Key points: • Best if treated within 48 hrs of symptom onset • For hospitalized patients, reasonable to start after this timeframe • Don’t wait for testing results if flu is clinically suspected • Renally adjust

Antibiotics… then Antibiotic Resistance Burgess DS, Rapp RP. Am J Health-Syst Pharm 2008.

Antibiotic Resistance – So What? • Impact on patient outcomes • Incorrect empiric antibiotics increases patient mortality • Higher mortality among patients with antibiotic-resistant infections • Big issues with alternative antibiotics • Broader antibiotics may be needed for simpler infections • Use of less effective, second-line antibiotics for resistant organisms • More toxic and less-well characterized antibiotics used to treat patients • Large impact on Healthcare • Higher cost of care and potentially longer lengths of stay: $20 billion excess direct costs annually and $35 billion in lost productivity

Rethink Our Relationship with Antibiotics • Antibiotics are not benign: short-term and long-term consequences • Antibiotics are “Drugs of Fear” • Deescalation is standard of care • For many infections, trend is that “less is more” • Patient education may help to reset expectations

Impact of Antibiotics on Our Gut Jernberg C et al. Microbiology 2010

Health Consequences of Microbiome Disruption Across a Lifetime Langdon A, Crook N, Dantas G. Genome Medicine 2016.

What are the most common infections treated with ABX in the outpatient setting? • Upper respiratory infections • Positive urine cultures (? Urinary tract infections)

National Data about ABX Prescribing in Ambulatory Settings

Appropriate vs. Inappropriate ABX by Conditions

Appropriate vs. Inappropriate ABX by Conditions

National Data about ABX Prescribing in Ambulatory Settings

URTIs

Principles of Appropriate ABX Use for Nonspecific URIs in Adults • Immunocompetent adults without complicating comorbid conditions (e. g. , lung disease or heart disease) • Acute rhinopharyngitis: • Viral in origin • Acute infection • Sinus, pharyngeal, and lower airway sx: present but not prominent • Purulent secretions from nares or throat predict neither bacterial infection nor response to ABX treatment Gonzales R et al. Ann Intern Med 2001; 134: 490 -4.

Basics of Nonspecific URIs • Most resolve spontaneously • Duration: 1 – 2 weeks • Small % complicated by bacterial rhinosinusitis or pneumonia • Rhinosinusitis (2%): obstruction of sinus ostia • Pnuemonia: effects of flu on host immunity • May have sinus involvement (seen on CT scan within 2 – 4 d of sx onset)

Pathogens involved in non-specific URIs • Rhinoviruses • With ache and fatigue: influenza and parainfluenza • Adenovirus • Respiratory syncytial virus (RSV)

Treatment of NS URIs • Supportive: • • • Drink more water/fluids Nasal saline spray to relieve congestion Ice chips, sore throat spray or lozenges Honey to relieve cough Specific medications: acetaminophen or ibuprofen http: //www. cdc. gov/getsmart/community/downloads/16_270228 -boneill_non-antibiotic_perscription_pads_508. pdf

ABX for NS URIs? Most RCTs for treatment of URIs have been performed in children (7) which did not affect resolution of illness [95% CI, 0. 7 - 1. 28] • Early ABX does not prevent pneumonia or acute otitis media 3 among adults showed no benefit of treating URIs with ABX • Do not address subsequent complications

Viral vs. ABRS • Distinguishing acute bacterial rhinosinusitis (ABRS) from viral (any 1 of 3) • Onset with persistent sx/signs consistent with acute rhinosinusitis lasting for >= 10 d without evidence for improvement • Onset with severe sx/signs of high fever (39 C) and purulent nasal drainage or facial pain for 3 – 4 consecutive days • Onset with worsening sx/signs with new onset fever, headache, or increase in nasal d/c following typical viral URI (5 -6 d) and were initially improving

Resources • • CDC Get Smart https: //www. cdc. gov/getsmart/index. html Adult Treatment Recommendations https: //www. cdc. gov/getsmart/community/for-hcp/outpatient-hcp/adulttreatment-rec. html Pediatric Treatment Recommendations https: //www. cdc. gov/getsmart/community/for-hcp/outpatienthcp/pediatric-treatment-rec. html Continuing Education about ABX use in Ambulatory settings https: //www. cdc. gov/getsmart/community/for-hcp/continuingeducation. html

UTIs

UTI Signs/Sx

ASB • Evidence that screening and treatment does not lead to improved clinical outcomes • May actually lead to an increased number of infections among some patient populations • More likely, unnecessary antibiotics may cause harm • • Adverse effects C difficile infection Antibiotic resistance Wasted expense

Which Groups Require Rx for ASB? • Definitive: • Pregnant Women • Anyone undergoing TURP or Urologic procedures during which mucosal bleeding is anticipated • Maybe: • Renal transplant patients** • Neutropenic patients Infectious Diseases Society of America (IDSA), ASB guidelines 2005

Uncomplicated vs. Complicated UTIs • Uncomplicated – premenopausal women • No structural or functional abnormalities in urinary tract • Not pregnant • Complicated – • • Structural abnormalities (e. g. , nephrolithiasis) Functional abnormalities (e. g. , ureteral reflux) Compromised hosts (e. g. , pregnant, diabetic) UTIs in boys/men: until structural/functional ruled out IDSA, Uncomplicated UTI Guidelines 2011 Dielubanza EJ. ID Clin N Am 2014.

Why Distinguish Between Uncomplicated vs. Complicated? • Guidelines for uncomplicated but none for complicated UTIs • More important than upper tract/lower tract • Complicated • • May need further evaluation (diagnostics, urology consult) Increased morbidity and mortality May encounter more drug resistance (IV ABX) Duration of therapy will likely be longer • Assess conversion from uncomplicated to complicated (may indicated underlying issues)

Review of UA for Evidence of Infection • Check squamous cells first… if > 20, likely a contaminated sample • Nitrites • Produced by many Gram-negatives • Requires hours for conversion of nitrate nitrite • Not by Gram-positives, candida species • WBCs • > 10 per high powered field • Leukocyte esterase • Enzyme found in neutrophils • If present, indicates neutrophil activity • No test alone is sufficient to dx a UTI • Neg LCE and Neg nitrites had NPV of 88% (preg women, elderly, family med, and urology pts)

Caveats • Pyuria in ASB does not need to be treated • Urine samples that sit will have alterations in UA results • Samples analyzed within 2 hours or refrigerated to limit false positive and false negative results

Treatment of UTIs – What Bugs? • Enteric flora colonizing perineum and urethra • E. coli • • 80% of first infection in women, children 50% of nosocomial UTIs Most common for acute uncomplicated cystitis Many episodes of complicated UTIs and pyelo • Staphylococcus saprophyticus • 11% of UTIs (sexually active, younger women) • Remaining • GNRs (Klebiella, Proteus mirabilis) increasingly MDROs • Gram-positive cocci (entercoccus and GBS)

How Long to Treat? • It depends! • Uncomplicated UTIs • Cystitis • Nitrofurantoin or Bactrim 3 days • 20% resistance in isolates is an indication not to use this for empiric coverage • Note: nitrofurantoin should not be used in patients with Creatinine clearance < 50 (does not reach bladder) • Pyelonephritis • FQ 5 – 7 days • Beta-lactams 10 – 14 days • Bactrim 14 days

Test of Cure? • Nope (please don’t) • Would follow symptoms

Take Home Points • Antimicrobial resistance continues to grow • Antibiotics are not as benign as previously thought • We can do better with our antibiotic use! • Use resources to help guide you and discussions with your patients

Questions?