Antibiotic Resistance in Urinary Tract Infection... Are we contributing to the crisis?

[aolmoz, MSN, NP]

Are we contributing to the crisis?

As a nurse practitioner often assigned the task of reviewing urine cultures from previous patient encounters in a suburban community hospital emergency department, I'm often required to contact a patient to change the antibiotic they were placed on at the time of their ED visit due to resistance issues. This begs the question, why am I personally seeing so much resistance in our community and is there a link between the outpatient provider and the increasing rate of resistance? You might think to yourself, my view of the issue is not necessarily the entire picture. My response to you would be this: 80-90 % of antibiotic prescriptions are written by general practitioners according to the US Centers for Disease Control and Prevention (CDC), of those, 30% are considered to be completely unnecessary in retrospective studies ( CDC, 2016). In 2011, The Infectious Diseases Society of America (IDSA) found that 60% of participants in a national survey of infectious disease specialists had developed pan-resistant, untreatable bacterial infections within the previous year (Spellberg, et al 2014). With these statistics, I ask have to wonder if our practices are partly to blame.

What are the contributing factors for antibiotic resistance?

Overuse and over-prescription of antibiotics

• Antibiotics are frequently prescribed for before there is evidence of bacterial infection. There can be overwhelming pressure from patients to receive an antibiotic prescription for their symptoms. In an age of " patient satisfaction" as a driving force for medical decision making, many providers feel the benefit of a return patient is greater than the risk of an " unsatisfied customer".
• Broad spectrum antibiotics are initiated based on an improperly collected urinary specimen. A 2014 by Pallin et at reported that 58% of the patients never received instruction on urine sample collection resulting in only 6% of the patients performing the correct technique for urine sample collection.
• Antibiotics are prescribed to patients based on routine point of care urine dipsticks in the absence of urinary symptoms. Urine dipsticks should be reserved only for those who have urinary signs or symptoms.
• Patients take leftover antibiotics from previous prescriptions. Patients should be educated on the importance of taking the entire course of antibiotics prescribed to them at any given time, and to never take an antibiotic prescribed for another person.
• Inappropriate prescribing patterns
  • As mentioned above, prescriptions for antibiotics that aren't necessarily needed. According to the Health Protection Agency (HPA), half of all women presenting with urinary symptoms have urethritis as opposed to urinary tract infection.
  • Failure of prescriber's to incorporate relevant patient data such as drug allergies, previous culture results, current renal function into clinical decisions. Additionally, choice of agent may be ineffective for the desired indication, suboptimal dosing and suboptimal duration of treatment have been found to contribute to the promotion of resistant bacteria. ( Gums, 2016)

What can we do better?

Antimicrobial Stewardship Intervention

• Evaluates adherence to established UTI treatment guidelines and diagnostic accuracy
• Audits and provides feedback to ED providers in regard to compliance
• Multiple studies support the use of antimicrobial stewardship programs to increase adherence to UTI guidelines and reduce unnecessary antibiotic therapy for urinary symptoms.
• Identify risk factors that contribute to antibiotic resistance when determining which agent to prescribe. Provider must ask themselves:
  • Has the patient has previous or recurrent use of a fluoroquinolone?
  • Has the patient had recurrent urinary tract infections?
  • Is the patient at least 50 years of age?
  • Has the patient undergone recent urinary catheterization?
  • Is the patient a male?
  • Is the patient a resident of a nursing home? If the answer is yes, the odds of drug resistance to standard antibiotics used to treat UTI are increased. Therefore, alternative antibiotic therapy should be considered.

• Prevent recurrent UTI
  • Importance of proper bladder emptying
    • Be aware of urogenital anomalies or bladder dysfunction that can impact a patient's ability to fully empty their bladder
    • Bladder outlet obstruction caused by BPH or changes in sensation caused by DM polyneuropathy can prevent a patient from fully emptying their bladder and therefore contribute to the incidence of acute cystitis
    • For incomplete bladder emptying as a result of bladder dysfunction, consideration of clean intermittent catheterization or the administration of medications to relax the urinary sphincter should be explored
  • Active use of non-antimicrobial prophylaxis such as
    • Hormonal replacement therapy for post-menopausal women ( Stamm, et al 1999)
    • Cranberry-based products to create a hostile environment for urinary pathogens along the urethra
    • Probiotic therapy, specifically Lactobacillus supplements
  • Proper hygiene techniques
    • Teach women to wipe front to back after urination to limit the transfer of E.coli and other bacteria from the orifice to the urethra
  • Teach patients to maintain adequate hydration

I believe that we can all provide some relief to the rate of antimicrobial resistance in regard to uncomplicated urinary tract infection by monitoring our individual practice and implementing basic education for patients to prevent urinary tract infections.

References:

Gums, J. To fight antibiotic resistance, we need to fight bad prescribing habits. The Conversation. June 21, 2016. To fight antibiotic resistance, we need to fight bad prescribing habits

Nazarko . Combating antibiotic resistance in urinary tract infection. Nurse Prescribing 2009: Vol 7 No10 P 450-455

Pallin DJ et al . Urinalysis in acute care of adults: pitfalls in testing and interpreting results. Open Forum Infec Dis March 2014:1 (1)

Stamm W E, Raz R. Factors contributing to susceptibility in postmenopausal women to recurrent urinary tract infections, Clinical Infectious Diseases, 1999, 28, 4, 723-725

US Centers for Disease Control and Prevention, CDC: 1 in 3 antibiotic prescriptions unnecessary. May 3, 2016.

[djmatte, ADN, MSN, RN, NP]

So nice to see serious articles around here.

Now here's a question and I'm not in a spot where I can look out up. I thought studies were showing direction of wiping had no relevance on increased UTI prevalence.

As for resistance, I think much of it comes down to knowing your practice region. I've never been wrong going with macrobid. But do see people still prescribing bactrim first line regularly and always see it not mentioned on cultures as sensitive.

[FullGlass, BSN, MSN, NP]

Primary care NP here. In my area, there is no sign of increasing antibiotic resistance for UTI. I always do C&S for suspected UTI and I have yet to see one come back that is resistant to everything.

[traumaRUs, MSN, APRN]

Per CDC guidelines:

Adult Treatment Recommendations | Community | Antibiotic Use | CDC

Use of your local antibiogram is also helpful

https://www.npjournal.org/article/S1555-4155(17)30635-9/pdf

That said, I work with an immunocompromised population and I often seen MDRO and am often forced to bring out the aminoglycosides.

[LubbDubb77, BSN, RN]

I really loved this article! I am not a nurse, I am currently a home health CNA, and enter into RN school in a few weeks. I personally have gone to urgent care with symptoms of a UTI and the NP there never collected specimen from me. The NP just asked some questions and then prescribed me Keflex. Was that wrong?

[ToFNPandBeyond]

I really loved this article! I am not a nurse, I am currently a home health CNA, and enter into RN school in a few weeks. I personally have gone to urgent care with symptoms of a UTI and the NP there never collected specimen from me. The NP just asked some questions and then prescribed me Keflex. Was that wrong?

Not necessarily. Some medical sources (i.e. EPOCRATES) will state that you can presumptively treat for UTI just based on symptoms alone. Though it's generally not how I practice, one would not be completely in the wrong based on the professional medical literature that is out there.

[djmatte, ADN, MSN, RN, NP]

I generally always culture a UA even if it's negative as long as the patient is symptomatic. While I generally strive to only prescribe abx with validated cultures, it isn't the be all end all.

[bbcewalters, NP]

I work in Sub Acute Rehab with 90% of my patient's 65 or older. I see resistance DAILY!! Per medicare we adhere to the recommended antibiotic stewardship and we do not treat a UA without a culture EVER. This does upset some families until you explain that perhaps grandma has been inappropriately treated the last 3 times and now they are resistant to most PO ABX. We also regularly talk about estrogen cream, cranberry caps, and florastor. We also tend to stop OAB meds that can contribute to UTIs. This was a great article in my opinion.

[mcaselogic]

Infectious Disease NP here practicing in South Florida - the amount of resistant UTIs we see here is insane. Patients from the community left and right showing ESBL organisms. I still see cipro given by primary care first line in the absence of a proper UA/C&S. Should also consider asymptomatic bacterurias that do not warrant treatment. A thorough clinical evaluation should be made before prescribing antibiotics. Also, urine colonization/contamination specifically in nursing home residents in simple indwelling urinary catheter replacement should do the trick.

If you're in Primary Care, don't be afraid to reach out to your ID consultant. Great article, hope more can find this useful.

[FullGlass, BSN, MSN, NP]

I wanted to add that I do treat UTIs based on symptoms. I always get a urine sample and always order a C&S even if the spot UA is negative. My experience is that the spot UA is not always accurate and misses a fair number of UTIs.