Original Title: Guides et normes: Initier des mesures diagnostiques en présence de symptômes et signes suggestifs d’une infection urinaire (cystite et pyélonéphrite) et initier un traitement pharmacologique per os de première intention pour la cystite chez une personne âgée de 14 ans et plus

Authors' objectives: Urinary tract infections are among the most common bacterial infections in primary care settings. They are the eighth most common reason for ambulatory care visits and the fifth most common cause of emergency department visits in Canada. They are also among the most common infections in the elderly. Timely and optimal diagnosis and treatment are key to preventing complications. Nevertheless, the management and treatment of urinary tract infections can be fraught with issues such as differential diagnosis with other genitourinary causes, as well as suboptimal practices such as overdiagnosis and overtreatment (e.g., treatment of asymptomatic bacteriuria in the elderly). These types of practices contravene the principles of antibiotic governance and impact on the judicious use of resources, particularly in the laboratory. Faced with these issues, the Direction des soins et services infirmiers of the Ministère de la Santé et des Services sociaux asked the INESSS to develop recommendations within a national medical protocol, along with a collective prescription model, on the initiation of diagnostic measures in the presence of symptoms and signs suggestive of cystitis or pyelonephritis in an adult with a decline in functional autonomy. Following the publication of this protocol and the collective prescription model, the network called on the INESSS to make recommendations for individuals aged 14 and over, considering the high prevalence of this health condition, particularly on the front line. To meet this need, the Institute deemed it appropriate to conduct work and revisit the national medical protocol and the collective matching prescription model published in 2021. This work should support settings in implementing best practices and thus facilitate inter-professional work within family medicine groups in particular.

Authors' results and conclusions: RESULTS: (#1 SETTING AND WORK SCOPE): The clinical situation covered by the present work includes individuals 14 years of age and older with at least two symptoms or signs of recent onset, suggestive of cystitis or pyelonephritis. Any condition or situation that a priori requires special management or further investigation are excluded from the scope. These include urinary catheter use, anatomical or functional abnormality of the urinary tract, recent urinary tract surgery, immunosuppression, pregnancy, recurrence (early relapse or reinfection) of a urinary tract infection, hemodialysis, chronic renal pathology (e.g., kidney stone) and inability to take oral pharmacologic therapy. Symptomatology consistent with another health condition, such as unusual vaginal discharge, sexually transmitted disease, gynecologic pathology, prostatitis, orchiepididymitis or urinary retention, is also excluded. Finally, hemodynamic instability, suspected sepsis, significant impairment of general condition and contraindication to the use of all recommended first-line antibiotics are also excluded from the work scope. (#2 HEALTH STATUS ASSESSMENT): Health status assessment includes looking for such things as symptoms suggestive of urinary tract infection, health history, risk factors for urinary tract infection complication, breastfeeding, risk of antibiotic resistance and medication history. New-onset symptoms or signs suggestive of cystitis include burning, discomfort or difficulty urinating (dysuria), urgency, frequent urination (urinary frequency), suprapubic pain or discomfort, or blood in the urine (hematuria). New-onset symptoms or signs suggestive of pyelonephritis are fever, costovertebral (back) or flank discomfort or pain, or at least one of the symptoms or signs suggestive of cystitis listed above. Being male, having poorly controlled diabetes, i.e., a glycated hemoglobin greater than or equal to 8.5% or repeated hyperglycemia (fasting blood glucose greater than 10 mmol/L or postprandial blood glucose greater than 14 mmol/L), severe renal insufficiency (estimated glomerular filtration rate less than 30 ml/min/1.73 m2 ) or a history of urological maneuvering are risk factors for complications. They should be considered in the decision to resort to medical biology tests and also in the choice of the most appropriate treatment. Physical examinations should be considered according to the items collected in the health history and according to clinical judgment. An abdominal examination is clinically relevant in order to look for suprapubic pain on palpation or costovertebral pain, suggestive of a urinary infection. In case of suspicion of a situation excluded from the work scope, an abdomino-pelvic, testicular or prostatic examination is usually necessary. (#3 MEDICAL BIOLOGY TESTS): Medical biology tests include urinalysis (outside or in the laboratory) and urine culture. The results are interpreted in conjunction with clinical symptoms and signs and may reduce or increase the suspicion of a urinary tract infection. Medical biology tests are optional if there is a high pretest probability of acute uncomplicated cystitis and no high risk of antibiotic resistance or concern about the individual's health status (e.g., geriatric profile, living environment, incomplete history, inconclusive symptoms). For all other cases, the use of laboratory tests before initiating pharmacological treatment is clinically relevant to reinforce diagnostic suspicion (by checking bacteriuria, pyuria or hematuria), document the infection (pathogen, susceptibility) and appropriately select the antibiotic. The urine dipstick used outside the laboratory is a point-of-care test (POCT). In the outpatient setting, the use of a urine dipstick is a simple, rapid and relatively inexpensive means of assisting in the decision to initiate empirical therapy. Dipstick results alone do not confirm a urinary tract infection because of the possibility of false-positive or negative results; the clinical picture is key. In addition, for facilities that have easy access to a medical analysis laboratory, the use of a laboratory urinalysis is preferable in order to directly characterize the abnormalities detected on the urinalysis dipstick by microscopy and for the traceability of the results in the person's file. (#4 TREATMENT GUIDELINES FOR THERAPY): Tolerance of symptoms (mild to moderate), the person's general health, the ability to follow up promptly after receiving laboratory results and the risk-benefit balance are all part of the decision to delay treatment, pending progression of symptoms or laboratory results. First-line treatment choices for cystitis in women, with or without risk factors for complications, include nitrofurantoin, trimethoprim-sulfamethoxazole and fosfomycin. In the presence of contraindications to these antibiotics, beta-lactams are an alternative option, while fluoroquinolones remain an option of last resort in the presence of a history of severe allergic reaction to beta-lactams. In the presence of a risk factor for complication, the duration of treatment is longer compared to treatment of uncomplicated cystitis. Some treatments are contraindicated or should be used with caution during breastfeeding. The choice of antibiotic differs in men. Trimethoprim-sulfamethoxazole and fluoroquinolones are preferred options for first-line treatment, as their prostatic distribution is superior to that of other antibiotics. However, shorter treatment durations than may have been prescribed in the past are now the norm in many of the clinical practice guidelines consulted. Beta-lactams and nitrofurantoin are alternative options when contraindications to all first-line antibiotics are present. CONCLUSION: Unidentified or inadequately treated urinary tract infection has a significant impact on a person's quality of life by increasing the risk of complications, including hospitalization and even death. The present work contributes to the proper management of people with urinary tract infections by equipping clinicians to: • identify symptoms and clinical signs suggestive of a urinary tract infection; • identify clinical situations requiring biological tests, including the use of urine dipsticks in the ambulatory setting; • make decisions to delay initiation of antibiotic therapy; • choose the right antibiotic regimen to address current antibiotic resistance issues. Ultimately, however, the changes and harmonization of practice that may result from this work will depend on: • the dissemination of the national medical protocol; • the acceptance of these changes and the appropriation of the recommendations by the health professionals concerned; • the commitment of family medicine group managers, councils of physicians, pharmacists and nursing directors to adopt or adapt the INESSS collective prescription model in their institution, medical clinic or family medicine group; • the implementation of winning conditions that promote interprofessional work in the various care settings, particularly on the front line.

Authors' recommendations: At the end of the work and following an iterative process with advisory committee members, in which scientific data, information and recommendations from the consulted literature, contextual factors and the perspective of various stakeholders consulted were triangulated, a series of recommendations were formulated. Where relevant, recommendations for the care of older adults were specified. These recommendations are at the core of this report, and are also integrated into the clinical tools resulting from the work and intended primarily for front-line clinicians, namely: • a national medical protocol; • a collective prescription model. These tools are complementary to the optimal usage guide for urinary tract infection treatment.

Authors' methods: Details of the methodology used to complete this work are described in appendix A. In summary, a systematic search of the scientific literature published between January 2017 and September 2020 was conducted in the PubMed, Cochrane database of systematic reviews and Embase databases, followed by a search update to identify relevant new papers published through October 2022. Specifically, a targeted review was conducted to identify any updates to the literature selected as part of the work of the optimal usage guide for antibiotics in the treatment of adult urinary tract infections published in the fall of 2017 [INESSS, 2017]. A manual search of the grey literature was also performed by consulting, among others, the websites of learned societies specialized in the field related to the work theme. Document selection, information extraction and methodological quality assessment were performed independently by two scientific professionals. The references of the selected publications were also consulted to identify other relevant documents, including systematic reviews in support of the recommendations published in the clinical practice guidelines. In order to contextualize the practice in Quebec, a manual search of the literature was also conducted by consulting the websites of regulatory agencies, health technology assessment agencies, government organizations, professional associations and health care institutions. Official monographs for Health Canada-licensed antibiotics were searched using Health Canada's drug product database, or alternatively, the electronic Compendium of Pharmaceuticals and Specialties (e-CPS). The analysis and synthesis of the information collected was performed by one professional and validated by a second. This analysis was carried out from the perspective of contextualizing the practice in Quebec, based in particular on the legislative, regulatory and organizational context specific to Quebec and on the perspectives of the various stakeholders consulted. To gather the perspective of stakeholders, an advisory committee of clinicians with various specialties and expertise was created. Finally, the overall quality of the work, its acceptability and applicability were assessed by external readers who are specialists in the field of interest as well as future users who did not participate in the work.

Authors' identified further research: Situations that require special attention, reassessment or further investigation include, but are not limited to: • pharmacologic treatment of pyelonephritis; • a discrepancy between the symptomatology and the results of bio-medical analyses • persistence or worsening of symptoms • detection of serious adverse events or drug interactions following antibiotic treatment.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/protocoles-medicaux-nationaux-et-ordonnances-associees/infections-urinaires.html

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/protocoles-medicaux-nationaux-et-ordonnances-associees/infections-urinaires.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec