Original Title: Infection urinaire chez une personne âgée de 14 ans et plus : repères diagnostiques, usage optimal des traitements de 1re et 2e intention et suivi

Authors' objectives: Urinary tract infections are among the most common bacterial infections in primary care settings. In fact, they are the eighth most common reason for outpatient consultations and the fifth most common cause of emergency room visits in Canada. They are also among the most frequent infections in the elderly. Faced with the challenges of differential diagnosis, antibiotic resistance and the sometimes inappropriate use of medical biology analyses, and given the publication in February 2023 of National Medical Protocol No. 888022 on the initiation of diagnostic measures in the presence of symptoms and signs suggestive of a urinary tract infection and first-line pharmacological treatment for cystitis in a person aged 14 and over, the Institute deemed it appropriate to revisit the optimal use guide for treatments of this infection published in 2017. This work is in line with the Institute's desire to formulate current recommendations that are consistent with the most recent scientific data and trends in good practice.

Authors' results and conclusions: RESULTS (#1 INFORMATION GATHERING IS THE CORNERSTONE OF CLINICAL MANAGEMENT ): The diagnostic approach is based primarily on a combination of symptoms and clinical signs suggestive of a urinary tract infection, information gathered from the patient's history and examination to assess the risk of complication of a urinary tract infection, medical biology tests, if indicated, and the exclusion of other health conditions sharing some of the symptoms or signs similar to those of a urinary tract infection. The physical examination is used to look for the presence of certain clinical signs suggestive of cystitis or pyelonephritis, and to rule out other health conditions. This examination should be considered on the basis of the health history and clinical judgment. The physical examination is particularly important in elderly patients or those with a geriatric profile, since they may have difficulty expressing their symptoms, or their symptoms may be masked or absent. (#2 APPROPRIATE USE OF MEDICAL BIOLOGY TESTS): On average, some 4.8 million urinalyses and 1.6 million urine cultures are conducted annually in Quebec laboratories, at an approximate annual cost of $12.6 million. For this work, the indications for the use of urinalysis and urine culture were re-examined. In particular, urinalysis is optional when there is a high pre-test probability of acute uncomplicated cystitis, and in the absence of a high risk of antibiotic resistance or concern about the person's health status (e.g., geriatric profile, unconvincing symptoms). In a person with an indwelling catheter, urinalysis is of little help in confirming the diagnosis of a UTI. Furthermore, due to persistent asymptomatic bacteriuria in these individuals, urine culture is generally of little clinical relevance, although it may be useful in some cases to identify the pathogen(s) and their antibiotic susceptibility when a clinical diagnosis of UTI is suspected. Moreover, screening for asymptomatic bacteriuria has no clinical relevance, except prior to urological procedures when mucosal trauma is anticipated, or for certain health conditions excluded from the present work (e.g., pregnancy, kidney transplantation). In all other cases, the use of medical biology tests prior to the initiation of pharmacological treatment is clinically relevant to reinforce diagnostic suspicion, document the infection, and appropriately select the antibiotic to be administered. (#3 PRESCRIBING ANTIBIOTICS RESPONSIBLY TO PREVENT RESISTANCE): Inappropriate or abusive use of antibiotics contributes to the spread of antibiotic resistance. Responsible prescribing includes identifying situations requiring such treatment. For example, asymptomatic bacteriuria should not be treated with antibiotics, except in rare cases. In the case of uncomplicated cystitis, the initiation of antibiotic treatment may be delayed depending on symptom tolerance, the patient's general state of health, the ability to follow up promptly after receiving laboratory results, and the riskbenefit balance. Since some cystitis is self-limiting, this strategy reduces the need for antibiotics while waiting for symptoms to evolve. (#4 TREATMENT CHOICES IN LINE WITH THE PRINCIPLES OF ANTIBIOTIC GOVERNANCE): In Quebec, Escherichia coli antibiotic resistance is a cause for concern for certain antibiotics commonly administered for the treatment of urinary tract infections - e.g., ciprofloxacin, trimethoprim-sulfamethoxazole (TMP-SMX). In view of the challenges associated with antibiotic resistance, and the consequent adverse effects of certain antibiotics, the first- and second-line treatment options and the preferred duration of treatment have been reviewed. (#5 PREVENTING RECURRENCES AND REDUCING ANTIBIOTIC PRESCRIPTIONS THROUGH EDUCATION AND AWARENESS-RAISING ): In cases of recurrent cystitis in women, adopting behaviours that can help reduce the risk of urinary tract infection is an important strategy for limiting recurrences. Nonantimicrobial preventive drug strategies are also available. According to current knowledge, the use of vaginal estrogens can reduce the frequency of UTIs in postmenopausal women with uncomplicated recurrent cystitis. On the other hand, current scientific data do not allow us to conclude with certainty that the use of cranberry-based products or intravaginal probiotics reduces the occurrence of urinary tract infections in women. (#6 FOLLOW-UP FOCUSED ON TREATMENT EFFICACY): Urine culture results are central to the person's follow-up, as they enable us to verify the sensitivity of the bacterial strain to the antibiotic prescribed. Once symptoms have been reassessed, treatment can be adjusted accordingly, using narrow-spectrum antibiotics wherever possible. (#7 SITUATIONS THAT MAY REQUIRE SPECIALIZED CARE): For the purposes of this work, the most critical clinical situations requiring hospital consultation were defined. For example, urinary tract obstruction in the presence of symptoms or signs of infection, complicated pyelonephritis, or risk factors for multiresistant enterobacteria, acute urinary retention, suspected sepsis, or the presence of systemic symptoms in a person with an indwelling urinary catheter should be considered. Situations requiring referral to specialist medicine have also been reviewed. (#8 ISSUES RAISED IN THE WORK): Choice of treatment dictated by antibiotic resistance – With resistance to first-line antibiotics predominating, the choice of treatment for urinary tract infections is becoming limited, leading to changes in practice such as the use of antibiotics with little evidence-based support, and the increasing use of parenteral treatments. • Heterogeneous and non-barrier-free access to local antibiotic resistance data – Although the prevalence of regional antibiotic resistance is relevant information to consider in the optimal choice of antibiotic in line with antibiotic stewardship principles, the complexity of accessing this information makes it difficult to apply, especially in the outpatient setting. CONCLUSION: An undetected or inadequately treated urinary tract infection has a major impact on a person's quality of life, increasing the risk of complications that can lead to hospitalization or even death. In addition, inappropriate use of laboratory tests can lead to overuse of antibiotics, with all the associated consequences, and to sub-optimal management of laboratory resources. Without taking the place of clinical judgment, the updated recommendations should support clinical assessment, promote the appropriate use of laboratory tests and optimal antibiotic selection in line with the principles of antibiotic stewardship.

Authors' methods: A systematic search of the scientific literature published between January 2017 and September 2020 was conducted in the PubMed, Embase and EBM Reviews - Cochrane Database of Systematic Reviews. Subsequently, relevant publications were monitored until the end of the project. A manual search of grey literature was also carried out, consulting, among others, the websites of learned societies specializing in the field related to the subject of the work. Document selection, information extraction, and methodological quality assessment were conducted independently by two scientific professionals. Official monographs on antibiotics approved by Health Canada were consulted, as were tertiary references in pharmacotherapy. The data and contextual information gathered were analyzed and synthesized by one professional, then validated by a second. This analysis was conducted to contextualize practice in Quebec, based in particular on volumetric data from the Centralab file of the Ministère de la Santé et des Services sociaux (MSSS), data on antibiotic resistance from Quebec establishments, aspects of the legislative, regulatory, and organizational context specific to Quebec, and the perspective of the various stakeholders consulted. To gather stakeholder perspectives, an advisory committee was set up, made up of clinicians from different specialties and areas of expertise. Population, clinical, organizational and economic dimensions were considered in assessing the totality of evidence. The identification of key clinical benchmarks and the formulation of recommendations were undertaken in collaboration with the members of the advisory committee. Finally, the overall quality of the work, its acceptability and applicability were assessed by external readers specializing in the field of interest, as well as future users who were not involved in the work.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/usage-optimal-des-traitements-dune-infection-urinaire-chez-les-personnes-de-14-ans-et-plus.html

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/usage-optimal-des-traitements-dune-infection-urinaire-chez-les-personnes-de-14-ans-et-plus.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: L'Institut national d'excellence en sante et en services sociaux (INESSS)