Australian Doctor Australian Doctor 7th September 2018 | Page 30

Grand Rounds
7 SEPTEMBER 2018 australiandoctor.com.au
Infectious diseases
PODCAST OF THE WEEK
THE EXAM ROOM
Cost Free
Source bit.ly/2wwdZ6U
HEALTHCARE, technology and
culture can be a winning com-
bination for a podcast, but
only if the producers can avoid
the traps of technobabble,
bureaucrat-speak and start-up
jargon.
The US podcast The Exam
Room does a good job of dodg-
ing these pitfalls in the hands
of paediatrician Dr Bryan
Vartabedian, who admits he’s
new to this podcasting gig.
The podcast’s strength is
choosing comprehensible top-
ics for discussion. Does the
use of computers contribute
to burnout? Should you let
patients can look at their med-
ical notes via a web portal? Is
it good form to take a photo
of a patient’s symptoms and
send it to other doctors?
Its weakness is relying on
people with confl icts of inter-
est to be guests. For example,
the discussion around why it’s
good for patients to view their
notes comes from the exec-
utive director of a company
that facilitates just that.
The majority of episodes
are still interesting, but it’s
those without the vested
interests that are most worth
your while.
Hard-to-
treat UTIs
They’re a common presentation in aged-care facilities,
but urinary tract infections are becoming increasingly
drug-resistant and many require precise pathology.
Dr Emma Tippett (top)
is an infectious diseases registrar at Eastern Health, Victoria.
Dr Lyn-li Lim (bottom)
is an infectious diseases and antimicrobial stewardship physician at
Eastern Health, Victoria.
J
UDITH is an 82-year-old woman from
a low-level care facility. Over the last
week, she has developed new urinary
incontinence and frequency. She has
a history of hypertension and osteoarthritis
and is allergic to nitrofurantoin (rash). Her GP
requests a mid-stream urine sample prior to
empirically starting cefalexin.
Subsequently, urine microscopy reveals
a white blood cell count of 200x10 6 /L (nor-
mal below 40x10 6 /L) and cultures Escherichia
coli, which is resistant to cefalexin as well as
ceftriaxone, norfl oxacin, nitrofurantoin and
trimethoprim.
When reviewed two days later, Judith
feels no better. Her observations are sta-
ble, and she is afebrile with heart rate and
blood pressure within normal range. Her
GP consults with a microbiology service for
treatment advice for mild cystitis related to
multidrug-resistant E. coli.
Discussion
Enterobacteriaceae are a family of gram-neg-
ative bowel commensals that include E.
coli and Klebsiella species and are common
causes of community acquired UTIs. Multid-
rug-resistance in Enterobacteriaceae is often
due to the production of extended-spectrum
beta-lactamases (ESBLs) or plasmid-mediated
AmpC enzymes rendering them resistant to
beta-lactam antibiotics. Injudicious antibi-
otic use is driving the selection of resistant
genes and plasmids that render commonly
used antibiotics ineff ectual. 1 These organ-
isms often carry high levels of resistance to
unrelated antibiotic classes, including fl uoro-
quinolones such as norfl oxacin, making anti-
biotic selection challenging. 2
Genetic material is readily transferred
between these organisms. Local transmission
of multidrug-resistant Enterobacteriaceae
between patients in aged-care facilities is
well documented. 3,4 Other risk factors include
travel to high-prevalence areas such as
South-East Asia in the previous six months,
prolonged hospitalisation, and recent or pro-
longed antibiotic use. 3,5
Clinical presentation
Symptoms of cystitis in the elderly include
fever, increased confusion, increased urinary
urgency, frequency or incontinence, suprapu-
bic tenderness, and haematuria. 5
Urine culture results should always be
correlated with clinical symptoms. Treat-
ing asymptomatic patients, with or without
an indwelling catheter, is unnecessary and
potentially associated with an increased risk
of adverse events, including the development
of multidrug-resistant UTIs and Clostridium
diffi cile infection.
Investigation
Collecting a good-quality urine specimen
prior to antibiotic initiation supports appro-
priate prescribing and allows de-escalation
from empiric to directed, narrow-spectrum
therapy. All patients residing in aged-care
facilities with symptoms of UTI should have
urine microscopy because of the increased
risk of infection caused by a multidrug-resist-
ant organism. 5
Management
Treatment for UTIs in patients in residential
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