Urinary Tract Infections
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Urinary Tract Infection
Anas Bahnassi PhD
Pharmacotherapy of Infectious Diseases
Anas Bahnassi 2014
A Case-Based Approach
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Ph
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h Goals of Therapy
• Ameliorate symptoms in acute infections.
• Prevent recurrent infection.
• Prevent pyelomephritis in pregnancy.
Anas Bahnassi 2014
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Ph
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Anas Bahnassi 2014
Syndrome Most common pathogens
Microbiologic culture
Urine Culture
•Acute uncomplicated UTI: Occurs in females with normal genitourinary tracts.
• Females have genetic predisposition for recurrent UTI.
• Behavioral factors promote infections: (sexually active, use of spermicides and diaphragm)
• Symptoms: dysuria, frequency, suprapublic discomfort, and urgency.
• Recurrences common at variable frequency.
• E-coli (80-90%) • S.Saprophyticus
(5-10%) • K.pneumonae,
P.mirabilis, Group B Strep.
Presence of any quantitative count of G- organism or S.Saprophyticus in a voided urine specimen with pyuria.
Generally not recommended. Culture if : failed to empiric AB therapy. Early (<1mo) recurrence following therapy. Diagnostic uncertainty. Pregnant patient.
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Ph
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h Investigations
Anas Bahnassi 2014
Syndrome Most common pathogens
Microbiologic culture
Urine Culture
•Acute nonbstructive pyelonephritis: Occurs in females who also experience uncomplicated UTI but at lower frequency than cystitis.
• Fever and flank pain with or without irritable symptoms.
•Bactericemic infection occurs most in diabetic women or women >65y.
•UTI patients with lower tract symptoms or asymptomatic bacteriuria occasionally have associated occult renal infections.
• E-coli (80-90%) • P.mirabilis (5%) • K.pneumonae
(5%) • S.Saprophyticus
≥107 Cfu/L in voided urine specimin.
Always indicated Obtain before initiating AB therapy. Consider blood culture.
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Ph
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h Investigations
Anas Bahnassi 2014
Syndrome Most common pathogens
Microbiologic culture
Urine Culture
• Complicated UTI: Occurs in individuals with abnormal genitourinary tract due to structural or functional abnormalities including indwelling catherter.
• Patients may present with cystitis (lower tract) symptoms or fever/ pylonephritis.
•Management includes search for correctable abnormalities, recurrent infection is common (50% by 6wks post therapy).
• E-coli (50%) • P.mirabilis (20%) • E.faecalis (10%) • P.aerugenose,
P.stuartil, Citrobacter.
≥108 Cfu/L in voided urine specimin, or any quantitative count in catheterized specimen.
Always indicated Obtain before initiating AB therapy.
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Ph
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Anas Bahnassi 2014
Syndrome Most common pathogens
Microbiologic culture
Urine Culture
Bacterial prostatitis: Acute: due to E-coli, or S.aureus, symptoms include chills, fever, perineal and lower back pain, irritative and obstructive voiding. Prostate is tender, swollen, indurated and warm. Prostatic message not recommended, it may cause bacteremia. Chronic: uncommon, with age, cystic-like symptoms, history of recurrent UTI. Prostate examination is usually normal.
• E-coli (50%) • P.aerugenose • S.aureus •Others
• E-coli (80%) • Klebserella • P.aerugenose • Proteus
≥108 Cfu/L in voided urine specimin. Blood culture positive Aspirate prostate abscess, Meares-Starney test (triple-glass test. Urine/prostate secretion samples before and after prostate message.
Voided urine sample before empiric therapy. Urine culture with acute symptoms
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Ph
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h Investigations
Anas Bahnassi 2014
Syndrome Most common pathogens
Microbiologic culture
Urine Culture
Asymptomatic bacteriurea: Microbiologic evidence of UTI in the absence of symptoms. More common in women, with age. In pregnancy, screening should be performed at 12-15 wks.
• E-coli (60-70%) • P.mirabilis •Group B strep.
≥108 Cfu/L in 2 consecutive specimens.
Screening only recommended in pregnancy or before invasive genitourinary procedures.
• E-coli is the most common organism causing UTI. • Individuals with complicated UTI or recent exposure to AB may have other than E-coli.
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h Management of Recurrent, Uncomplicated Acute UTI
Anas Bahnassi 2014
Recurrent Infection (>2 in 6m or >3 in 12 m)
yes no
Treat individual episodes (self-therapy)
Consider
Short course self-therapy Post-intercourse
prophylaxis
One dose after sexual intercourse of: • SMX/TMP (220/40mg) • TMP 100mg • Nitrofurantoin 50mg • Cephalexin 125mg • Norfloxacin 200mg • Ciprofloxacn 250mg
Long-term prophylaxis
• SMX/TMP (220/40mg) QHS (daily or 3 d/wk)
• TMP 100mg QHS • Nitrofurantoin 50mg daily • Norfloxacin 200mg daily
Self therapy: 3 day of self administered
therapy on the appearance of
symptoms.
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Condition 1st line therapy 2nd line therapy
Acute uncomplicated UTI SMX/TMP po X3 days or TMP X3 days po or Nitrofurantoin po X7days
Fluroquinolone po X3 days Cephalexin po X7 days. Fosfomycin single dose
Pyelonephritis (Mild/Moderate)
Fluroquinolone po (10-14d) Amox/Clav (10-14d) or SMX/TMP (10-14d) or TMP (10-14d)
Pyelonephritis (Severe) Aminoglycoside iv ± Ampicillin iv (10-14d)
Fluroquinolone iv (10-14d) or 3rd Gen. Cephalospiron iv ± Aminoglycoside iv (10-14d)
Complicated UTI (Mild/Moderate)
Fluroquinolone po (7-10d) SMX/TMP po (7-10d) TMP po (7-10d) Nitrofurantoin po (7-10d)
Amox/Clav (7-10d)
Anas Bahnassi 2014
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Ph
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h Recommended Empiric Treatment of UTI
Condition 1st line therapy 2nd line therapy
Complicated UTI (Severe) Aminoglycoside iv ± Ampicillin iv (10-14d)
Fluroquinolone iv (10-14d) or 3rd Gen. Cephalospiron iv
Prostatitis (Acute) Aminoglycoside iv ±Cloxacillin iv ± Ampicillin iv (10-14d)
Fluroquinolone iv (10-14d) or po or SMX/TMP po (7-10d)
Prostatitis (Chronic) Fluroquinolone po X 4-8wk SMX/TMP po X 4-6 wks or TMP po X 4-6 wks
Anas Bahnassi 2014
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• Whenever possible, base initial selection of antimicrobial therapy on urine culture results.
• Antimicrobial susceptibility in population is dynamic. • Base selection of empiric therapy in symptomatic patients on
anticipated local antimicrobial suscseptibilies and an individual patient’s recent antimicrobial exposure and tolerance.
• Use parenteral therapy for patients who are septic, unable to tolerate oral medication, pregnant with pyelonephritis, or those with resistant organisms requiring parenteral therapy.
• Consider prophylaxis for women with frequent recurrent uncomplicated UTI.
• Without microbiologic confirmation of a bacterial infection, symptoms of chronic prostatitis are not an indication for antimicrobial therapy.
Anas Bahnassi 2014
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Penicillins Amoxicillin Amox/Clav
500mg po TID
Hyper-sensitivity reactions. GI effects
effects of OC. MTX levels.
$
1st Gen. Cephalosporins
Cefazolin Cephalexin
1g Q6H iv 500mg QID po
Hyper-sensitivity reactions. GI effects Renal and hepatic.
nephrotoxicity of aminoglycosides. INR with warfarin
$ 2nd Gen.
Cephalosporin Cefaclor 250mg
TID po
3rd Gen. Cephalosporin
Cefexime 400mg daily po
Nitrofuran derivatives
Nitro-furantoin
50-100mg QID po
HA, nausea, loss of appetitie, pulmonary and hepatic toxicity
absorption with iron/antacids. Etc…
$
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Fluro-quinolones
Cipro-floxacin Levo-floxacin
250-500mg po BID 250mg daily po
Abdominal pain, photosensitivity, dizziness, headache, GI effects. Potential ADR in developing cartlage avoid in children and pregnancy.
absorption with iron/antacids. Etc… INR with warfarin. Theophylline and Caffeine elimination.
$
Amino-glycosides
Amikacin 15mg/kg/d iv
Nephrotoxicity (reversible) increased with dose and duration. Ototoxicity (reversible)
Ototoxicity with loop diretic. Inactive if mixed with some penicillins
$$$
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Phosphoric acid derivatives
Fosfo-mycin
One 3g sachet
GI effects, vaginitis.
levels with meto-cloperaamide and propencid
$$
Sulfonamide derivatives
SMX/ TMP
800/160 mg po BID
GI effects, false in serum Cr, renal impairment, neutropenia, thrombocytopenia, anemia.
Phenytoin levels. INR with warfarin. Hypoglycemia with sulfonylurea. Nephrotoxicity with cyclosporin
$
Folate anatgonists
TMP 100mg BID po
Rash, pruritis. Phenytoin levels, Myelo-suppression with MTX
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Ph
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Infectious Diseases:
Anas Bahnassi PhD
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http://www.linkedin.com/in/abahnassi Anas Bahnassi 2014