UTI 101: Antimicrobial agents, duration and prophylaxis April 30, 2012 Jennifer J. Schimmel, MD...

UTI 101 Antimicrobial agents duration and prophylaxis

April 30 2012

Jennifer J Schimmel MDBaystate Medical Center

Division of Infectious Diseases and Antimicrobial Stewardship

Objectives

bull Describe the agents used for treating bacterial urinary tract infections (UTIrsquos) and understand how to choose the most appropriate agent

bull Understand the appropriate duration of therapy and monitoring

bull Understand the options for prophylaxis of recurrent UTI

Background

bull UTI is one of the most common infections in the elderly in the community and in long-term care

bull Two problems overdiagnosis and overtreatmentbull Subsequent issuesndash C difficilendash Antibiotic resistance

bull Whatrsquos importantndash Proper diagnosisndash Appropriate antibiotic choice and duration

Defining the Problemsbull Lower UTI infection in bladder andor urethrabull Uncomplicated UTI lower UTI AND

ndash Not pregnantndash No urinary tract abnormalitiesndash No indwelling urinary device

bull Complicated UTI ndash Upper UTI (systemic symptoms extension beyond urethrabladder)ndash Functional or structural urinary tract abnormalityndash UTI in menndash Urinary catheter (CA-UTI)

ndash Older female patientsbull Many have functional or structural abnormalities

Microbiology in Nursing Homes

bull New Haven CT bull 5 Nursing Homes May 2005-2007bull 551 patients presumed UTI

Das R et al ICHE 200930(11)1116-1119

Case 1

bull 75 year old woman sp recent vertebral fracture in NH for past 2 weeks no prior UTIrsquos

bull Now several days of urinary frequency urgency burning

bull No fevers or back painbull Ua with significant pyuria bull Started empirically on ciprofloxacin

What to use empiricallybull Take into account most likely uropathogensbull Patient Factorsndash Other medicationsinteractionsndash Allergiesndash Other past infectionsndash Other medical problems (renal insufficiency Cdiff

etc)bull Threshold for failurebull Local epidemiologybull Cost

Antibiogram

bull Helps to determine best choices for empiric therapy

Case 1 Culture DataWhat can you do now

Collect date 041512 0835 Result Status Auth (Verified)Result Date 041712 0933

SPECIMEN DESCRIPTION URINE CLEAN CATCHMIDSTREAM

SPECIAL REQUESTS NONE

CULTURE gt100000 COLML ESCHERICHIA COLI TEST PERFORMED AT BAYSTATE MEDICAL CENTER SPRINGFIELD MA 01199

REPORT STATUS FINAL 04172012

ORGANISM gt100000 COLML ESCHERICHIA COLIMETHOD MIN INHIB CONC (MCGML)AMPICILLIN RESISTANTAMPICILLINSULBACTAM INTERMEDIATEAMOXICILLINCLAVULAN SUSCEPTIBLECEFAZOLIN SUSCEPTIBLECEFEPIME SUSCEPTIBLECEFTRIAXONE SUSCEPTIBLECIPROFLOXACIN SUSCEPTIBLEERTAPENEM SUSCEPTIBLEGENTAMICIN SUSCEPTIBLELEVOFLOXACIN SUSCEPTIBLEMEROPENEM SUSCEPTIBLENITROFURANTOIN SUSCEPTIBLEPIPERACILLINTAZOBAC SUSCEPTIBLETRIMETHSULFAMETHOX SUSCEPTIBLETETRACYCLINE SUSCEPTIBLE

Seeking the perfect antibiotichellipbull Needs to get into urinary tractndash And sometimes the prostate

bull Treat specific organismbull Narrowest spectrum possiblebull Minimize adverse effectsbull Avoid drug interactionsbull No allergybull Compliancebull Cost

bull Oral option

Case 2

bull 75 year old woman with well-controlled Crohnrsquos disease on mesalamine admitted with syncopal event

bull Found to have conduction abnormalitybull Allergy to penicillin (unknown)bull Has pacemaker placed (perioperative Clindamycin)bull 2 days after procedure still has unexplained

leukocytosis with WBC 13bull no obvious source of infection no urinary symptoms

no diarrhea CXR unremarkable ua with 1 wbc

Case 2

bull Urine culture pending at the time of discharge to rehab

bull What would be the next best stepA) Discharge on 5 days of Levofloxacin for possible UTIB) Follow off antibioticsC) Keep her in the hospital and repeat ua tomorrowD) Treat with Ceftriaxone 1g IV and additional antibiotics base on culture dataE) Treat with Tobramycin 5mgkg and additional antibiotics based on culture data

C diff-o-genicitybull High risk

ndash Carbapenemsndash 2nd ndash 4th generation

cephalosporinsndash Fluoroquinolones ndash Clindamycin

bull Medium riskndash Penicillinsndash 1st generation cephalosporinsndash Macrolidesndash Aztreonam

bull Low riskndash Aminoglycosidesndash Vancomycinndash Daptomycinndash Nitrofurantoinndash Linezolidndash Trimethoprim

sulfamethoxazolendash Tetracyclinesndash Rifampinndash Colistinndash Fosfomycin

Mullane et al Clin Infect Dis 201153440-447

Recommendations from the Guidelines

Uncomplicated UTI Lower Tract

Gupta K et al Clinical Infectious Diseases 201152(5)e103-120

Nitrofurantoin (Macrobid Macrodantin)

bull Minimal ldquocollateralrdquo damage

bull DRUG INTERACTIONSndash Minimalndash Concomitant administration

of a magnesium trisilicate antacid may decrease the absorption of nitrofurantoin

ndash Nitrofurantoin may reduce the effect of quinolone antibiotics

ndash Fluconazole increased risk of pulmonary and hepatic toxicity

bull Avoid if creatinine clearance less than 60ndash Due to potentiation of

adverse effectsbull Common side effects

nausea headachebull Other serious adverse

effects ndash Peripheral neuropathyndash Pulmonary hypersensitivity ndash Hepatoxicityndash Decreased renal functionndash Hemolytic anemia

Fosfomycinbull Issues

ndash Minimal resistancendash Minimal collateral damagendash High urinary levelsndash Prolonged bactericidal effectndash Minimal drug interactionsndash Not always availablendash Susceptibility data not

routinely availablendash Role for treatment of

resistant organisms such as ESBLrsquos VRE MRSA

ndash Maybe less effective than other short-course regimens

TrimethoprimSulfamethoxazoleTMPSMX (Bactrim)

bull DRUG INTERACTIONSndash Warfarinndash Methotrexatendash Fluconazole (incr QT)ndash TCA antipsychotics

antiarrhythmicsndash Antihyperglycemics

bull Common side effects nausea vomiting rash

bull Other serious adverse effects ndash Bone marrow suppressionndash Hepatic necrosisndash Severe rashndash Hyperkalemiandash Hypoglycemia (esp with renal

and liver disease)

bull Increased creatininehellipmay be falsely elevated

Quinolones Ciprofloxacin and Levofloxacin

bull Highly efficacious in a 3-day regimen

bull Numerous issues with collateral damage Cdifficile and resistance

bull Save for other usesbull Black Box Warning

tendonitistendon rupture esp over age 60 steroids transplant

bull Interactions ndash calcium aluminum magnesium

iron and zinc (antacids nutritional supplements multivitamin and mineral supplements) sucralfate

ndash Warfarinndash Antihyperglycemics

bull Other issues ndash QT prolongation esp in elderlyndash Decreased seizure threshold

Upper Tract Infection Acute Pyelonephritis

bull Not requiring hospitalization (and resistance less than 10)ndash Ciprofloxacin 500mg PO BID for 7 daysndash Ciprofloxacin 1000mg ER for 7 daysndash Levofloxacin 750mg for 5 days

ndash Bactrim DS BID for 14 days (if pathogen susceptible)

ndash Alternative initial IV antibiotic Ceftriaxone 1g IV or Aminoglycoside

ndash Alternative Oral -lactam (initial IV dose Ceftriaxone) and 10-14 days

bull Hospitalizedndash IV regimen

bull Fluoroquinolonebull Aminoglycoside +- ampicillinbull 2nd or 3rd generation cephalosporin +- aminoglycoside

bull Extended spectrum penicillin +- aminoglycosidebull Carbapenem


Catheter-Associated UTI (CA-UTI)

bull Most common health care-associated infection worldwide

bull 40 of hospital-acquired infectionsbull 5-10 of LTCF residents with long-term

indwelling cathetersndash Almost all have bacteriuriandash Single organism in short-term catheterndash Multiple organisms in long-term catheterization

Hooton TM et al Clinical Infectious Diseases 201050625-663

CA-UTI

bull Ecoli (30) Klebsiella species Serratia species Citrobacter species Enterobacter species Pseudomonas aeruginosa coagulase-negative staphylococci Enterococcus species

bull Long-term catheters the organisms above and Proteus mirabilis Morganella morganii Providencia stuartii

CA-UTIbull Duration

ndash Prompt resolution of symptoms 7 days

ndash Delayed response 10-14 daysndash Not severely ill 5 day Levofloxacin may be consideredndash Women aged 65 or under with CA-UTI and no upper tract symptoms

with removal of catheter consider 3 days of therapy

bull Other issuesndash De-escalationnarrowing of therapy as soon as possiblendash If catheter in place for gt2 weeks and is still needed catheter should be

replacedbull More rapid resolution of symptomsbull Decrease risk of subsequent CA-bacteriuria and CA-UTI


Case 3

bull 68 yo woman with poorly-controlled diabetes dysuria fever and chills

bull Prior history of UTIrsquos with resistant Klebsiellabull No allergiesbull WBC 18Kbull Cr 26bull Ua with gt182 wbc 2 rbc 1 sq epith cell

Limited Therapeutic Options URINE CULTURE Final Organism 1 KLEBSIELLA PNEUMO SSP PNEUMO COLONY COUNT gt100000 CFUml RESULT COMMENT DRUG RESISTANT

ORGANISM Drug Resistant Organism KLEBSIELLA PNEUMO SSP PNEUMO MULTIPLE DRUG RESISTANCE TRIMETHOPRIMSULFAMETHOXAZOLE R gt=320 AMPICILLIN R gt=32 AMPICILLINSULBACTAM R gt=32 CEFAZOLIN R gt=64 CEFOXITIN R gt=64 CEFTAZIDIME R gt=64 CEFTRIAXONE R gt=64 CEFEPIME R gt=64 CIPROFLOXACIN R gt=4 GENTAMICIN R gt=16 LEVOFLOXACIN R gt=8 IMIPENEM R gt=16 NITROFURANTOIN R gt=512 TOBRAMYCIN R gt=16 AMIKACIN R gt=64 PIPERACILLINTAZOBACTAM R gt=128

bull What are the antibiotic options in this casea) Noneb) Colistinc) Gatifloxacind) Ertapeneme) Other ideas

New FDA Antibiotic Approvals

Boucher HW et al Clinical Infect Diseases 2009481-12

Increasing Resistant Organisms

Answers

bull Colistinbull Tigecyclinebull Fosfomycin

Case 3 Part 2

bull Patient is treated with colistin has resolution of her symptoms leukocytosis and eventually improved renal function

bull Which of the following should be doneA) Repeat ua 7 days after therapy completedB) Repeat urine culture 7 days after therapy completedC) A and BD) Repeat ua and culture are not indicated

Test of Cure

bull Not routinely recommended

Case 4

bull 70 year old woman with 4 Ecoli UTIrsquos in the past 6 months urologist notes a mild cystocele and atrophic vaginal mucosa on exam

bull What do you recommendedA) NothingB) Bactrim DS BID indefinitelyC) Cranberry juice 8 oz dailyD) Topical estrogenD) Cipro 500mg weekly

Recurrent UTI Risk Factorsbull Post-menopausal

ndash estrogen deficiency ndash urogenital surgery ndash incontinence cystocele post-void residuals

bull Menndash Prostatic disease

bull Both Men and Womenndash Obstruction stones tumor

bull Complicated UTIndash MDRO obstruction stasis foley catheter stent diabetes pregnancy

renal failure transplant immunosuppression

Franco AV Best Pract amp Res Clin Obstet amp Gynec 200519(6)861-73

What else other than antibioticsbull Fluids to promote a dilute urine flow bull Topical estrogenndash In some postmenopausal women it can normalize the

vaginal flora and reduce recurrent UTIbull Methenaminebull Adhesion blockers (D-mannose)ndash Not evaluated in clinical trials

bull Drinking cranberry juice or cranberry tabletsndash Clinical Data Cochrane Review 2008ndash Recent studiesndash Pilot Study in LTC

Mayo Clinic Proceedings 2012 Feb87(2)143-50Recurrent urinary tract infection and urinary Escherichia coli in women ingesting cranberry juice daily a randomized controlled trialStapleton AE Dziura J Hooton TM Cox ME Yarova-Yarovaya Y Chen S Gupta KSourceDepartment of Medicine University of Washington Seattle USAAbstractOBJECTIVE To compare the time to urinary tract infection (UTI) and the rates of asymptomatic bacteriuria and urinary P-fimbriated Escherichia coli during a 6-month period in women ingesting cranberry vs placebo juice dailyPATIENTS AND METHODS Premenopausal women with a history of recent UTI were enrolled from November 16 2005 through December 31 2008 at 2 centers and randomized to 1 of 3 arms 4 oz of cranberry juice daily 8 oz of cranberry juice daily or placebo juice Time to UTI (symptoms plus pyuria) was the main outcome Asymptomatic bacteriuria adherence and adverse effects were assessed at monthly visitsRESULTS A total of 176 participants were randomized (120 to cranberry juice and 56 to placebo) and followed up for a median of 168 days The cumulative rate of UTI was 029 in the cranberry juice group and 037 in the placebo group (P=82) The adjusted hazard ratio for UTI in the cranberry juice group vs the placebo group was 068 (95 confidence interval 033-139 P=29) The proportion of women with P-fimbriated urinary E coli isolates during the intervention phase was 10 of 23 (435) in the cranberry juice group and 8 of 10 (800) in the placebo group (P=07) The mean dose adherence was 918 and 903 in the cranberry juice group vs the placebo group Minor adverse effects were reported by 242 of those in the cranberry juice group and 125 in the placebo group (P=07)CONCLUSION Cranberry juice did not significantly reduce UTI risk compared with placebo The potential protective effect we observed is consistent with previous studies and warrants confirmation in larger well-powered studies of women with recurrent UTI The concurrent reduction in urinary P-fimbriated E coli strains supports the biological plausibility of cranberry activity

Juthani-Mehta M et al Journal of the American Geriatric Socety 201058(10)2028-2030

What about for CA-UTIbull Reduce indwelling catheter usebull Remove catheters the as soon as they are no

longer clinically necessary

bull Cathetersndash Care

bull Insertion with aseptic techniquesterile equipmentbull Closed drainage systems with drainage bag and tube always

below bladder levelndash Antimicrobial coating

bull May delay onset of CA-bacteriuria in short-term


What about for CA-UTIbull Methenamine not recommended in long-term catheterization

ndash Data unconvincing that it is effectivendash May be effective with intermittent catheterization and short-term

catheterization (studied in specific population)bull Methenamine hippurate 1 g BIDbull Methenamine mandelate 1g 4 times daily

ndash And it may help to acidify urine when using these agents (Vit C)

bull Cranberryndash 34 double-blind placebo controlled trials no effectndash Studies are poor mostly negative

bull Antimicrobial prophylaxis can reduce CA-ASB but not CA-UTIndash Not recommended because of cost potential for adverse effects and

development of antimicrobial resistance


In Summarybull Decide if treatment is necessarybull Appropriate antibiotic and durationndash Choice based on patient (allergiescomorbiditiesprior

history) epidemiologic factors organismndash Minimize adverse effects minimize development of

resistance avoid Cdifficilebull Narrowest spectrum possiblebull If empiric therapy is more broad than needed narrow after

culture data bull Prophylaxisndash Several options that do not affect antimicrobial resistancendash Avoid antimicrobial agents if possiblendash If such an agent is chosen would re-evaluate after several

months

Questions

Referencesbull Barbosa-Cesnik C et al Cranberry Juice Fails to Prevent Recurrent Urinary Tract Infection Results from a

Randomized Placebo-Controlled Trial Clinical Infectious Diseases 201152(1)23-30 bull Beerepoot MAJ et al Cranberries vs Antibiotics to Prevent Urinary Tract Infections Archives of Internal

Medicine 2011171(14)1270-78 bull Beveridge LA et al Optimal Management of Urinary Tract Infections in Older People Clinical

Interventions in Aging 20116173-180 bull Boucher HW et al Bad bugs no drugs no ESKAPE An update from the Infectious Diseases Society of

AmericaClinical Infect Diseases 2009481-12 bull Das R et al Antimicrobial Susceptibility of Bacteria Isolated from Urine Samples Obtained from Nursing

Home Residents ICHE 200930(11)1116-1119bull Franco AV Recurrent Urinary Tract Infections Best Pract amp Res Clin Obstet amp Gynec 200519(6)861-73bull Gupta K et al International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis

and Pyelonephritis in Women A 2010 Update by the Infectious Diseases Society of America and the European Society of Microbiology and Infectious Diseases Clinical Infectious Diseases 201152(5)e103-120

bull Hooton TM Uncomplicated Urinary Tract Infection NEJM 20123661028-37bull Hooton TM et al Diagnosis Prevention and Treatment of Catheter-Associated Urinary Tract Infection in

Adults 2009 Internation Clinical Practice Guidelines from the Infectious Diseases Society of America Clinical Infectious Diseases 201050625-663

bull Jepson RG et al Cranberries for preventing urinary tract infections Cochrane Review 2008 bull Juthani-Mehta M et al Feasibility of Cranberry Capsule Administration and Clean-Catch Urine Collection

in Long-Term Care Residents Journal of the American Geriatric Socety 201058(10)2028-2030bull Mcmurdo MET et al Does Ingestion of Cranberry Juice Reduce Urinary Tract Infections in Older People in

Hospital A Double-Blind Placebo-Controlled Trial Age and Aging 200534256-261bull Mullane et al Clin Infect Dis 201153440-447bull Nicolle LE et al Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of

Asymptomatic Bacteriuria in Adults Clinical Infectious Diseases 200540643-54 bull Stapleton AE et al Recurrent Urinary Tract Infection and Urinary Escherichia coli in Women Ingesting

Cranberry Juice Daily A Randomized Controlled Trial Mayo Clinic Proceedings 201287(2)143-50

UTI 101 Antimicrobial agents duration and prophylaxis April 30 2012

Objectives

Background

Defining the Problems


Case 1

What to use empirically

Antibiogram

Case 1 Culture Data What can you do now

Seeking the perfect antibiotichellip

Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin

TrimethoprimSulfamethoxazole TMPSMX (Bactrim)




CA-UTI

Slide 28

Case 3

Limited Therapeutic Options


Answers

Case 3 Part 2

Test of Cure

Case 4

Recurrent UTI Risk Factors

What else other than antibiotics

Slide 38

Slide 40

What about for CA-UTI

Slide 43

In Summary

Questions

References

Objectives

bull Describe the agents used for treating bacterial urinary tract infections (UTIrsquos) and understand how to choose the most appropriate agent

bull Understand the appropriate duration of therapy and monitoring

bull Understand the options for prophylaxis of recurrent UTI

Background










Das R et al ICHE 200930(11)1116-1119

Case 1






Antibiogram











bull Oral option

Case 2





Case 2

































and liver disease)

























CA-UTI



CA-UTIbull Duration







Case 3









Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References

Background










Das R et al ICHE 200930(11)1116-1119

Case 1






Antibiogram











bull Oral option

Case 2





Case 2

































and liver disease)

























CA-UTI



CA-UTIbull Duration







Case 3









Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References







Das R et al ICHE 200930(11)1116-1119

Case 1






Antibiogram











bull Oral option

Case 2





Case 2

































and liver disease)

























CA-UTI



CA-UTIbull Duration







Case 3









Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References

Case 1






Antibiogram











bull Oral option

Case 2





Case 2

































and liver disease)

























CA-UTI



CA-UTIbull Duration







Case 3









Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References



Antibiogram











bull Oral option

Case 2





Case 2

































and liver disease)

























CA-UTI



CA-UTIbull Duration







Case 3









Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References










bull Oral option

Case 2





Case 2

































and liver disease)

























CA-UTI



CA-UTIbull Duration







Case 3









Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References

Case 2





Case 2

































and liver disease)

























CA-UTI



CA-UTIbull Duration







Case 3









Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References

Case 2

































and liver disease)

























CA-UTI



CA-UTIbull Duration







Case 3









Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References































and liver disease)

























CA-UTI



CA-UTIbull Duration







Case 3









Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References
























CA-UTI



CA-UTIbull Duration







Case 3









Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References

CA-UTIbull Duration







Case 3









Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References

Case 3









Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References







Answers


Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References

Case 3 Part 2



Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References

Test of Cure


Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References

Case 4


































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References
































months

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References

Questions
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References
















Objectives

Background



Case 1


Antibiogram



Case 2

Case 2

C diff-o-genicity


Slide 17



Fosfomycin





CA-UTI

Slide 28

Case 3



Answers

Case 3 Part 2

Test of Cure

Case 4



Slide 38

Slide 40


Slide 43

In Summary

Questions

References

UTI 101: Antimicrobial agents, duration and prophylaxis April 30, 2012 Jennifer J. Schimmel, MD...

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Transcript of UTI 101: Antimicrobial agents, duration and prophylaxis April 30, 2012 Jennifer J. Schimmel, MD...