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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h Goals of Therapy

• Ameliorate symptoms in acute infections.

• Prevent recurrent infection.

• Prevent pyelomephritis in pregnancy.

Anas Bahnassi 2014

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h Investigations

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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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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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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h Investigations

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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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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h Recommended Empiric Treatment of UTI

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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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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h Therapeutic Tips

• 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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h Pharmacotherapy:

Infectious Diseases:

Anas Bahnassi PhD

abahnassi@gmail.com

http://www.twitter.com/abpharm

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http://www.linkedin.com/in/abahnassi Anas Bahnassi 2014