Term
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Definition
Bacteria usually originate from the bowel flora
80-90% of community acquired infections are
caused by Escherichia coli
Others include Staphylococcus saprophyticus,
Klebsiella pneumoniae, Proteus spp.,
Pseudomonas aeruginosa, and Enterococcus spp.
Complicated infections are generally caused by
more resistant strains like Enterococcus spp.
Most UTI’s are caused by a single organism,
growth of multiple organisms may mean the
sample was contaminated |
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Term
| Three routes of entry to the urinary tract |
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Definition
Ascending: through the urethra
Descending: from the kidney through the ureters
Lymphatic: little evidence of this occurring |
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Term
| CLINICAL PRESENTATION IN Older adults |
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Definition
Often don’t experience urinary symptoms
Present with altered mental status
Change in eating habits
GI complaints |
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Term
| CLINICAL PRESENTATION IN Catheterized patients |
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Definition
Often won’t feel lower urinary symptoms but will develop
upper urinary symptoms |
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Term
| CLINICAL PRESENTATION IN Pediatrics |
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Definition
Infants: irritability, fever, refuse to eat
Young children: low-grade fever, N/V/D, just don’t feel well
Older children may c/o of abdominal pain, and painful
urination |
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Term
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Definition
Urinalysis
Bacterial counts
Pyuria
Hematuria
Proteinuria
Nitrite
Leukocyte Esterase |
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Term
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Definition
Gold standard testing involves a culture and sensitivity
The streak plate method is used in most diagnostic labs
After the bacteria is identified and quantified it is tested to determine sensitivity to different anti-microbials |
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Term
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Definition
In the primary care setting many use urine test
strips
Also available over the counter
Tests for nitrite and pyuria
Advantage: Faster results
Disadvantage: May not be accurate, no culture
Generally accurate for uncomplicated cystitis
Should do a culture if the patient has a hx of
infection, or has a recurrence
Treat empirically until culture results are
obtained |
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Term
|
Definition
Eradicate the micro-organism
Get rid of the symptoms
Prevent systemic consequences
Prevent the recurrence of infection |
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Term
1st Line Therapy Uncomplicated
Cystitis |
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Definition
Nitrofurantoin macrocrystals 100mg twice a day for 5d
TMP-SMX DS twice a day for 3d
Fosfomycin 3g in a single dose
3-7d depending on the drug chosen |
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Term
2nd Line Therapy Uncomplicated
Cystitis |
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Definition
Ciprofloxacin 250mg twice a day for 3d
Levofloxacin 250-500mg once a day
Beta-lactams for 3-7d
3-7d depending on the drug chosen |
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Term
1st Line Therapy Complicated
Cystitis |
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Definition
Ciprofloxacin or Levofloxacin preferred
7-14d |
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Term
| 1st Line Therapy Pyelonephritis |
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Definition
Uncomplicated: TMPSMX DS twice a day for 2wks or a fluoroquinolone for 2wks
Complicated: Broad spectrum i.e. pip/tazo or carbapenem plus vancomycin if MRSA suspected
14-21d depending on severity |
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Term
2nd Line Therapy Complicated
Cystitis |
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Definition
Broad spectrum Betalactams
7-14d |
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Term
| 2nd Line Therapy Pyelonephritis |
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Definition
Depends on C&S
14-21d depending on severity |
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Term
| UNCOMPLICATED CYSTITIS Choice of antibiotic |
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Definition
Choice of antibiotic
Patient allergy/adverse reactions
Compliance
Local resistance pattern (if known)
Ampicillin resistance is 20% or higher in all regions
Growing resistance to fluroquinolones and trimethoprimsulfamethoxazole
Spectrum of antimicrobial activity
IDSA guidelines have placed fluorquinolones as
second line placement to try to slow the growth of
bacterial resistance to these agents** |
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Term
| Nitrofurantoin Macrocrystals |
|
Definition
Macrobid
Common side effects: GI complaints, headache
Rare but serious adverse effects: Pulmonary toxicity,
Hepatic toxicity, Hemolytic anemia, Peripheral
Neuropathy
Administration: Take with food to increase
absorption and decrease side effects
Contra-indicated with CrCl <60ml/min?
Few serious drug interactions:
Interacts with birth control pills
Not used for pyelonephritis |
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Term
Trimethoprim 160mg/Sulfamethoxazole 800mg
DS |
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Definition
(Bactrim™ DS, Septra®DS)
Common side effects: GI complaints, rash, pruritis
Rare adverse effects: severe dermatologic reactions,
blood dyscrasias, and hepatotoxicity
Administer with 8oz of water with or without a meal
Dose adjust for renal impairment CrCl <30ml/min
use 50% of the normal dose, less than <15ml/min do not use. Use caution with hepatic impairment.
***Many drug interactions: warfarin (increases bleeding risk), birth control pills (back up contraception should be used) |
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Term
| Ciprofloxacin Levofloxacin |
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Definition
(Cipro®)(Levaquin®)
Common side effects: neurologic events (i.e. dizziness,
drowsiness), GI complaints, LFT’s increased
Serious adverse effects: QTc prolongation,
hepatotoxicity, tendon rupture
Administer without regards to meals but take 2h
before antacids or other products containing calcium,
iron or zinc – including dairy products. DO NOT
TAKE with MILK
Dose adjust for renal impairment
Drug interactions: Avoid combining with moderate to
high QTc prolonging agents (i.e. Sotolol), Multivitamins (take 2h before), warfarin (increases INR) |
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Term
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Definition
Recurrence 1-2wks after treatment – culture and treat with a broad spectrum agent such as levofloxacin
Recurrence 1month after treatment – treat as a
first time infection
Recurrence 1-6months after treatment – choose a different agent than originally used |
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Term
| PROPHYLAXIS OF RECURRENT CYSTITIS |
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Definition
A woman with 3 or more UTI in one year or 2 or
more in the past 6months, and non-antimicrobial
therapy was not effective
Rule out complications (i.e. calculi, cyst)
2 strategies
Post-coital antimicrobial prophylaxis – one dose of
antimicrobial as soon as possible after intercourse
Nitrofurantoin 50-100mg, TMP-SMX SS, Cephalexin
250mg
Continuous daily prophylaxis at bedtime
Nitrofurantoin 50-100mg, TMP-SMX 40/200mg,
Cephalexin 125-250mg, Fosfomycin 3g sachet every 10d |
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Term
| Self-diagnosis and self-treatment of cystitis |
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Definition
Women with previously diagnosed cystitis can accurately self-diagnose ~85-95%
Prescriber writes a prescription for future use, patient takes it when symptoms present
Less exposure to antimicrobials then with
prophylaxis
Must rely on the patient to be compliant a and not treat other infections with the prescription |
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Term
| ACUTE UNCOMPLICATED PYELONEPHRITIS |
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Definition
Presence of fever and flank pain – treat as pyelonephritis
Mild cases can be treated outpatient with oral
antibiotics
Moderate to severe cases (N/V, dehydration) should
be hospitalized and initiated on IV antibiotics
**Fluoroquinolones: Cipro 500mg BID or 1g daily
for 7d, Levofloxacin 750mg for 5d
TMP-SMX DS twice daily for 14d
Beta-lactams for 10-14d
After results of gram stain and C&S therapy can be altered if needed |
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Term
|
Definition
Parenteral Therapy with broad spectrum antibiotics aimed at potential UTI bacterium
IV Fluoroquinolone
Beta-lactamase inhibitor combination like
piperacillin-tazobactam
Add vancomycin if MRSA is suspected
14-21d of treatment
Adjust treatment based on C&S results
Once the patient is a-febrile can convert them over to oral therapy to complete two weeks of oral antibiotics |
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Term
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Definition
Generally occurs in those >60y/o
Is always considered complicated
Usually caused by catheterization, obstruction (BPH, calculi)
Require prolonged treatment – initially at least 10-14 days
***Treatment should not be started until C&S results are received
***Males should be re-cultured 4-6wks after treatment to ensure cure
TMP-SMX or fluoroquinolones have both been affective, tailor treatment to the pathogen |
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Term
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Definition
Physiologic changes increase the prevalence of UTI during pregnancy
Dilation of the renal pelvis and ureters
Decreased ureteral peristalsis
Reduced bladder tone
All of the above cause urinary stasis
In addition increased urine content of nutrients encourages bacterial growth
Asymptomatic bacteriuria occurs frequently and should be treated to avoid pyelonephritis
Amoxicillin, amoxicillin-clavulanate, or cephalexin are all safe choices for 7d duration
Nitrofurantoin, tetracyclines = teratogenic
Fluoroquinolones may inhibit cartilage and bone development
Follow up culture 1-2 wks after treatment and then monthly until gestation is recommended |
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Term
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Definition
The most common cause of hospital acquired infection
Reasonably preventable no longer reimbursed by CMS
Related to a variety of factors
Method and duration of catheterization
Patient risk factors
Insertion technique
Bacteria get to the bladder in a number of ways
Direct insertion during catheterization
Bacteria may travel up the catheter
Bacteria may get around the sheath that surrounds the catheter in the urethra
Sterile technique is key to prevention of infection
Duration of catheterization is also important
Patients with indwelling catheters acquire UTI’s 5%/day
After 30d the incidence of bacteriuria is ~80-95% |
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Term
| short term catheterization with bacteriuria |
|
Definition
Change the catheter
If the patient becomes symptomatic – remove the catheter and treat as a complicated UTI |
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Term
| Indwelling catheters – bacteriuria is inevitable |
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Definition
Treat symptomatic infections to prevent pyelonephritis (treat as a complicated UTI)
Re-infection occurs in 50%
Resistant organisms often develop
Should not use prophylactic antibiotics
Insert a new sterile catheter if the current one has been in for 2wks |
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Term
|
Definition
Key to treatment is early diagnosis and treatment
Choice of antibiotic and route of administration is determined by:
Age of the child
Severity
Location of infection
Complications
Antibiotic resistance
Main concern with UTI in children is renal scarring ocurring ~15%
Younger children may not have typical symptoms
Urine culture should be obtained prior to treatment
Urine culture in younger children may be obtained via catheter, while clean catch can be used in older children
Young infants, severe dehydration, vomiting, or unable to take oral medication should be hospitalized for IV therapy
IV antibiotics should be received for at least three days or until culture is negative, or symptoms are relieved
If able to tolerate oral therapy, may switch to an
oral regimen for 7-14d depending on severity
Children with first febrile UTI between 2-24mon
should have a renal bladder ultrasound (RBUS)
Assess for renal scarring
Rule out/in any urinary tract abnormalities i.e.
vesicoureteral reflux (VUR)
Children with recurrent UTI or abnormal RBUS should have further testing done |
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Term
|
Definition
UTI is the second most frequent infection in older adults
Physiologic changes i.e. decreased estrogen, BPH, other co-morbid conditions may contribute to the
prevalence
Because older adults may not be able to express symptoms it is difficult to distinguish between
asymptomatic bacteriuria (ASB) and UTI
ASB is frequently treated and leads to increasing resistance in this population
Pharmacists need to be vigilant in antibiotic stewardship to decrease the unnecessary tx of ASB
One proposed algorithm |
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