Urinary Tract Infections

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Presentation Transcript

Urinary Tract Infections (UTIs): 

Urinary Tract Infections (UTIs) Brooke Y. Patterson, PharmD, BCPS NU 7080 Advanced Pharmacology Research College of Nursing

Definitions: 

Definitions Asymptomatic bacteriuria High quantities of uropathogens Colony counts ≥105 CFU/mL on clean-catch specimen Absence of symptoms Acute cystitis Bacteriuria and symptoms Pyelonephritis Infection of renal parenchyma De novo or ascending bladder infection 2

Urinary Tract Infections in Women: 

Urinary Tract Infections in Women

Anatomy: 

Anatomy 4

Microbiology: 

Microbiology Uropathogens from fecal flora Predominately E. coli (80-85%) Staphylococcus saprophyticus Proteus mirabilis Klebsiella species Other causes in immunosuppressed or ‘complicated’ infections Candida MRSA 5

Pathogenesis: 

Pathogenesis Introduction of uropathogens to urinary tract Sexual intercourse Spermicide-containing contraceptives Diaphragm use Bacterial virulence Selective advantage Adhesins, fimbriae, hemolysin 6

Asymptomatic Bacteriuria: 

Asymptomatic Bacteriuria 2 consecutive clean-catch urine specimens in counts ≥105 CFU/mL Increased prevalence in certain populations Young, sexually active Diabetic women Elderly Patients with indwelling bladder catheter Urinary colonization? Decreased virulent strains 7

Treatment: 

Treatment NO measurable benefit to treatment in most groups 2005 IDSA guidelines recommend screening and treatment in the following settings ONLY: Pregnant women Prior to urologic procedures Young children with anatomical deformity (VCR reflux) 8

Acute Cystitis: 

Acute Cystitis Uncomplicated Healthy, young, non-pregnant female Complicated Anyone else Increased risk of failing therapy Infection that ascends urethra to bladder and stimulates a host response 9

Clinical Features: 

Clinical Features Dysuria Multiple etiologies including STIs/STDs, PID, vaginitis Frequency Urgency Suprapubic pain Hematuria Highly specific for UTI Non-specific complaints (elderly) 10

Urinalysis: 

Urinalysis Pyuria Cloudiness of specimen Leukocyte esterase positive (dipstick) Detection of pyuria Nitrite positive (dipstick) Detection of Enterobacteriaceae (fecal flora) Urine culture** 11

Treatment: 

Treatment 3-day short course regimens 1-day course no longer recommended Increasing fluoroquinolone-resistance among E. coli species Nitrofurantoin for patients with contraindication to TMP/SMX 7-day course necessary 12

Treatment: 

Treatment TMP-SMX 160/800 mg BID X 3 days 13 Nitrofurantoin macrocrystals 50mg QID X 7 days Fluoroquinolone X 3 days NOT moxifloxacin

Recurrent Cystitis: 

Recurrent Cystitis Reinfection vs. relapse Infecting strain Timing of infection (within 2 weeks) Prevention strategies Post-coital voiding Fluid intake Cranberry juice(?) Antimicrobial prophylaxis 2+/6 months OR 3+/12 months Post-coital, self-treatment, or continuous 14

Pyelonephritis: 

Pyelonephritis De novo or ascension of acute cystitis to kidneys Less common than cystitis Risk Factors Frequency of sexual intercourse UTI within previous 12 months Diabetes Stress incontinence New sex partner in last 12 months Recent spermicide use UTI history in patient’s mother 15

Clinical Features: 

Clinical Features Flank pain (right-sided) Nausea/vomiting Fever >38° Strong correlation Cystitis symptoms Dysuria Frequency Urgency Differentiate from pelvic pain 16

Diagnosis: 

Diagnosis Urinalysis Leukocyte esterase(+), pyuria, nitrite(+) White cell casts Signs and symptoms Urine culture and susceptibility 17

Treatment: 

Treatment High drug concentrations in kidney tissue correlated to cure Different treatment than cystitis Hospitalization vs. outpatient treatment Inability to maintain oral hydration Compliance issues Severe illness (high fever, pain, marked debility) Complicated infection (pregnant, elderly, males) Empiric therapy C/S guided treatment 14-day regimen 18

Treatment: 

Treatment Oral Fluoroquinolones NOT moxifloxacin, trovafloxacin TMP-SMX + amoxicillin NOT nitrofurantoin Parenteral Ceftriaxone Fluoroquinolones Gentamicin +/- ampicillin 19 Once culture and sensitivities are available—treatment should be pathogen-guided

Pregnant Women: 

Pregnant Women Drug safety Avoid TMP/SMX during 1st trimester Fluoroquinolones contraindicated Amox, cephalexin, nitrofurantoin OK 3-7 day course for acute cystitis Hospitalization for pyelonephritis IV therapy Avoid ceftriaxone 20

Urinary Tract Infections in Men: 

Urinary Tract Infections in Men

Pathogenesis: 

Pathogenesis Less common in men Less frequent colonization Increased length of urethra Antibacterial substances in prostatic fluid Complicated 15-50 year old men generally uncomplicated 22

Asymptomatic Bacteruria: 

Asymptomatic Bacteruria No treatment IDSA guidelines Before TURP Before urologic procedures 23

Acute Cystitis: 

Acute Cystitis Clinical manifestations similar to female Likely E. coli, however, broader spectrum suspected All men should be evaluated for causative factors Except young men Fluoroquinolone drug of choice 7-day regimens ONLY 24

Case: 

Case

Case: 

Case JW is a 34 yo WF with a h/o GERD, HTN, and hypothyroidism, who presents to clinic complaining of dysuria. Current Meds: Allergies: PCN (hives) HCTZ 25 mg QD Levothyroxine 100 mcg QD Ranitidine 150 mg BID Vitals: BP: 130/78 Pulse: 78 Temp: 99° F LMP 2 weeks ago; unprotected sex (+), 2 new sexual partners in last 2 months. 26

Case: 

Case Patient denies change in vaginal discharge, pelvic pain Notes that symptoms are similar to a couple of months ago when she went to a local urgent care center and was diagnosed with a 'kidney infection' Patient does not know what medication she was given, just remembers a 'big white pill that made my stomach hurt' UA color: Yellow (normal-yellow) pH: 6.0 (normal 4.5-7.5) specific gravity: 1.015 (normal 1.001-1.035) protein, ketones, glucose: negative (normal-negative) blood: trace (normal-none) nitrite: positive (normal-negative) leukocyte esterase: positive (normal-negative) 27

Case: 

Case What would be your initial choice for therapy in this patient? How long would you treat this patient for? What would you change if this patient was a man? If UA was normal….what would you do? 28