Urinary Tract Infections

1. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Urinary Tract Infection
Anas Bahnassi PhD
Pharmacotherapy of Infectious Diseases
Anas Bahnassi 2014 A Case-Based Approach

2. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Goals of Therapy
•Ameliorate symptoms in acute infections.
•Prevent recurrent infection.
•Prevent pyelomephritis in pregnancy.
Anas Bahnassi 2014

3. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
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.

4. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
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.

5. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
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.

6. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
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

7. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
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.

8. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
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.

9. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
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

10. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
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

11. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
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

12. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
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…
$

13. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
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
$$$

14. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
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

15. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Pharmacotherapy: Infectious Diseases: Anas Bahnassi PhD
abahnassi@gmail.com
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Anas Bahnassi 2014