Urinary Tract Infections UTIs

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Urinary Tract Infections (UTIs)

• Brooke Y. Patterson, PharmD
• Clinical Assistant Professor of Pharmacy Practice
• January 17, 2005

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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

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Urinary Tract Infections in Women
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Anatomy
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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

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Pathogenesis

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

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Pathogenesis
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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

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Treatment

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

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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

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Clinical Features

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

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Urinalysis

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

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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

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Treatment

• TMP-SMX 160/800 mg BID X 3 days

Fluoroquinolone X 3 days NOT moxifloxacin
Nitrofurantoin macrocrystals 50mg QID X 7 days
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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

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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 patients mother

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Clinical Features

• Flank pain (right-sided)
• Nausea/vomiting
• Fever gt38
• Strong correlation
• Cystitis symptoms
• Dysuria
• Frequency
• Urgency
• Differentiate from pelvic pain

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Diagnosis

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

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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

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Treatment

• Oral
• Fluoroquinolones
• NOT moxifloxacin, trovafloxacin
• TMP-SMX amoxicillin
• NOT nitrofurantoin

• Parenteral
• Ceftriaxone
• Fluoroquinolones
• Gentamicin /- ampicillin

Once culture sensitivities are
availabletreatment should be pathogen-guided
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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

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Urinary Tract Infections in Men
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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

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Asymptomatic Bacteruria

• No treatment
• IDSA guidelines
• Before TURP
• Before urologic procedures

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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

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Case
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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 12/31/05 unprotected sex (), 2 new sexual
  partners in last 2 months.

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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)

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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?