Henry

Question 1

What are important predisposing factors for the development of UTI

Answer 1

• Females:
  
  • Short urethral distance
  • acquisition of gut flora
  • chronic vaginal colonization seeds urethra
  • sexual intercourse displaces bacteria into the bladder
• strcutral abnormalities
• Obstruction.disruption of urine flow (kidney stones, tumors, pregnancy, prostatic hypertrophy)
• Instrumentation (CATHETERIZATION)

Question 2

Why is catheterization a predisposing factor for UTI

Answer 2

• Disrupts normal protective function of the bladder
• Introduction of bacteria
• contamination of the catheter drainage system
• duration of catheterization (risk Increase 3-5% each day of catheterization)

Question 3

what are important bacterial virulence factors:

pili/fimbriae

urease

hemolysin

capsule

Answer 3

• Pili or fimbriae
  
  • consists of pilins and adhesins that can facilitate attachment of host
• Urease
  
  • create a buffered microenvironment
• Hymolysin
  
  • toxins that disrupt eukaryotic cell membranes and causes cell lysin
• Capsule
  
  • polysacchardie structure that prevent phagocytes from engulfing bacteria

Question 4

Cystitis

Answer 4

Bladder or lower urinary tract infection

• dysuria (painful urination
• Increased frequency of urination
• feeling of urgency
• WBC’s and bacteria in urine
• hematuria (possible)
• FEVER IS ABSENT

Question 5

Pyelonephritis

Answer 5

(kidney or upper urinary tract infection)

• FLANK PAIN
• FEVER
• dysuria (painful urination)
• increased frequency
• feeling of urgency
• WBC and bacteria in urine
• hematuria (possible)

Question 6

Uncomplicated cystitis vs complicated cystitis

Answer 6

UNCOMPLICATED

• Healthy, ambulatory persone with no history suggestive of anatomical or functioanl abnormality
• DX made on the basis of typical symptoms
• resistance can be predicated
• TX: typical 5-14 days of antimicrobial agents

COMPLICATED:

• Other things going on: obstruction, strone, pregnancy, males, DIABETES
• DX is made on symtpoms or symptoms that are ATYPICAL and subtle (urinalysis and urine culture is indicated)
  
  • IMPAIRED SENSATION
• Multidrug can be common and LESS PREDICTABLE
• TX: longer tx strategy: broader spectrum drugs, more aggressive antibiotics

Question 7

Nitrofurantoin

Answer 7

• MoA: bacterial reduction of compound to generate DNA damaging intermediates (similar to metranizole)
• USE: FIRST LINE TX for UNCOMPLICATED CYSTITIS
• Adverse: nausea, diarrhea, headache, flatulence, rew ecological effects
  
  • ecological effects = knock down normal flora

Question 8

Trimethoprim/sulfamethoxazole (TMP-SMX)

Answer 8

• 1ST LINE TX OF UNCOMPLICATED CYSTITIS (93%) AND PYELONEPHRITIS (83%)
• MoA
  
  • Disrupt foalte metabolism (inhibits DNA synthesiis)
• Adverse
  
  • few ecological effects
  • folate deficiency
  • dermatological rxns (PHOTOSENSITIVITY)
  • rash
• Resistance to E.Coli is 20%

Question 9

Fosfomycin

Answer 9

• MoA: cell wall synthesis inhibitor
• 1st LINE AGENT in UNCOMPLICATED CYSTITIS (less efficacious as other drugs… TMP-SMX and Nitrofurantoin)
• Adverse (very few)
  
  • few ecological effects

Question 10

Ciprofloxacin

lecofloxacin

Answer 10

• MoA: DNA replication inhibitor by binding gyrase and topoisomerase
• 2nd LINE TX of UNCOMPLICATED CYSTITIS
• 1ST LINE TX of UNCOMPLICATED PYELONEPHRITIS
  
  • ciprofloxacin > levofloxacin
• Adverse:
  
  • RESISTANCE***
  • ecological effects –> gives rise to drug resistance, and knocks down normal microbacterial

Question 11

amoxicillin

Answer 11

• 2nd line agent in uncomplicated pyelonephritis
• 2nd line agent in uncomplicated cystitis (Beta-lactam)
  
  • failed with other agents first
• MoA: cell wall synthesis inhibitor
• Adverse:
  
  • nausea, omiting, diarrhea, rash
  • RESISTANCE can occur

Question 12

what are some non-pharmacological considerations

Answer 12

• Behavioral counseling (reduce some risk factors)
  
  • abstinence or reduction in frequency of sex
  • drink fluids, urination after sex, avoid tight fitting underwear, etx
• Cranberry juice –> no actual benefit
• topical estrogen –> topical estrogen normalizes the vaginal flora and reduces risk of recurrent UTIs
• Adhesion blockers –> Mannosides could block adhesion
  
  • D-mannose has not been evaluated in clinical trials

Question 13

Recurrent infection (acute cystitis)

Answer 13

Self-diagnosed/self-tx

• First-line antimicrobial reginmen is prescribed for future use
  
  • patient is advised to take it at onset of UTI symptoms
    
    • women previously diagnosed can accurately more than 85-95% of cases and successfully tx themselves

ANtimicrobial prophylaxis

• postcoital antimicrobial prophylaxis (single dose)
• Continous antimicrobial prophylaxis

Question 14

Key concepts:

Answer 14

• Fluoroquinolones (ciprofloxacin or levofloxacin)
  
  • NOT 1st line agents for tx of uncomplicated cystitis, but are used for uncomplicated PYELONEPHRITIS
• Key factors for making clinical decision is based on BACTERIAL RESISTANCE to antibiotics in a region and ECOLOGICAL ADVERSE EFFECTS such as selection for drug resistant pathogenic bacteria and suppression of normal flora
• COMPLICATED INFECTS are just that… complicated
  
  • tx is not predictable and requires longer duration of therapy
• High rate of successful self-diagnosis with RECURRENT INFECTIONS