Urinary Tract Infections Flashcards
What is the difference between a relapse and reinfection of urinary tract infection?
Relapse= recurrence with same organism (usually in prostate or kidney)
- within short period
Reinfection= recurrence with a new organism
- reoccurs after >2 weeks
What is acute uncomplicated UTI (cystitis)?
Occurs in women with normal genitourinary tracts.
What factors could increase the chance of cystitis?
- Genetics
- Sexual intercourse
- Spermicide use
- Diaphragm use
What are the usual symptoms of cystitis?
Frequency
Urgency
Suprapubic discomfort
What are the typical infecting organisms in acute uncomplicated cystitis?
E.coli (most common)
Staphylococcus saprophyticus
Klebsiella pneumoniae
Proteus mirabilis
What is acute non-obstructive pyelonephritis?
Infection that has spread to kidneys
What is classic presentation of pyelonephritis?
Fever
Flank pain with or without irritative urinary symptoms
Nausea and vomiting
What are typical infecting organisms for acute pyelonephritis?
E.coli (most common)
Klebsiella pneumoniae
Proteus mirabilis
What is complicated UTI?
Men with UTI
UTI in those with abnormal genitourinary tract (structural, functional, or catheter)
What is acute bacterial prostatitis? What symptoms are involved?
Tender, swollen, indurated (thickening or hardening), warm prostate
Fever, chills, perineal, and low back pain.
Is prostatic massage recommended for prostatitis?
No, can lead to bacteremia
What is chronic bacterial prostatitis?
Common cause of recurrent UTI in older men.
Prostate exam is usually normal
What is asymptomatic bacteriuria?
Microbiologic evidence of UTI in the absence of associated symptoms
We don’t usually need to screen for asymptomatic bacteriuria. However, which population is this practice indicated in?
Pregnant patients
Screen at 12-16 weeks
Urine culture are indicated for all types of UTI’s except?
Acute uncomplicated UTI
What are some non-pharms for UTI prevention?
Increase water intake (more studies needed) and avoid use of spermicidal products
When should antibiotic therapy be recommended for patients?
For all symptomatic patients regardless of symptom intensity
On that note, if patient chooses to delay therapy, acute uncomplicated UTI may become symptom free within ____ days without antibiotic use?
7 days
IS NSAID a good option for UTI treatment?
No, greater incidence of complications including pyelonephritis
What are first line therapies for acute uncomplicated UTI (including durations)?
- Nitrofurantoin x 5 days
- Septra x 3 days
- Trimethoprim x 3 days
- Fosfomycin x 1 dose
What are second line options for acute uncomplicated UTI (including durations)?
- Cephalexin x 7 days
- Ciprofloxacin, norfloxacin, levofloxacin x 3 days
What is first line treatments for mild to moderate pyelonephritis?
Ciprofloxacin or levofloxacin x 7-14 days
What are second line treatments for mild to moderate pyelonephritis?
- Septra PO x 10-14 days
- Trimethoprim PO x 10-14 days
- Amoxi-Clav PO x 10-14 days
What is first line treatment for severe pyelonephritis?
Aminoglycoside IV ± ampicillin x 10-14 days
If clinically appropriate, step down to oral
What are second line options for severe pyelonephritis?
- Ciprofloxacin or levofloxacin IV x 10-14 days
- Third-gen cephalosporin IV +/- aminoglycosides IV x 10-14 days
- Carbapenem IV x 7-14 days for ESBL- producing organisms
- Pip-taz IV x 7-10 days
- Amoxi/clav PO x 7-10 days
- Cephalexin PO x 7-10 days
What are first line options for mild to moderate complicated UTI?
- Nitrofurantoin PO x 7-10 days
- Septra PO x 7-10 days
- Trimethoprim POx 7-10 days
- Ciprofloxacin or levofloxacin PO x 7-10 days
What are second line options for mild to moderate complicated UTI?
Amoxi-clav PO x 7-10 days
Cephalexin PO x 7-10 days
Cefixime PO x 7-10 days
What are first line options for severe complicated UTI?
Aminoglycosides IV ± ampicillin for x 10-14 days.
If clinically appropriate, step down to oral.
What are second line options for severe complicated UTI?
- Ciprofloxacin or levofloxacin IV x 10-14 days
- Third generation cephalosporin IV x 10-14 days
- Carbapenem IV x 7-10 days (if ESBL possible)
- Pip-taz IV x 7-10 days
What are first line options for acute bacterial prostatitis?
Aminoglycoside IV ± cloxacillin ± ampicillin IV
What are second line options for acute bacterial prostatitis?
- Ciprofloxacin or levofloxacin IV or PO x 4 weeks
- Septra PO x 4 weeks
What is first line for chronic bacterial prostatitis?
Ciprofloxacin or levofloxacin PO x 4-6 weeks
What are second line options for chronic bacterial prostatitis?
Septra PO x 4-6 weeks
When is Septra a potential drug of choice?
Why is it’s use slowly decreasing?
If local rates of E.coli resistance is <20%.
Resistance is growing
Can patients with sulfa allergy use Septra?
No, they can use trimethoprim alone instead
When is nitrofurantoin contraindicated?
Pyelonephritis or if patient has CrCl < 60ml/min
What is the difference between Macrodantin and MacroBID?
Macrodantin
- Macrocrystals
- QID
MacroBID
- Macrocrystals/monohydrate
- BID
- better tolerated
When is fosfomycin recommended? Is it equally as effective as the therapies?
Acute uncomplicated UTI
Slightly less effective
Even though fluoroquinolones are just as effective, why do we reserve its use for patient with no other alternative treatment options?
Bacterial resistance and serious adverse effects
Reserve for complicated UTI or those with resistant organisms.
What are the cephalosporins that we use for treatment of UTI?
Cephalexin, cefuroxime, cefixime, cefazolin
Why do we not use them often for acute cystitis?
Not as well studied as the other options.
Somewhat less effective for acute cystitis
Greater likelihood of vulvovaginal candidiasis
Can cephalosporins be used for treatment of pyelonephritis? If so, what agents are used?
Yes if parenteral.
Ceftriaxone, cefotaxime, ceftazidime
Is amoxicillin used for treatment of uncomplicate UTI?
No, less effective.
Is amoxi-clav used used in UTI treatment?
Yes third line for uncomplicated UTI.
Aminoglycosides remain first choice for pyelonephritis requiring parenteral therapy. When do we switch back to oral therapy?
Total therapy is usually for 10-14 days.
Can switch back to oral once signs and symptoms have settled (72-96 hours)
What are severe side effects with aminoglycosides? Are they a concern with use in UTI?
Ototoxicity
Nephrotoxicity
Unlikely due to short duration of therapy
When do carbapenems come into play for UTI?
Severe UTI with suspected ESBL
What are risk factors for ESBL?
- Recent hospitalization
- Residence in a long-term care facility
- Prolonged use of broad spectrum antibiotics
- Travels to countries where strains are endemic
What does carbapenem have cross-reactivity with?
Penicillin
Are there any natural health products that benefit UTIs?
No. Cranberry has no evidence to prevent UTI.
What is asymptomatic bacteriuria?
Presence of bacteria in the urine in the absence of symptoms
Should we treat patients with asymptomatic bacteriuria?
No, does not reduce the development of symptomatic UTI or its complications
Which population should we treat asymptomatic bacteriuria?
Pregnant patients
What is considered recurrent urinary tract infections?
≥2 episodes of acute cystitis within 6 months or
≥3 episodes within 12 months
What are the three management strategies for rUTI?
1) Patient self-therapy
2) Post-coital prophylaxis
3) Long-term, low-dose prophylaxis
What is patient self therapy? When is it indicated?
Uncomplicated cystitis
Prescriber provides patient with a prescription to be started at the onset of symptoms
Any of the first or second line agents
What is post coital prophylaxis?
When is it indicated?
Repeated UTIs associated with intercourse
Single dose of antibiotic following intercourse
Any of the first or second line options
What is long-term, low-dose prophylaxis?
When is it indicated?
Low dose of antibiotics for 6-12 months
Nitrofurantoin 50-100 mg daily or Septra 200/40mg once daily
Which drug class do we avoid for long-term, low-dose prophylaxis?
Fluoroquinolones
For peri- and post-menopausal women with rUTI’s, what’s a therapy they can use?
Vaginal estrogen
When do we screen pregnant patients for asymptomatic bacteriuria?
Week 12-16 of pregnancy
What’s the risk of untreated bacteriuria in pregnancy?
Can progress to pyelonephritis and harm fetus
Once the pregnant patient has completed their course of antibiotics, how often are monitoring parameters?
Urine culture 1-2 weeks later and then monthly until baby is born
What medications are safe for the management of asymptomatic bacteriuria and cystitis in pregnancy?
- Nitrofurantoin (avoid near term due to risk of hemolytic anemia)
- Amoxi-Clav
- Cephalexin
- Fosfomycin
What is the treatment of choice for pyelonephritis in pregancy?
Ceftriaxone and then can step down to oral options like amoxi clav or cephalexin
What drugs should we avoid in pregnancy?
Fluoroquinolones
Septra and trimethoprim (first trimester)
Sulfamethoxazole (last 6 weeks of pregnancy)
Which drugs can be used breastfeeding for UTI?
Fluoroquinolones
Nitrofurantoin
Septra
Amoxicillin and cephalosporins
Which prophylaxis agents are safe for pregnancy and breastfeeding?
Nitrofurantoin and cephalexin
What patient factor makes it very likely to have candida albicans as the cause of UTI?
Indwelling catheter
Does ciprofloxacin need to be renally adjusted?
Yes, if patient has CrCl< 30mL/min. Needs to be renally adjusted. Not contraindicated.
Of the ertapenem (nuclear bombs), which has the most narrow spectrum?
Ertapenem
- Does not cover Enterococcus faecalis and Pseudomonas aeruginosa
