UTI tx-Table 1 Flashcards
What is a UTI?
Presence of bacteria/yeast in uncontaminated urine
What is “significant” bacteriuria?
> 100,000/mL; can be lower in certain situations (abx, sx, complicated UTIs)
What differentiates complicated from uncomplicated UTI?
Complicated: presence of urinary tract abnormalities (males, pH, tumors, congenital, stones, catheter, reflux, retention, neuropathies)
What is reinfection vs relapse?
- Reinfection: new organism (majority of UTI’s)
* Relapse: same organism
What host factors affect UTIs?
•Gender differences
urethral length, moisture, estrogen, lactobacilli
•Mechanical - Diuresis
•Environmental
pH, osmolality, urea, organic acids
•Specific antibacterial substances
IgG, IgA (present in upper UTI)
Tamm-Horsfall protein (ascending loop)
Glycosaminoglycan (bladder)
Prostatic fluid
What are risk factors for UTI?
•Congenital abnormalities (UTIs in children)
•Incomplete voiding
•Urinary catheters
•Sexual activity (esp. in young women)
Spermicide use
•Decreased host defensesWhat organisms can cause UTI?
- E. coli
- Enterococcus spp.
- Klebsiella spp.
- Proteus spp.
- Enterobacter spp.
- Pseudomonas aeruginosa
- Staphylococcus aureus
- Coagulase negative staphylococcus
- Group B streptococci
What are symptoms of lower UTI?
Urgency, dysuria, frequency, nocturia, suprapubic tenderness/pain/heaviness, gross hematuria
What are symptoms of an upper UTI?
Lower tract symptoms, fever, +/- chills, flank pain, N/V
What are some pts that present atypically with UTI? How do they present clinically?
•Children
How is UTI diagnosed?
UA and culture
What indicates pyelonephritis?
hyaline or leukocyte casts
How are UTI tx?
•Acidification
Cranberry juice
Nitrofurantoin works better in acid environment
•Analgesics
Phenazopyridine (Pyridium)
100-200 mg PO TID after mealsx2days w/ABX
Avoid use if CrCl
What can increase the amount of drug needed to tx UTI?
Cation concentration- High concentration of Mg or Ca can increase aminoglycoside MIC against Gram-negative bacteria
What are the basics of acute uncomplicated UTI tx?
- Single dose regimens not recommended
- Initial urine culture not necessary
- If patient fails 3-day course then culture and treat for 2 weeks
- 7-day course recommended in pregnancy
What is the tx for an acute uncomplicated UTI with e coli resistance to TMP/SMX
TMP/SMX DS 1 PO BID x 3 days
What are alternative tx for pts with sulfa allergy?
- Nitrofurantoin (Macrodantin) 100 mg PO q6h X 5 days
* Fosfomycin 3 g powder as single dose
What is the tx for an acute uncomplicated UTI with e coli resistance to TMP/SMZ >20%?
- Ciprofloxacin (Cipro) 250 mg PO BID X 3 days
- Cipro ER 500 mg PO daily X 3 days
- Levofloxacin (Levaquin) 250 mg PO daily X 3 days
- Amoxicillin/Clavulanate 875/125mg BID X 5-7 days or an oral Cephalosporin (Cephalexin 500mg QID x 5-7 days)
Which of the above meds should be reserved for cases when other agents cannot be used?
The beta lactams- these are usually less efficacious and we want to avoid resistance
What meds should not be used to tx UTI?
gemifloxacin (Factive) or moxifloxacin (Avelox)
What is the typical pt presentation of acute uncomplicated pyelonephritis?
women 18-40 y.o, T>102°F, CVA tenderness
If you have an outpt (mild-moderately ill) pt with pyelo, what is your first line tx?
FQ PO X 7 days
•Ciprofloxacin 500 mg 1 PO BID, or Cipro ER 1000 mg 1 PO daily for 5-7 days
•Levofloxacin 750 mg 1 PO daily or Ofloxacin 400mg BID for 5-7 days
What should be your first line for uncomplicated outpt pyelo if there is FQ resistance?
Ceftriaxone 1gm or 5-7 mg/kg Gentamicin or tobramycin (if normal renal function) as one time dose
What are alternative tx for uncomplicated outpt pyelo?
14 days of…..
•Amoxicillin/clavulanate (Augmentin) 500/125 mg PO TID or 875/125 mg PO BID
•Cephalexin (Keflex) 500 mg PO QID- or other oral cephalosporin
•If an oral cephalosporin is used administer Ceftriaxone 1gm or 5-7mg/kg Gent or tobra as a one time dose
•TMP/SMX DS PO BID
How is uncomplicated pyelo in hospitalized pts tx?
IV until pt afebrile 24-48 hrs then PO to complete 14 days
What are the 1st line tx options for acute uncomplicated pyelo in a hospitalized pt?
FQ IV
•Ciprofloxacin 400 mg IV q12h
•Levofloxacin 750 mg IV daily
Ampicillin 2 g IV Q6H + gentamicin 5 mg/kg IV Q24H
Ceftriaxone (Rocephin) 1-2 g IV q24h
Piperacillin/tazobactam 3.375 g IV q8h ext inf over 4 h
What are alternative tx for the above pt?
- Piperacillin/tazobactam (Zosyn) 3.375 g IV q6h or 4.5 g IV q8h
- Ampicillin/sulbactam (Unasyn) 3 g IV q6h
- Ertapenem (Invanz) 1 g IV q24h
What constitutes a complicated UTI?
Obstruction, reflux, azotemia, transplant, male
How long should complicated UTI be tx?
2-3 weeks
How should the tx be administered in complicated UTI?
IV- switch to PO when afebrile for 24-48 hours
What are the 1st line tx options for complicated UTI ?
- Amp 2 g IV Q6H + gentamicin 5 mg/kg IV Q24H
- Pip/tazo 3.375 IV Q8h ext infusion
- Imipenem/cilastatin (Primaxin) 500 mg IV Q12H
- Meropenem 1gm IV q 8h
What are alternative tx for complicated UTI?
- Ciprofloxacin 400 mg IV Q12H
- Levofloxacin 750 mg IV daily (FDA approved for 5 days)
- Ceftazidime 2gm IV q 8h
- Cefepime 2gm IV q 12h
What should you switch to for PO tx of complicated UTI?
Fluoroquinolones (Cipro-ER 1000 mg PO QD, Levo 500 mg PO QD) or TMP/SMX DS 1 PO BID
How should recurrent UTI be tx?
Tx the uncomplicated UTI, then try one of the following options if they have >/= 3 UTI/yr
•Patient-initiated therapy: TMP/SMX DS 2 tabs at onset sx
•Postcoital prophylaxis: TMP/SMX DS 1 tab PO postcoitus or single dose nitrofurantion 100mg postcoitus- if you are sarah M this could be up to 20x a day ;)
•Continuous prophylaxis: TMP/SMX SS 1 PO QDay long term
Is screening and tx for asymptomatic bacteriuria recommended in most pts?
NO
When should you screen for bacteriuria in pregnancy?
1st trimester then periodically
Why should you screen in pregnancy?
- 20-30-fold increase in rate of pyelonephritis
* Increased risk of premature delivery and low birth weight
How long should you tx asymptomatic bacteriuria in preggos?
Treat for 3-7 days
•Amoxicillin/clavulanate (Augmentin) 875/125 mg PO BID
•Nitrofurantoin (Macrodantin) 100 mg PO QID
•Cephalexin (Keflex) 500 mg PO QID
•TMP/SMX (Bactrim) DS 1 PO BID (avoid within 2 weeks of delivery)
What is urethral syndrome?
UTI symptoms without significant bacteriuria
How common is urethral syndrome?
40% of young women have this
What are the common organisms that cause urethral syndrome?
Chlamydia trachomatis, N. gonorrhoeae, G. vaginalis, U. urealyticum, and chemical irritation also possible
What is the tx for urethral syndrome?
Standard tx for uncomplicated UTI
If gonococcal: Ceftriaxone 250mg IM X 1 dose + Azith 1gm po x 1 dose or Doxycycline 100mg po q 12h X 7 days
If non-gonococcal and symptoms persist: Metronidazole 2gm po single dose or azithromycin (1 gm X 1)
What are the causative organisms in short-term cath (
•Yeast (~32%)
•E. coli (12-29%)
Coag-negative Staph (23-26%)
What are the causative organisms in long-term cath (>30 days) associated UTIs?
•Proteus Mirabilis (10-60%)
•Providencia spp.(~50%)
•Pseudomonas (10-60%)
E. coli (18-35%)
How do you tx nosocomial/catheter associated UTI?
Tx for 7 days if prompt resolution of symptoms and 10-14 days if delayed response
Start with IV then switch to PO as symptoms/course allows
If a pt
•N. gonorrhoeae, C. trachomatis
tx for 10days
What should you tx the above pt with?
- Risk STD: Ceftriaxone 250 IM X1 dose or cefixime 400mg po x 1 dose + doxycycline 100 mg PO BID x 10days
- Low risk STD- as below Cipro or levofloxacin or TMP-SMX
If a pt >35 presents with prostatitis, what organism should you suspect and how long should you tx/
•Enterobacteriaceae
tx for 10-14 days
What meds should you tx the above pt with?
- Cipro ER 500 mg PO BID or 400 mg IV BID
- Levofloxacin 500-750 mg IV/PO Qday
- TMP/SMX DS 1 PO BID
If there is resistant enterobacteriaceae in the above pt what can you use to tx instead?
Ertapenem 1gm IV q day for at least 2 weeks (may continue for up to 4 weeks)
If there is resistant pseudomonas in the above pt what can you use to tx instead?
Imipenem/ cilastin 500mg IV q 6h or meropenem 500mg IV q 8h for 4 weeks
What are the main organisms in chronic prostatitis?
Enterobacteriaceae 80%, enterococci 15%, P.aeruginosa
How is chronic prostatitis tx?
- Ciprofloxacin 500 mg PO BID X 4 wks
- Levofloxacin 500 mg PO QD X 4 wks
- TMP/SMX DS 1 PO BID X 1-3 months
