UTI (updated) Flashcards by Natalie Foo

Causative organisms in uncomplicated cystitis in women?

E. coli (> 85%)
Staphylococcus saprophyticus (5-15%)
Enterococcus faecalis
Klebsiella pneumoniae
Proteus spp.

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Causative organisms in complicated cystitis in women?

E. coli (~50%)
Enterococci
Proteus spp
Klebsiella spp
Enterobacter spp
P. aeruginosa

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Give an overview of all the abx used for uncomplicated cystitis

First-line:
- Nitrofurantoin

Otherwise:
- Amoxicillin-clavulanate
- Fosfomycin

High levels of local resistance, only use if supported by C&S results:
- Co-trimoxazole
- Ciprofloxacin

Alternatives (if all above are not possible):
- Cefuroxime
- Levofloxacin

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What is the first line empiric treatment, dosing and duration for uncomplicated cystitis?

C/I to this Tx?

PO nitrofurantoin 50mg QID x 3-5d

C/I in:
- Do not use if CrCl < 30mL/min
- Use with caution if CrCl 30–60 (benefits > risk)

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For uncomplicated cystitis, if the first line empiric Tx (nitrofurantoin) is not available, what are the other Tx options, dosing and duration?

PO amoxicillin-clavulanate 875/125mg BD x 5-7d (severe cases)
PO amoxicillin-clavulanate 500/125mg BD x 5-7d (mild-moderate cases)
PO fosfomycin 3g single dose

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PO amoxicillin-clavulanate 500/125mg x 5-7d (mild-moderate uncomplicated cystitis), what is the dosing for renal impairment?
(CrCl 10 to <30 mL/min and CrCl <10mL/min)

Dosing in CrCl 10 to <30 mL/min: PO amoxicillin-clavulanate 500/125mg 250–500mg BD
Dosing in CrCl <10mL/min: PO amoxicillin-clavulanate 500/125mg 250–500mg OD-BD

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Can we use fosfomycin in renal impairment?

Do not use if CrCl < 10mL/min and if pt undergoing HD

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For uncomplicated cystitis, what are the 2 other medications that have high local resistance, and should only be used if supported by C&S results

PO co-trimoxazole 800/160mg BD x 3d
PO ciprofloxacin 250mg BD x 3d

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What are some things to note about using PO co-trimoxazole for uncomplicated cystitis/ pyelonephritis? (hint: allergy)

Do not use in patients with sulfa drug allergy

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What are some things to note about using PO ciprofloxacin for uncomplicated cystitis/ pyelonephritis?

When possible, reserve FQs for more serious infections than acute uncomplicated cystitis.
But if used, advise pts about the uncommon but potentially serious MSK and neurological ADEs a/w it

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For uncomplicated cystitis, what are the last 2 abx we can use if all the first-line Tx are not possible?

PO cefuroxime 250 mg BD x 5-7d
PO levofloxacin 250mg daily x 3d

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What is the Tx duration for complicated cystitis?

And what is the dose for fosfomycin

Treat for longer duration of e.g. 7-14 days, fosfomycin dose: PO 3g EOD x 3 doses

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What are the treatment durations for UTI in pregnancy?

Treat 4-7 days for asymptomatic bacteriuria or cystitis

Treat 14 days for pyelonephritis

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What are the Tx options for UTI in pregnancy? (pick only the pregnancy-safe drugs!)

PO beta-lactams x 5-7d:
- PO cefuroxime 250mg BD
- PO amoxicillin-clavulanate 625mg BD

PO fosfomycin 3g single dose

PO co-trimoxazole 800/160mg bid x 3d (avoid in first and third trimester)
PO nitrofurantoin 50mg qid x 5d (avoided in first trimester and at term; 38-42 weeks)

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What are the causative organisms for community-acquired pyelonephritis in women

E. coli (> 85%)
Staphylococcus saprophyticus (5-15%)
Enterococcus faecalis
Klebsiella pneumoniae
Proteus spp.

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Give an overview of the Tx options for community-acquired pyelonephritis in women (not severely ill, not hospitalised)

First line:
- Amoxicillin-clavulanate

Cefuroxime

High levels of local resistance, only use if supported by C&S results:
- Co-trimoxazole
- Ciprofloxacin

Otherwise:
- Levofloxacin

Give an overview of the Tx options for community-acquired pyelonephritis in women (severely ill, requires hospitalisation and unable to take PO drug)

IV ciprofloxacin 400mg bid
IV cefazolin 1g q8h
IV amoxicillin-clavulanate 1.2g q8h
AND/ OR
IV/ IM gentamicin 5mg/kg
THEN
Switch to PO when pt improves/ able to take oral

In community-acquired pyelonephritis in women, what is the first-line Tx, dosing, and duration?

And what is the dosing in CrCl 10 to <30 mL/min and CrCl <10mL/min?

PO amoxicillin-clavulanate 875/125 mg BD x 10-14d

Dosing in CrCl 10 to <30 mL/min: 250–500mg BD
Dosing in CrCl <10mL/min: 250–500mg OD-BD

In community-acquired pyelonephritis in women, if the first-line Tx is not available, what are the other alternatives? Give the strength and duration.

PO cefuroxime 250-500mg BD x 7-10d

High levels of local resistance, only used if supported by C&S results:
- PO co-trimoxazole 160/800mg BD x 10-14d
- PO ciprofloxacin 500mg BD x 7d

PO levofloxacin 750mg OD x 5d

What are the causative organisms in community-acquired UTI in men?

E. coli (~50%)
Enterococci
Proteus spp
Klebsiella spp
Enterobacter spp
P. aeruginosa

For community-acquired UTI in men, what is the Tx duration?

Treat for 10-14 days, need longer duration if prostatitis is confirmed (6w)

For community-acquired UTI in men, what is the Tx regimen like for cystitis with NO concern for prostatitis?

Regimen as per complicated cystitis in women (but longer duration)

For community acquired UTI in men, what is the Tx regimen like for cystitis with concern for prostatitis?

PO ciprofloxacin 500mg bd
PO co-trimoxazole 160/800mg bd

What are the causative organisms for nosocomial/ healthcare associated UTI

Pseudomonas aeruginosa
Other resistant bacteria (ESBL-E. coli and ESBL-Klebsiella) should be considered and broad spectrum beta-lactam may be used

What is the definition of a nosocomial/ healthcare-associated UTI?

Nosocomial: UTI onset > 48h post hospital admission Healthcare-associated: pts hospitalised, underwent invasive urological procedures in last 6 months, indwelling urine catheter, exposure to abx etc

What is the Tx for nosocomial/ healthcare-associated UTI? Give dosing, duration.

Treat for 7-14 days - IV cefepime 2g q12h +/- IV amikacin 15mg/kg/d - IV imipenem 500mg q6h or IV meropenem 1g q8h - PO levofloxacin 750mg (for less sick pts) - PO ciprofloxacin 500mg bid (for less sick pts)

What are the causative organisms for catheter-associated UTI?

Pseudomonas aeruginosa Other resistant bacteria (ESBL-E. coli and ESBL-Klebsiella) Short term catheterisation (< 7 days) 85% single organisms Long term catheterisation (> 28 days) 95% polymicrobial (2-3 organisms)

What is the definition of catheter-associated UTI?

Definition: presence of UTI s/sx with no other identified source of infection along with 103 cfu/mL ≥ 1 bacterial species in pts with: - Indwelling urethral - Indwelling suprapubic - Intermittent catheterisation - Midstream voided urine specimen in pt whose catheter has been removed within past 48h

What are the risk factors for development of catheter-associated UTI?

- Duration of catheterization - Colonisation of drainage bag, catheter and periurethral segment - DM - Female - Renal function impairment - Poor quality of catheter care, including insertion

In catheter-associated UTI, do we treat for asymptomatic bacteriuria?

No, we only treat for symptomatic infection!

What is the Tx duration for catheter-associated UTI?

- Treat for 7 days if prompt resolution of s/sx (deferverse in 72h) - Treat for 10-14 days if delayed response

Non-pharmacological for catheter-associated UTI?

- Avoid unnecessary catheter use - Use for minimal duration - Long-term indwelling catheters changed before blockage is likely to occur - Use of closed system - Ensure aseptic insertion technique - Topical antiseptic or antibiotics not recommended - Prophylactic antibiotics and antiseptic not recommended - Chronic suppressive antibiotics is not recommended

What are some considerations regarding the catheter in catheter-associated UTI?

- Removal of catheter should always be considered - If an indwelling catheter has been in place for >2 weeks at the onset of CA-UTI and is still indicated, the catheter should be replaced to hasten resolution of symptoms and to reduce the risk of subsequent CA bacteriuria and CA-UTI.

In what situation for catheter-associated UTI do we not start abx Tx immediately?

If patient is stable and fever is low grade, consider observation rather than immediate antibiotics therapy

What are the abx Tx for catheter-associated UTI?

- IV imipenem 500mg q6h or IV meropenem 1g q8h - IV cefepime 2g q12h +/- IV amikacin 15mg/kg (1 dose or daily) - PO/ IV levofloxacin 750mg x 5d (mild CA-UTI) - PO co-trimoxazole 960mg bid x 3d (for women ≤ 65 y/o with CA-UTI without upper urinary tract s/sx after indwelling catheter has been removed)