UTIs Flashcards
Clinical Presentation of Cystitis (bladder)
- Irritative voiding symptoms (frequency, urgency, dysuria)
- Gross hematuria (blood in urine)
Clinical Presentation of Pyelonephritis (kidney)
- Fever, flank pain, shaking, chills
- N/V
- Irritative voiding symptoms (frequency, urgency, dysuria)
- Gross hematuria (blood in urine)
- CVA tenderness
Atypical Presentation of UTI in Elderly
- Altered mental status
- Change in appetite
- GI sxs
- Incontinence
Macroscopic Urinalysis (UA)
- Leukocyte esterase: detects presence of WBC, pyuria (pus in urine)
- Nitrites: detects bacteria that reduce nitrate to nitrite (Enterobacteraceae)
- pH: alkaline urine (pH 8.5-9) can mean presence of urease-producing bacteria (Proteus, Klebsiella)
Microscopic Urinalysis (UA)
- WBC: >5-10 suggests pyuria
- Presence of Bacteria: urine is normally sterile, so any bacteria in urine can mean UTI
- Squamous Epithelial Cells: Normal is 0-5 (clean catch), higher indicates a contaminated sample
Most Common Pathogen Causing UTI
E. coli
Uncomplicated UTI
- Occurs in healthy, non-pregnant, non-immunocompromised women
- Caused by a single pathogen
Complicated UTI
- Anything that is not “uncomplicated” (males, pregnancy, immunocompromised, etc.)
- Often caused by multiple pathogens
First-Line Agents for Treatment of Uncomplicated Cystitis
- Nitrofurantoin (Macrobid)
- Trimethoprim/Sulfamethoxazole (Bactrim)
- Fosfomycin
Nitrofurantoin Duration for Uncomplicated Cystitis
5 days
Nitrofurantoin Spectrum of Coverage
- Staphylococcus saphrophyticus
- Enterococci (including VRE)
- E. coli (including ESBL)
Can nitrofurantoin be used in pyelonephritis and prostatitis?
No
Nitrofurantoin Renal Cutoff
Avoid in CrCl < 30
Nitrofurantoin ADRs
- Acute pulmonary sxs (onset: hours to weeks)
- Pulmonary fibrosis (>6 months)
Nitrofurantoin in Pregnancy
Safe in pregnancy EXCEPT at term (38-42 weeks)
TMP/SMX Duration for Uncomplicated Cystitis
3 days
TMP/SMX Spectrum of Coverage
- Staphylococcus saphrophyticus
- E. coli
Can TMP/SMX be used in pyelonephritis and prostatitis?
Yes
When to avoid TMP/SMX
- If local E. coli resistance > 20%
- If used for UTI in previous 3 months
TMP/SMX ADRs
- Rash
- Hyperkalemia
- Bone marrow suppression
TMP/SMX in Pregnancy
AVOID in 1st and 3rd trimester
Safe in 2nd trimester
Fosfomycin Duration for Uncomplicated Cystitis
1 dose
Fosfomycin Spectrum of Coverage
- Enterococcus faecalis (including VRE)
- E. coli (including ESBL)
Can fosfomycin be used in pyelonephritis?
No
Fosfomycin ADRs
- Diarrhea
- Nausea
- Dyspepsia
Fosfomycin in Pregnancy
Safe in pregnancy (even at term)
Second Line Agents for Uncomplicated Cystitis
Beta-lactams
Beta-Lactams Duration for Uncomplicated Cystitis
3-7 days
Beta-Lactams in Pregnancy
Drug of choice for uncomplicated cystitis in pregnancy
How to predict susceptibility of PO cephalosporins for UTI due to E. coli, Klebsiella, and Proteus?
- Use cefazolin susceptibility as predictor
- If cefazolin is susceptible, can use any generation of PO cephalosporin
- If cefazolin is not susceptible, can not use any PO cephalosporin
Last Line Therapy for Uncomplicated Cystitis
Fluoroquinolones
Fluoroquinolone Duration of Therapy for Uncomplicated Cystitis
3 days
When to avoid fluoroquinolones
If local E. coli resistance > 10%
Fluoroquinolones BBW
- Tendonitis/tendon rupture
- Peripheral neuropathy
- CNS effects
Fluoroquinolones in Pregnancy
AVOID in any trimester
Complicated Cystitis Duration of Treatment
10-14 days
Catheter-Associated UTI
- Asymptomatic patients: do NOT treat
- Symptomatic patients: remove/change catheter and treat for 10-14 days (if prompt resolution of sxs, 7 days of treatment)
- May present with non-specific sxs: fever, pelvic discomfort, altered mental status
Cystitis in Pregnancy
- ALWAYS treat both asymptomatic and symptomatic infections
- DOC: beta-lactams (amoxicillin, Augmentin, cephalexin)
- May consider Bactrim or Nitrofurantoin in 1st trimester if no other suitable alternatives
- AVOID fluoroquinolones
First-Line Agents for Outpatient Treatment of Pyelonephritis
- Ciprofloxacin
- Levofloxacin
- TMP/SMX DS
Ciprofloxacin Duration for Pyelonephritis
7 days
Levofloxacin Duration for Pyelonephritis
5 days
TMP/SMX Duration for Pyelonephritis
14 days
Clinical Pearls of Ciprofloxacin and Levofloxacin for Pyelonephritis
If local E. coli resistance > 10%, give one dose of IV antibiotic (such as ceftriaxone or gentamicin)
Clinical Pearls of TMP/SMX DS for Pyelonephritis
If local E. coli resistance > 20%, give one dose of IV antibiotic (such as ceftriaxone or gentamicin)
First-Line Agents for Inpatient Treatment of Pyelonephritis (with NO risk for drug resistance)
- Ceftriaxone IV
- Ciprofloxacin IV
- Levofloxacin IV
- Gentamicin IV
- Tobramycin IV
Duration of Inpatient Treatment of Pyelonephritis (with NO risk for drug resistance)
7-14 days
Clinical Pearls of Ceftriaxone for Pyelonephritis
Active against enterobacteraceae
Clinical Pearls of Ciprofloxacin and Levofloxacin for Pyelonephritis
Consider if E. coli resistance rates < 10%
Gentamycin and Tobramycin Clinical Pearls for Pyelonephritis
- No gram-positive coverage
- Add ampicillin if concerned about enterococcus
First-Line Agents for Inpatient Treatment of Pyelonephritis (with risk for drug resistance)
- Piperacillin/tazobactam (Zosyn)
- Cefepime
- Ertapenem
- Meropenem
Duration of Inpatient Treatment of Pyelonephritis (with risk for drug resistance)
7-14 days
Clinical Pearls of Piperacillin/Tazobactam for Pyelonephritis
Broad coverage, including Enterococcus, PEK, and Pseudomonas
Clinical Pearls of Cefepime for Pyelonephritis
- Broad coverage, including PEK and Pseudomonas
- No activity against Enterococcus
Clinical Pearls of Ertapenem for Pyelonephritis
- DOC for ESBL-producing Enterobacteraceae
- NO activity against Enterococcus or Pseudomonas
Clinical Pearls of Meropenem for Pyelonephritis
Broad coverage, including Enterococcus, ESBl-producing Enterobacteraceae, and Pseudomonas
Asymptomatic Bacteriuria
Presence of bacteriuria in patient without symptoms of UTI
When to Treat Asymptomatic Bacteriuria
Do NOT treat unless:
- Pregnant
- Undergoing urological surgical procedure associated with mucosal trauma
Treatment of Asymptomatic Bacteriuria in Pregnancy
- DOC: beta-lactams
- Duration: 4-7 days
Treatment of Asymptomatic Bacteriuria in Urological Surgery
Give 1-2 doses of antimicrobial 30-60 mins before procedure
Recurrent UTI
- At least 2 UTIs within 6 months
- At least 3 UTIs within 1 year
Reinfection
- Caused by a different organism
- Majority of recurrent UTIs
Relapse
Caused by the same initial organism
Lifestyle Modifications for Recurrent UTIs
- Change contraceptive method if using spermicides
- Postcoital voiding
- Do not routinely delay voiding
- After voiding, wipe front to back
- Increase daily water intake to at least 1.5 L
Is cranberry recommended for UTI?
No
Antimicrobial Prophylaxis for Recurrent UTI
May be considered if all non-pharmacologic strategies attempted/considered
Drugs used for Antimicrobial Prophylaxis of Recurrent UTI
- TMP/SMX
- Nitrofurantoin
- Cephalexin
- Given at half the dose of normal tx dose
Continuous Prophylaxis of Recurrent UTI
Taken daily for up to 6-12 months
Postcoital Prophylaxis of Recurrent UTI
Single dose taken after sex
Most Common Pathogen causing Bacterial Prostatitis
E. coli
Risk Factors for Bacterial Prostatitis
- Hx of lower UTI
- Urinary instrumentation (catheter)
- Urethritis
Clinical Presentation of Acute Bacterial Prostatitis
- Fever, chills, N/V
- Pain in urogenital regions
- Urinary sxs
Clinical Presentation of Chronic Bacterial Prostatitis
- Pain in urogenital regions
- Urinary sxs
- Sexual dysfunction sxs
Drugs for Treatment of Acute Bacterial Prostatitis
- Ciprofloxacin
- Levofloxacin
- TMP/SMX DS
Duration of Treatment of Acute Bacterial Prostatitis
6-8 weeks
Drugs for Treatment of Chronic Bacterial Prostatitis
- Ciprofloxacin
- Levofloxacin
- TMP/SMX DS
+ Alpha Blockers
Duration of Treatment of Chronic Bacterial Prostatitis
Up to 6 months