Unformatted text preview:

Urinary Tract InfectionsKhalid Ibrahim, Pharm.DUniversity of MinnesotaOverview!Urinary Tract Infections (UTI)! Uncomplicated! Complicated!ProstatitisEpidemiology!Approximately 7 million physician visits annually (community)!25 – 35% women ages 20-40!<1% men ages 21 – 50!Most commonly occurring nosocomial infection!UTI in children!Belief that trend was underestimated in the past!Prevalence ranging from 4.1-7.5% febrile childrenCrit Care Med 1999 May;27(5):853-4 Pediatr Clin North Am - 1997 Oct; 44(5): 1133-69 Infect Dis Clin North Am - 1997 Sep; 11(3): 551-81Definitions!Urinary Tract Infection (UTI)! M/o present in the urine not accounted for by contamination!Cystitis! Lower tract infections!Pylonephritis! Upper tract infections (kidneys, systemic)Definitions (cont.)!Uncomplicated!Typically in females of childbearing age!No structural/neurologic abnormalities interfering with urine flow!Complicated!Flow impedance secondary to!Lesion !Congenital abnormality!Stone!Indwelling catheter!Prostatic hypertrophy!Physical obstruction!Neurologic deficitDefinitions (cont.)!Recurrent!Re-infection or relapse with same organism!Reinfection!New organism culprit. !Asymptomatic bacteriuria (ASB)!Significant bacteriuria (>105) without symptoms!Symptomatic abacteriuria!Symptoms without 105 CFU/mlPathogen reservoirs!Females (urethra proximal)! Rectal! Vaginal!Males (urethra distal)! RectalPredisposing factorsMiscellaneous CatheterizationPregnancyDiabetesStructural abnormalitiesObstructionVesicouretral reflexResidual urineProstatic hypertrophyTumors Anti-ACH agentsCalculiNeurologic diseasePathogenesis!Ascending! Rectal and/or vaginal reservoirs! Colonization of perianal area/ migration to perivaginal!Hematogenous !LymphaticPathogenesis (cont.)!Facilitating issues!Females!Reservoir(s) and urethra proximity!Urethra length!Sexual intercourse!Spermicide and diaphragm!Condoms!Pregnancy!Biofilm (slime) theory:!Bacteria interact "microcolonies!Small microcolonies coalesce "form bacterial biofilms!GlycocalyxPathogenesis (cont.)!Facilitating issues (cont.)!Catheters!Can be traumatic!Biofilm adherence!Bacterial aggregates can block catheter!Catheter can shed bacteria!Abx drained immediately!Aging!Bladder wall collagen content!Detrussor muscle thickens!Neurologic diseasesHost defense mechanisms!pH (normal range 5-8)!Urea concentrations!Osmolality!Organic acid concentrations!Prostatic secretions (males)!Urine flowClinical presentation!Common symptoms of lower UTIs! Dysuria! Frequency! Urgency! Hesitancy! Nocturia! Superpubic pain/heavinessClinical presentation (cont.)!Common symptoms of upper UTIs! Flank pain! Costovertebral tenderness! Abdominal pain! Fever! HA! N+V! MalaiseClinical presentation (cont.)!Elderly! Typically not specific urinary symptoms! Altered mental status! Altered dietary habitsLaboratory findings!U/A!Pyuria ( > 5 WBC/HPF or WBC esterase)!Sensitivity of dipstick WBC esterase method 75-85% !Bacteria ( > 105CFU/ml urine)!microscopic or dipstick NO3 --> NO2!Hematuria (approximately 1/3 gross hematuria)!Elevated pH (6.5-8)!Leukocyte esterase and nitrite dipsticks!U/C !100-100,000 CFU/mlAdjunctive diagnostic measuresProcedure!Abdominal radiograph!Ultrasound!Stamey-Meares 4-glass test!Urethral catheterization!IVP, retrograde cystographyCondition#Nephrolithiasis#Hydronephrosis#Prostatic Localization#Upper vs. Lower or Bladder Washout#Anatomical defect functional disorderDifferential diagnosis!Uncomplicated UTI!Vaginitis!Urethritis!STD!Odor!Itching!Pain on intercourse!Complicated UTI!Depends on contributing underlying diseasesNon-Rx treatment/prevention!Behavior modification! Personal toilet hygiene! Patient’s choice of fabric and clothes! Frequent voiding! Voiding after intercourse! Method of contraceptionNon-Rx treatment/prevention (cont.)!Cranberry juice!Believed to have preventative/treatment effects!Increases fluid intake and urine output!Acidifies urine (study pH = 6 vs. CTN pH = 5.5)!May interfere with bacterial attachment (Fructose or polymeric cpd acts as lectin inhibitor)!Benzoic acid --> hippuric acid which may have intrinsic antibacterial properties!Database review of literature conclusion!Small number/poor quality trials : no reliable evidence re: Px!No randomized trials assessing Tx effectsCochrane Database of Systematic Reviews. (2):CD001321 and CD001322, 2000.Treatment!Algorithms !Goal is to deliver optimal patient care!Large literature base to draw from!Uncomplicated UTI is short term condition!Eliminates wide variation in management and antibiotic prescribing!Should reflect national trends and local needs!Should limit legal liabilityTreatment (cont.)!Algorithms (cont.)! Streamlines the use of healthcare professionals! Both functional for daily practice and educational for training programs! Provides for the cost effective use of laboratory studies and antibiotics! Feedback loop provides for continuous refinement and state of the art careTreatment (cont.)!Complicating factors!Symptoms > 7 day duration!Rigors!Flank pain!Temperature > 101 F!Pregnancy!DM!Immune-suppressed !Kidney stones!Catheterization/instrumentization within 2 weeks!Hospital D/C within 2 weeks!>4 UTI’s within last 12 monthsUncomplicated UTIEtiologyYoung women• E. coli 80%• S. saprophyticus 10-15%• Others 5-10%(Klebsiella/Proteus)Women >65 years• E. coli 70%• P. mirabilis 10%• Other Gram (-) 20%(Pseudomonas)Uncomplicated UTITreatment!Conventional therapy! PO abx 7-14 days!3-Day therapy! Superior to single-dose! Optimal regimen for SMX/TMP!β-lactams should be admin > 5 days! Fluoroquinolones are valid options of 3-dayUncomplicated UTITreatment (cont.)Drug DosageCiprofloxacin 100 mg q12hEnoxacin (Penetrex) 400 mg q12hLomafloxacin HCl (Maxaquin) 400 mg q24hNorfloxacin (Noroxin) 400 mg q12hOfloxacin (Floxin) 200 mg q12hTrimethoprim (Proloprim, Trimpex) 100 mg q12hTrimethoprim/sulfamethoxazole 160 mg TMP/ (Bactrim, Cotrim, Septra, etc.) 800 mg SMX q12h• 3 day treatment optionsUncomplicated UTIFluoroquinolones!Advantages!Excellent bioavailability (PO = IV)!Uncomplicated dosage regimen (BID or QD for 3 days)!Broad spectrum with low incidence of resistance for UTI pathogens !Drug concentrates in urinary tract (& prostate for males)!Quinolones are concentration dependent killers!Rapid rate of kill!With AUC / MIC ratios >250 limited selection of resistant subvariant bacterial populationsUncomplicated UTIFluoroquinolones!Disadvantages! Some limited drug interaction problems! Expensive in


View Full Document

U of M PHAR 6124 - Urinary Tract Infections

Download Urinary Tract Infections
Our administrator received your request to download this document. We will send you the file to your email shortly.
Loading Unlocking...
Login

Join to view Urinary Tract Infections and access 3M+ class-specific study document.

or
We will never post anything without your permission.
Don't have an account?
Sign Up

Join to view Urinary Tract Infections 2 2 and access 3M+ class-specific study document.

or

By creating an account you agree to our Privacy Policy and Terms Of Use

Already a member?