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Urinary Tract Infections
- 1. Pharmacotherapy of Infectious Diseases A Case-Based Approach Urinary Tract Infection Anas Bahnassi PhD Pharmacotherapy of Infectious Diseases Anas Bahnassi 2014 A Case-Based Approach
- 2. Pharmacotherapy of Infectious Diseases A Case-Based Approach Goals of Therapy •Ameliorate symptoms in acute infections. •Prevent recurrent infection. •Prevent pyelomephritis in pregnancy. Anas Bahnassi 2014
- 3. Pharmacotherapy of Infectious Diseases A Case-Based Approach Investigations Anas Bahnassi 2014 Syndrome Most common pathogens Microbiologic culture Urine Culture •Acute uncomplicated UTI: Occurs in females with normal genitourinary tracts. •Females have genetic predisposition for recurrent UTI. •Behavioral factors promote infections: (sexually active, use of spermicides and diaphragm) •Symptoms: dysuria, frequency, suprapublic discomfort, and urgency. •Recurrences common at variable frequency. •E-coli (80-90%) •S.Saprophyticus (5-10%) •K.pneumonae, P.mirabilis, Group B Strep. Presence of any quantitative count of G- organism or S.Saprophyticus in a voided urine specimen with pyuria. Generally not recommended. Culture if : failed to empiric AB therapy. Early (<1mo) recurrence following therapy. Diagnostic uncertainty. Pregnant patient.
- 4. Pharmacotherapy of Infectious Diseases A Case-Based Approach Investigations Anas Bahnassi 2014 Syndrome Most common pathogens Microbiologic culture Urine Culture •Acute nonbstructive pyelonephritis: Occurs in females who also experience uncomplicated UTI but at lower frequency than cystitis. •Fever and flank pain with or without irritable symptoms. •Bactericemic infection occurs most in diabetic women or women >65y. •UTI patients with lower tract symptoms or asymptomatic bacteriuria occasionally have associated occult renal infections. •E-coli (80-90%) •P.mirabilis (5%) •K.pneumonae (5%) •S.Saprophyticus ≥107 Cfu/L in voided urine specimin. Always indicated Obtain before initiating AB therapy. Consider blood culture.
- 5. Pharmacotherapy of Infectious Diseases A Case-Based Approach Investigations Anas Bahnassi 2014 Syndrome Most common pathogens Microbiologic culture Urine Culture •Complicated UTI: Occurs in individuals with abnormal genitourinary tract due to structural or functional abnormalities including indwelling catherter. •Patients may present with cystitis (lower tract) symptoms or fever/ pylonephritis. •Management includes search for correctable abnormalities, recurrent infection is common (50% by 6wks post therapy). •E-coli (50%) •P.mirabilis (20%) •E.faecalis (10%) •P.aerugenose, P.stuartil, Citrobacter. ≥108 Cfu/L in voided urine specimin, or any quantitative count in catheterized specimen. Always indicated Obtain before initiating AB therapy.
- 6. Pharmacotherapy of Infectious Diseases A Case-Based Approach Investigations Anas Bahnassi 2014 Syndrome Most common pathogens Microbiologic culture Urine Culture Bacterial prostatitis: Acute: due to E-coli, or S.aureus, symptoms include chills, fever, perineal and lower back pain, irritative and obstructive voiding. Prostate is tender, swollen, indurated and warm. Prostatic message not recommended, it may cause bacteremia. Chronic: uncommon, with age, cystic-like symptoms, history of recurrent UTI. Prostate examination is usually normal. •E-coli (50%) •P.aerugenose •S.aureus •Others •E-coli (80%) •Klebserella •P.aerugenose •Proteus ≥108 Cfu/L in voided urine specimin. Blood culture positive Aspirate prostate abscess, Meares-Starney test (triple-glass test. Urine/prostate secretion samples before and after prostate message. Voided urine sample before empiric therapy. Urine culture with acute symptoms
- 7. Pharmacotherapy of Infectious Diseases A Case-Based Approach Investigations Anas Bahnassi 2014 Syndrome Most common pathogens Microbiologic culture Urine Culture Asymptomatic bacteriurea: Microbiologic evidence of UTI in the absence of symptoms. More common in women, with age. In pregnancy, screening should be performed at 12-15 wks. •E-coli (60-70%) •P.mirabilis •Group B strep. ≥108 Cfu/L in 2 consecutive specimens. Screening only recommended in pregnancy or before invasive genitourinary procedures. •E-coli is the most common organism causing UTI. •Individuals with complicated UTI or recent exposure to AB may have other than E-coli.
- 8. Pharmacotherapy of Infectious Diseases A Case-Based Approach Management of Recurrent, Uncomplicated Acute UTI Anas Bahnassi 2014 Recurrent Infection (>2 in 6m or >3 in 12 m) yes no Treat individual episodes (self-therapy) Consider Short course self-therapy Post-intercourse prophylaxis One dose after sexual intercourse of: •SMX/TMP (220/40mg) •TMP 100mg •Nitrofurantoin 50mg •Cephalexin 125mg •Norfloxacin 200mg •Ciprofloxacn 250mg Long-term prophylaxis •SMX/TMP (220/40mg) QHS (daily or 3 d/wk) •TMP 100mg QHS •Nitrofurantoin 50mg daily •Norfloxacin 200mg daily Self therapy: 3 day of self administered therapy on the appearance of symptoms.
- 9. Pharmacotherapy of Infectious Diseases A Case-Based Approach Recommended Empiric Treatment of UTI Condition 1st line therapy 2nd line therapy Acute uncomplicated UTI SMX/TMP po X3 days or TMP X3 days po or Nitrofurantoin po X7days Fluroquinolone po X3 days Cephalexin po X7 days. Fosfomycin single dose Pyelonephritis (Mild/Moderate) Fluroquinolone po (10-14d) Amox/Clav (10-14d) or SMX/TMP (10-14d) or TMP (10-14d) Pyelonephritis (Severe) Aminoglycoside iv ± Ampicillin iv (10-14d) Fluroquinolone iv (10-14d) or 3rd Gen. Cephalospiron iv ± Aminoglycoside iv (10- 14d) Complicated UTI (Mild/Moderate) Fluroquinolone po (7-10d) SMX/TMP po (7-10d) TMP po (7-10d) Nitrofurantoin po (7-10d) Amox/Clav (7-10d) Anas Bahnassi 2014
- 10. Pharmacotherapy of Infectious Diseases A Case-Based Approach Recommended Empiric Treatment of UTI Condition 1st line therapy 2nd line therapy Complicated UTI (Severe) Aminoglycoside iv ± Ampicillin iv (10-14d) Fluroquinolone iv (10-14d) or 3rd Gen. Cephalospiron iv Prostatitis (Acute) Aminoglycoside iv ±Cloxacillin iv ± Ampicillin iv (10-14d) Fluroquinolone iv (10-14d) or po or SMX/TMP po (7- 10d) Prostatitis (Chronic) Fluroquinolone po X 4-8wk SMX/TMP po X 4-6 wks or TMP po X 4-6 wks Anas Bahnassi 2014
- 11. Pharmacotherapy of Infectious Diseases A Case-Based Approach Therapeutic Tips •Whenever possible, base initial selection of antimicrobial therapy on urine culture results. •Antimicrobial susceptibility in population is dynamic. •Base selection of empiric therapy in symptomatic patients on anticipated local antimicrobial suscseptibilies and an individual patient’s recent antimicrobial exposure and tolerance. •Use parenteral therapy for patients who are septic, unable to tolerate oral medication, pregnant with pyelonephritis, or those with resistant organisms requiring parenteral therapy. •Consider prophylaxis for women with frequent recurrent uncomplicated UTI. •Without microbiologic confirmation of a bacterial infection, symptoms of chronic prostatitis are not an indication for antimicrobial therapy. Anas Bahnassi 2014
- 12. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Penicillins Amoxicillin Amox/Clav 500mg po TID Hyper-sensitivity reactions. GI effects effects of OC. MTX levels. $ 1st Gen. Cephalosporins Cefazolin Cephalexin 1g Q6H iv 500mg QID po Hyper-sensitivity reactions. GI effects Renal and hepatic. nephrotoxicity of aminoglycosides. INR with warfarin $ 2nd Gen. Cephalosporin Cefaclor 250mg TID po 3rd Gen. Cephalosporin Cefexime 400mg daily po Nitrofuran derivatives Nitro- furantoin 50- 100mg QID po HA, nausea, loss of appetitie, pulmonary and hepatic toxicity absorption with iron/antacids. Etc… $
- 13. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Fluro- quinolones Cipro- floxacin Levo- floxacin 250-500mg po BID 250mg daily po Abdominal pain, photosensitivity, dizziness, headache, GI effects. Potential ADR in developing cartlage avoid in children and pregnancy. absorption with iron/antacids. Etc… INR with warfarin. Theophylline and Caffeine elimination. $ Amino- glycosides Amikacin 15mg/kg/d iv Nephrotoxicity (reversible) increased with dose and duration. Ototoxicity (reversible) Ototoxicity with loop diretic. Inactive if mixed with some penicillins $$$
- 14. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Phosphoric acid derivatives Fosfo- mycin One 3g sachet GI effects, vaginitis. levels with meto- cloperaamide and propencid $$ Sulfonamide derivatives SMX/ TMP 800/160 mg po BID GI effects, false in serum Cr, renal impairment, neutropenia, thrombocytopenia, anemia. Phenytoin levels. INR with warfarin. Hypoglycemia with sulfonylurea. Nephrotoxicity with cyclosporin $ Folate anatgonists TMP 100mg BID po Rash, pruritis. Phenytoin levels, Myelo- suppression with MTX
- 15. Pharmacotherapy of Infectious Diseases A Case-Based Approach Pharmacotherapy: Infectious Diseases: Anas Bahnassi PhD abahnassi@gmail.com http://www.twitter.com/abpharm http://www.facebook.com/pharmaprof http://www.linkedin.com/in/abahnassi Anas Bahnassi 2014