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Flashcards in 22 - Treatment of UTI Deck (60):
1

Which of the following agents inhibits DNA synthesis?

- Ciprofloxacin
- Levofloxacin
- Fosfomycin
- Trimethoprim/ sulfamethaxazole
- Nitrofurantoin

Trimethoprim/sulfamethaxazole

2

Which of the following agents inhibits cell wall synthesis?

- Ciprofloxacin
- Levofloxacin
- Fosfomycin
- Trimethoprim/ sulfamethaxazole
- Nitrofurantoin

Fosfomycin

NOT a beta-lactam though

3

Which of the following agents inhibits DNA gyrase and topoisomerase?

- Ciprofloxacin
- Levofloxacin
- Fosfomycin
- Trimethoprim/ sulfamethaxazole
- Nitrofurantoin

- Ciprofloxacin
- Levofloxacin

4

Which bacteria are most often associated with uncomplicated urinary tract infections?

E coli

5

What is the second most common cause of uncomplicated UTIs?

Other gram negatives

6

Which is NOT a first line agent for the treatment of uncomplicated UTI?

- Nitrofurantoin
- TMP-SMX
- Fosfomycin
- Ciprofloxacin

Ciprofloxacin

First line
- Nitrofurantoin
- TMP-SMX
- Fosfomycin

7

What are some important predisposing factors for the development of a UTI?

Female anatomy
- Short urethral distance
- Acquisition of gut flora
- Chronic vaginal colonization seeds urethra
- Sexual intercourse displaces bacteria into the bladder

Bottom line - just being female is a predisposing risk factor

8

What other factors can result in a UTI?

- Structural abnormalities
- Obstruction/disruption of urine flow
- Instrumentation (catheter)

9

Describe the types of structural abnormalities which result in UTI

- Congenital malformation
- Vesicoureteral reflux

10

Describe the types of obstruciton/disruption in urine flow which results in UTI?

- Renal calculi (kidney stones)
- Tumors
- Neurologic problems
- Pregnancy
- Prostatic hypertrophy

11

Describe catheterization as a predisposing risk factor for UTI

- Disrupts normal protective function of the bladder
- Introduction of bacteria
- Contamination of the catheter drainage system
- Duration of catheterization (risk increases by 3-5% each day of catheterization)

**** KNOW that the duration of catheterization is important ****

12

What factors of the BACTERIA aid in the development of a UTI?

- Pili or Fimbriae
- Urease
- Hemolysins
- Capsule

13

How does pilli or fimbriae aid bacteria in UTI?

Consists of pilins and adhesins that can facilitate attachment to host cells

14

How does urease aid bacteria in UTI?

Create a buffered microenvironment

15

How does hemolysins aid bacteria in UTI?

Toxin that disrupts eukaryotic cell membranes and causes cell lysins

16

How does a capsule aid bacteria in UTI?

Polysaccharide structure that prevents phagocytes from engulfing bacteria

17

What are common manifestations of UTI?

- Cystitis
- Pyelonephritis

18

What is cystitis?

Bladder or lower urinary tract infection

19

What are the symptoms of cystitis?

dysuria (painful urination)
increased frequency of urination
feeling of urgency
WBC’s & bacteria in urine
hematuria (possible)

**fever is usually absent

20

What is pyelonephritis?

Kidney or upper urinary tract infection

21

What are the symptoms of pyelonephritis?

flank pain*
fever*

dysuria (painful urination)
increased frequency of urination
feeling of urgency
WBC’s & bacteria in urine
hematuria (possible)

22

What is the difference between complicated and uncomplicated cystitis?

Uncomplicated
- Healthy, ambulatory, no abnormalities
- Mild cystitis to severe pyelonephritis
- No predisposing factors
- First line short course of antimicrobial regimen (5-14 days - SHORTER)

Complicated
- Diabetes
- Impaired sensation
- Stone or obstruction
- 7 day or longer course of fluoroquinolone preferred
- 14-21 day duration recommended in general (LONGER)
- Not going to focus on these treatment options (more aggressive)

23

Describe the classification systems for uncomplicated and complicated

NOTE: Current classification schemes are overly simplistic, especially for patients with complicated infections, but the value of more complex classification schemes has not yet been shown

24

What drugs are the first line agents for uncomplicated cystitis?

- Nitrofurantoin
- TMP-SMX
- Fosfomycin

25

What are ecological effects?

- You're getting collateral damage
- You promote the growth of resistant bacteria
- Knock down normal microbiota

26

Describe the type and MOA of nitrofurantoin

- Synthetic nitrofuran, antiseptic drug
- MOA: Bacterial reduction of compound to generate DNA damaging intermediates

27

Describe the efficacy and clinical consideration of nitrofurantoin

- 93% (84-95%)
- Few ecological effects, nausea, diarrhea, headache, flatulence

28

Describe the type and MOA of TMP-SMX

- Diaminopyrimidine +sulfonamide
- MOA: Disrupt folate metabolism

29

Describe the efficacy and clinical consideration of TMP-SMX

- 93% (90-100%)
- Few ecological effects, folate concerns if there is a deficiency, dermatological rxns (photosensitivity), rash

30

Describe the type and MOA of fosfomycin

- “Other cell wall inhibitors”
- MOA: Cell wall synthesis inhibitor

31

Describe the efficacy and clinical consideration of fosfomycin

- 91%
- Few ecological effects

32

What are the second line agents for uncomplicated cystitis?

- Ciprofloxacin
- Levofloxacin
- Amoxicillin

33

Describe the type and MOA of cipro and levo

- Fluoroquinolone
- MOA: DNA replication inhibitor by binding gyrase and topoisomerase

34

Describe the efficacy and clinical consideration of cipro and levo

- 90% (85-98%)
- Ecological adverse effects, resistance********

35

Describe the type and MOA of amoxicillin

- Beta-lactam
- MOA: Cell wall synthesis inhibitor

36

Describe the efficacy and clinical consideration of amoxicillin

- 89% (79-98%)
- Mild adverse effects: nausea, vomiting, diarrhea, rash; resistance*******

37

What are the first line agents used to treat uncomplicated pyelonephritis?

- Ciprofloxacin1
- Levofloxacin2
- TMP-SMX

38

Describe the type and MOA of cipro and levo

- Fluoroquinolone
- MOA: DNA replication inhibitor by binding gyrase and topoisomerase

39

Describe the efficacy and clinical consideration of cipro and levo

- 96% (cipro) and 86% (levo)
- Ecological adverse effects; nausea, vomiting, diarrhea, headache

40

Describe the type and MOA of TMP-SMX

- Diaminopyrimidine +sulfonamide
- MOA: Disrupt folate metabolism

41

Describe the efficacy and clinical consideration of TMP-SMX

- 83%
- If E. Coli resistance exceeds 20% in an area, DO NOT USE
- Few ecological effects, folate concerns if there is a deficiency, dermatological rxns (photosensitivity), rash

42

What are the second line treatment options for uncomplicated pyelonephritis?

- Amoxicillin
- Ceftriaxone (IV)+
- Cefuroxime (oral)

43

Describe the type and MOA of amoxicillin

- Beta-lactam
- MOA: Cell wall synthesis inhibitor

44

Describe the efficacy and clinical consideration of amoxicillin

- 89% (79-98%)
- Mild adverse effects: nausea, vomiting, diarrhea, rash; resistance*******

45

Describe the type and MOA of ceftriaxone (IV) or cefuroxime (oral)

- 3rd generation cephalosporin + other cephalosporin
- Cell wall synthesis inhibitor

46

Describe the efficacy and clinical consideration of ceftriaxone (IV) or cefuroxime (oral)

- Not sure on efficacy
- Hypersensitivity reactions possible

47

What should you focus on for treatment options?

Know adverse effects, especially the ones with resistance ***

Do NOT emphasize MOA

48

What are some non-pharmacological consideration for treatment uncomplicated UTI?

Behavioral counseling
- Abstinence or reduction in frequency of intercourse
- Don't use spermicide
- Urinate after sex, don't wear tight underwear, don't douche (these are not going to hurt the patient, but have not been shown to be effective)

Biological mediators
- Cranberry juice (maybe)
- Topical estrogen (normalize vaginal flora, reduce recurrence)
- Adhesion blockers (not been evaluated in clinical trials)

49

Describe self-diagnosis and treatment

**** KNOW THIS *****

- First-line antimicrobial regimen is prescribed for future use
- Patient is advised to take at onset of UTI
- Women with previously diagnosed cystitis can accurately self-diagnose subsequent cystitis in more than 85-95% of cases and can successfully treat themselves

KNOW THIS ******

50

What are some other clinical considerations?

- Antimicrobial prophylaxis (single dose) can be effective (take one after sex)
- Continuous antimicrobial prophylaxis can also be effective

51

What is the KEY POINT about fluroquinolones?

***

Fluoroquinolones, such as Ciprofloxacin or Levofloxacin are not 1st line agents for the treatment of uncomplicated cystitis, but are used for uncomplicated pyelonephritis.

52

What are the KEY FACTORS about resistance?

***

Key factors in making a clinical decision on how to treat should consider BACTERIAL RESISTANCE to antibiotics in a region (this information is not always accessible or reflective of the hospital environment) and ECOLOGICAL adverse effects such as the selection for drug resistant pathogenic bacteria and suppression of normal flora.

53

Describe the KEY POINT about complicated infections

***

Complicated infections are just that….complicated. Treatment responsiveness is not predictable and in general will require longer durations of therapy.

54

What is the KEY POINT about recurrent infections?

***

There is a high rate of successful self-diagnosis with recurrent infections.
- Several strategies can be used that include prophylactic treatment.

55

Which drug is NOT a first line agent for uncomplicated UTI

Ciprofloxacin

Nitrofurantoin, TMP-SMX and fosfomycin are first line

56

Describe case 2

A 30-year old woman calls you to report a 2-day history of worsening dysuria and urinary urgency and frequency. She reports having no fever, chills, back pain, or vaginal irritation or discharge. One month ago, you treated her with a 3-day course of trimethoprim-sulfamethoxazole for presumptive cystitis, and her symptoms resolved. She is otherwise healthy, but this is her third episode in the past year. How should her case be managed?

57

What type of case is this

Uncomplicated cystitis = the key point here is recurrence (does NOT make it complicated)

This is recurrent cystitis - requires more aggressive therapy

Think... Is it resistant, so we need a different abx, or should we give her self-diagnosis and treatment options? Clinical decision

58

Describe case 3

A 34-year-old woman who is otherwise healthy has had a fever, nausea, and right-sided back pain for 2 days. The physical examination shows a temperature of 39.0ºC (102.2ºF), blood pressure of 120/60 mm Hg, pulse of 110, respiratory rate of 18, and right-sided costovertebral angle tenderness to percussion. Dipstick urinalysis is positive for leukocytes, nitrites, and blood.

59

What is the distinguishing factor?

FEVER - uncomplicated pyelonephritis

60

Which drug is a first line agent?

Fluoroquinolones

TMP-SMX would be another option