Urinary Tract Infections

Question 1

Epidemiology

Answer 1

• Incidence in ♀ ≈ 12% annually
▫ 50% of ♀ report to have had a urinary tract infection (UTI) by age 32
▫ Significantly less common in ♂
▫ Incidence increases with age (as does asymptomatic bacteriuria)
• Recurrence occurs in 25% of ♀ within 6 months of 1st UTI
▫ This increases when > 1 prior UTI experienced
• UTI is the 8th most common reason for ambulatory clinic visits and 5th
most common reason for emergency department visits in Canada

Question 2

pt prescribed TMP/SMX BID x 3 days
for UTI
what is first thing pharmacist should do?

Answer 2

assess to confirm symtpoms

Question 3

pathophys

Answer 3

ascend urethra and getinto bladder to cause infection and occasinally to kdines

urethra shorter in females than males so more common

Question 4

Urinary Tract Infection (UTI)

symptoms

Answer 4

• Bacterial infection of urinary tract
▫ Cystitis (lower)
▫ Pyelonephritis (upper)
• Symptoms
▫ Cystitis (LOW UT) → dysuria ± increased frequency, urgency, suprapubic pain, or hematuria
▫ Pyelonephritis (UPPER UT)→ fever, chills, flank pain/tenderness, ± typical cystitis symptoms (more systemic)

• Asymptomatic bacteriuria (ASB) → bacteria in urine in quantitative counts that are consistent with growth in bladder/kidneys without symptoms referable to the urinary tract
▫ Usually treatment of this is unnecessary, no evidence to treat, sometimes ppl get symptoms after treating

TERT for prostate enlargement

Question 5

Predisposing Factors - ♀

Answer 5

• Sexual intercourse (75-90%) (freq of intercourse correlated to infection)
• Spermicide use
• New sexual partner within past year
• Previous urinary tract infection
• Family history of urinary tract infection in first degree female relative
• Menopause
• Diabetes and other complicating factors (see slide on complicating
factors)

Question 6

Predisposing Factors - ♂

Answer 6

• Benign prostatic hypertrophy
• Previous urinary tract surgery
• Recent procedures (including cystoscopy, catheterization, prostate
biopsy)
• Anatomic or physiologic abnormalities (incomplete bladder emptying)
• Age > 65 years
• Uncircumcised
• Immunocompromised
• In young sexually active men, engaging in sex with infected female
partner or engaging in anal intercourse

Question 7

Complications of UTI

outcome less than ideal as result of UTI

Answer 7

More common in the setting of complicated than with uncomplicated UTI
• Bacteremia - into blood
• Sepsis (urosepsis)
• Systemic inflammatory response syndrome
• Renal abscess (rare 1/1,000 cases) - more common in diabetes
• Prostatitis, epididymitis, orchitis in men

Question 8

UTI Investigations

Answer 8

• Symptoms to ask about
▫ Dysuria, frequency, urgency, suprapubic pain, hematuria
▫ Vaginal discharge, odour, pruritis; painful intercourse
(Vaginitis becomes more likely when these are present, especially if no urinary frequency or urgency)
▫ Flank pain/tenderness, fever/chills, nausea/vomiting
• Cloudy, foul-smelling urine ≠ UTI symptoms!
gives pressure to treat, need symptoms first, could be asymptomatic bactinnuria

Question 9

older aldut pt

criteria for symptomatic UTI

Answer 9

see slide 13

noncath vs catherized

Question 10

Older Adult Patients

• Nonspecific symptoms

Answer 10

▫ Worsening mental status
▫ Worsening functional status
▫ Increased confusion, delirium, or agitation
▫ New or more frequent falls
▫ These do NOT indicate UTI!
▫ If medical status not rapidly declining (and not on fluid restriction)
 Hold (i.e., don’t start) antibacterials
 Ensure adequate hydration (push fluids, water, tea , juice)
 Observe (24 hours)

▫ If typical UTI symptoms develop, treat as UTI
▫ If nonspecific symptoms continue without development of typical symptoms,
assess for other causes of nonspecific symptoms

Question 11

Complicating Factors

Answer 11

• Complicated UTI if symptomatic of UTI in presence of complicating factors – Structural, functional, or metabolic conditions that promote UTI and put the patient at risk of resistant pathogens and/or treatment
failure
• Examples of complicating factors:
▫ Male sex
▫ Chronic obstruction
▫ Diabetes (poorly controlled)
▫ Indwelling urinary catheter
▫ Nephrolithiasis
▫ Immunosuppression
▫ Pregnancy
• In absence of complicating factors, considered uncomplicated UTI

Question 12

Microbiology – Usual Pathogens

Answer 12

• Escherichia coli (up to 95% of uncomplicated UTI, still majority in complicted)

• Others:
▫ Klebsiella pneumoniae
▫ Proteus mirabilis
▫ Other Enterobacterales
▫ Staphylococcus saprophyticus
▫ Pseudomonas aeruginosa
▫ Enterococcus spp
▫ Streptococcus agalactiae (if pregnant or diabetic)

Question 13

T/F a urine culture is required for diagnosis of UTI

Answer 13

false
ppredictable microbiology
high rate of spontaneous resolution

Question 14

Laboratory Investigations

when is urine C&S needed

Answer 14

• Sending urine for C&S generally not recommended if asymptomatic

• Uncomplicated UTI → urine C&S usually not necessary
▫ Potential exceptions:
 Early recurrence of infection
 Recent travel outside Canada/US or recent hospitalization
 Atypical presentation
 Pyelonephritis

• Complicated UTI → urine C&S recommended
▫ If urinary catheter in place for ≥ 2 weeks, it should be discontinued or changed before specimen collection

• Blood C&S → recommended if patient febrile, hemodynamically unstable, pyelonephritis, or immunocompromised

biofilm on catheter, higher rate of tx failure

Question 15

Laboratory Investigations
pyruia
nitrites

Answer 15

• Pyuria (identified via urinalysis or urine dipstick)
▫ Does not identify symptomatic infection (present in majority of ASB patients)
▫ High negative predictive value, particularly in older patients (rule out UTI)
 In younger patients with uncomplicated UTI, urinalysis/urine dipstick should not be obtained and patients should be treated on basis of presence of
symptoms alone

• Nitrites (identified via urinalysis or urine dipstick)
▫ Reduction of nitrates to nitrites by Gram negative bacteria
▫ Not particularly helpful
• Ultrasound or CT sometimes used when pyelonephritis is suspected

Question 16

• If urine C&S sent

Answer 16

▫ antibacterial initiation should be delayed until results of culture available, if
possible
▫ When antibacterials started empirically, choice of agent should be re-evaluated once culture results available

tx should usually be offed, dont wait

Question 17

Treatment – Uncomplicated UTI

Cystitis

Answer 17

• Nitrofurantoin monohydrate/macrocrystals 100 mg po BID x 5 days
• Fosfomycin 3 g po x 1 dose
• Alternatives: no antibacterial exposure within last 6 months
▫ Cephalexin 250-500 mg po QID x 5-7 days
▫ TMP/SMX i DS tab po BID x 3 days
 Can use TMP 100 mg po BID x 3 days if sulfa allergy
• Alternatives: Other
▫ Cefixime 400 mg po once daily x 5-7 days
▫ Fluoroquinolone* x 3 days

some countries just use TMP

norfloxacin - narrowest spectrum

Question 18

FDA Advisory – Fluoroquinolones (2016)

Answer 18

• Fluoroquinolone antibacterials associated with disabling and potentially permanent side effects of the tendons, muscles, joints, nerves, and central nervous system that can occur together in the
same patient.
• …fluoroquinolones should be reserved for use in patients who have no other treatment options for acute bacterial sinusitis, ABECB, and uncomplicated urinary tract infections because the risk of these serious side effects generally outweigh the benefits in these patients

Question 19

Empiric Treatment – Uncomplicated UTI

Pyelonephritis

Answer 19

Outpatient
• Ceftriaxone 1-2 g IV/IM x 1 dose, followed by oral therapy
• Gentamicin 5-7 mg/kg IV/IM x 1 dose, followed by oral therapy

Oral therapy
• Cefixime 400 mg po once daily
• Amoxicillin-clavulanate 875^ mg po BID
• Fluoroquinolone
• TMP-SMX i DS tab po BID
x 7-10 days

Hospitalized/Septic
• Ceftriaxone 1-2 g IV q24h
• Gentamicin 5-7 mg/kg IV q24h
x 7-10 days

Question 20

Empiric Treatment – Complicated UTI
Prolonged fever, renal function deterioration,
or septic presentation requires further
investigation for abscess/undrained collection

Answer 20

Lower urinary tract – no systemic features
• Cefixime 400 mg po once daily
• Amoxicillin-clavulanate 875^ mg po BID
• Fluoroquinolone
• TMP-SMX i DS tab po BID
x 7-10 days*

Pyelonephritis and/or systemic features
• Ampicillin 1-2 g IV q6
PLUS
[Ceftriaxone 1-2 g IV q24h OR Gentamicin 5-7 mg/kg IV q24h]
x 7-10 days*#

Septic/Hemodynamically Unstable
• Piperacillin-tazobactam 3.375 g IV q6h
± Gentamicin 5-7 mg/kg IV q24h
x 7-10 days*#

* Continue Abx therapy for 3-5 days after defervescence or elimination of obstruction/infected focus
If lower tract infection and prompt response (within 48h), treat for 7 days.
If delayed response or structural abnormality, treat for 10-14 days.
# Reasonable to step down to PO therapy to complete course, if clinically appropriate

Question 21

Follow Up

Answer 21

• Improvement in symptoms can usually be expected in 48-72 hours
• Ask about systemic symptoms (or factors concerning for pyelonephritis, including nausea and vomiting)
• Repeat urine C&S after completion of therapy generally not recommended unless treatment failure
▫ (or pregnant patients, for whom ongoing screening and treatment of ASB is indicated)

if symptoms are gone bbut bac is still there, creating pressure to treat it

Question 22

Clinical Case
• JS is a 45 year old ♀ who presents to your pharmacy requesting treatment for what she suspects is a urinary tract infection. She states that she has a burning sensation when she urinates and also notes that she feels like she has to “go all the time”. On examination, her BP is 140/90, HR 80, RR 20, O2
sat 99% RA, temperature 37.2ºC. Her home
medications include candesartan, metformin, vitamin D, and citalopram and she does not have any medication allergies.
▫ What is your approach to this patient?

Answer 22

have they experienced it before, how recently?
back or flank pain, nausea/vomiting
vaginal discharge, painful intercourse
most STIs are asymptomatic in females
ask for how well diabetes control is good or not

if good -> uncomp cystitis

Nitrofurantoin monohydrate/macrocrystals 100 mg po BID x 5 days

Question 23

Clinical Case #2
• BR is a 68 year old ♂ who presents to your pharmacy with a prescription from his physician for amoxicillin-clavulanate 500 mg PO TID x 10 days. He states that it is for an “infection in his bladder”. You
check Netcare and see that there was a urine culture from a couple days ago that grew E. coli which is susceptible to amoxicillinclavulanate, cephalexin, gentamicin, and nitrofurantoin; and
resistant to ampicillin and TMP-SMX.

Answer 23

rule out TMP-SMX (resistant)
nitrfurantoin –> not used as much for males
cephalexin –> narrowest spectrum

Question 24

Pregnant Patients – Empiric Treatment

Cystitis

Answer 24

• Nitrofurantoin 50-100 mg po QID (or Macrobid 100 mg BID) x 7 days
(not to be used at term)
• Cephalexin 250-500 mg po QID x 7 days
• Cefixime 400 mg po once daily x 7 days
• Fosfomycin 3 g po x 1 dose
• TMP/SMX i DS tab po BID x 7 days (not to be used in 1st or 3rd trimester)

Post-treatment (1 wk) urine C&S recommended followed by monthly follow-up cultures during remainder of pregnancy

Question 25

Pregnant Patients – Empiric Treatment

Pyelonephritis

Answer 25

• Ceftriaxone 1-2 g IV q24h x 10 days#
• Ampicillin 2 g IV q6h + Gentamicin 7 mg/kg IV q24h x 10 days#
Post-treatment (1 wk) urine C&S recommended followed by monthly
follow-up cultures during remainder of pregnancy Bugs & Drugs
# Reasonable to step down to PO therapy to complete course, if clinically appropriate

Question 26

Recurrence of Infection

Answer 26

Relapse vs Reinfection
• Relapse → Same organism
▫ typically within 2-4 weeks after completion of therapy
▫ Consider investigation for pyelonephritis or renal abscess

• Re-infection → Same or different organism
▫ Over 90% of recurrences are due to this

Question 27

Prevention

Answer 27

• Avoid the use of spermicides or spermicide-coated condoms
• Adequate hydration
• Post-coital voiding
• Cranberry products (conflicting evidence of efficacy, but little harm)
• Topical vaginal estrogen (postmenopausal ♀)

Question 28

Recurrence of Infection

prophylactic tx

Answer 28

Females with Frequent Recurrences
(≥ 3 episodes/year or ≥ 2 episodes/6 months)
May consider prophylactic antibacterials (should confirm eradication of UTI with negative urine culture 1-2 weeks post-treatment before initiating prophylaxis)

Pericoital prophylaxis
• TMP/SMX i SS tab po (or TMP 100 mg po)
• Nitrofurantoin 50 mg po (or Macrobid 100 mg po)
• Cephalexin 125-250 mg po

Continuous prophylaxis
• TMP/SMX i SS tab (or TMP 100mg) po HS (or 3x/week) x 6 months

Question 29

The Pharmacist’s Role

Prescribing for UTI in Alberta
• Nitrofurans: ↑ from 20% in 2010 to
32% in 2016
• Trimethoprim-sulfamethoxazole (TMPSMX): ↓ from 20% in 2010 to 13% in
2016
• Fluoroquinolones: ↓ from 43% in 2010
to 29% in 2016

Answer 29

• Pharmacists have very important roles to play in the assessment and
management of urinary tract infections
▫ Access of appropriate care
▫ Antimicrobial stewardship
• Study of pharmacists assessing and managing patients with
uncomplicated urinary tract infections
▫ Both de novo prescribing and those that originally prescribed by physician
▫ Care by pharmacists found to be very effective (88.9% clinical cure at 2
weeks) and safe
▫ Patient satisfaction very high

Question 30

Prostatitis

epid

Answer 30

• ~15% of men will have prostatitis in lifetime
• Effective antibacterial options limited and need to give for prolonged periods
• Significant failure rates (up to 75%)
• Acute bacterial prostatitis → urinary symptoms and pain (which may be suprapubic, perineal, rectal, or in external genitalia). May include fever and urosepsis.
• Chronic bacterial prostatitis → lasting for > 3 months.
▫ (Recurrent infections of prostate caused by same organisms – intermittent symptoms)

Question 31

Bacterial Prostatitis

Usual Pathogens

Answer 31

• E. coli
• Other Enterobacterales (e.g., Klebsiella, Proteus spp, etc.)
• Enterococcus
• Pseudomonas (moreso in nosocomial)
• Staphylococci and Streptococci (rare)
• STIs are less common causes

Question 32

unequiv diagnosis

Answer 32

unequiv diagnosis

catch first 10mL
ctch midtream
collect prostatic secretions
then collect 10mL after prostate massage

Question 33

Bacterial Prostatitis - Treatment

beta lactams dont get there as well

Answer 33

Acute
Mild-Moderate
• Ciprofloxacin 500-750 mg po BID x 2-4 weeks*
• TMP-SMX i DS tab po BID x 2-4 weeks*
• [Ampicillin 2 g IV q6h
\+ Gentamicin 5-7 mg/kg IV q24h] switch to po agents when clinical
improvement to complete 2-4 wks*
Severe
• Piperacillin-tazobactam 4.5 g IV q6h

Chronic
• Ciprofloxacin 500-750 mg po BID x 4-6 weeks#
• TMP-SMX i DS tab po BID x 4-6 weeks#
• Doxycycline 100 mg po BID x 4-6 weeks#