- Occurs in healthy, non-pregnant, non-immunocompromised women - Caused by a single pathogen

- Anything that is not “uncomplicated” (males, pregnancy, immunocompromised, etc.) - Often caused by multiple pathogens

- Acute pulmonary sxs (onset: hours to weeks) - Pulmonary fibrosis (\>6 months)

- Rash - Hyperkalemia - Bone marrow suppression

UTIs Flashcards by Madison Crutcher

Clinical Presentation of Cystitis (bladder)

Irritative voiding symptoms (frequency, urgency, dysuria)
Gross hematuria (blood in urine)

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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

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Atypical Presentation of UTI in Elderly

Altered mental status
Change in appetite
GI sxs
Incontinence

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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)

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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

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Most Common Pathogen Causing UTI

E. coli

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Uncomplicated UTI

Occurs in healthy, non-pregnant, non-immunocompromised women
Caused by a single pathogen

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Complicated UTI

Anything that is not “uncomplicated” (males, pregnancy, immunocompromised, etc.)
Often caused by multiple pathogens

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First-Line Agents for Treatment of Uncomplicated Cystitis

Nitrofurantoin (Macrobid)
Trimethoprim/Sulfamethoxazole (Bactrim)
Fosfomycin

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Nitrofurantoin Duration for Uncomplicated Cystitis

5 days

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Nitrofurantoin Spectrum of Coverage

Staphylococcus saphrophyticus
Enterococci (including VRE)
E. coli (including ESBL)

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Can nitrofurantoin be used in pyelonephritis and prostatitis?

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Nitrofurantoin Renal Cutoff

Avoid in CrCl < 30

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Nitrofurantoin ADRs

Acute pulmonary sxs (onset: hours to weeks)
Pulmonary fibrosis (>6 months)

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Nitrofurantoin in Pregnancy

Safe in pregnancy EXCEPT at term (38-42 weeks)

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TMP/SMX Duration for Uncomplicated Cystitis

3 days

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TMP/SMX Spectrum of Coverage

Staphylococcus saphrophyticus
E. coli

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Can TMP/SMX be used in pyelonephritis and prostatitis?

Yes

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When to avoid TMP/SMX

If local E. coli resistance > 20%
If used for UTI in previous 3 months

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TMP/SMX ADRs

Rash
Hyperkalemia
Bone marrow suppression

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TMP/SMX in Pregnancy

AVOID in 1st and 3rd trimester

Safe in 2nd trimester

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Fosfomycin Duration for Uncomplicated Cystitis

1 dose

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Fosfomycin Spectrum of Coverage

Enterococcus faecalis (including VRE)
E. coli (including ESBL)

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Can fosfomycin be used in pyelonephritis?

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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?

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

UTIs Flashcards

(76 cards)