Effective Management and Treatment of Urinary Tract Infection

Pleasecheckthe editingfile to seeif thereareanychanges Management & Treatmentfor Urinary Tract Infection Important! Doctor sNotes Onlyfoundinfemales slides Only found in males slides ExtraNotes I m n o t t e l l i n g y o uit s g o i n g t o b e e a s y . I m t e l l i n g y o uit s g o i n g t o b e w o r t hit.

Objectives Recall the principal goal of management of urinary tract infection (UTI) and that antibiotics are the main treatment of UTI Discuss the factors that management of UTI depends on Describe the management/ treatment of different conditions of UTI ( cystitis, pyelonephritis, catheter associated UTI, etc.)

Goal of Management ofUTI TheprincipalgoalofmanagementofUTIistoeradicatetheoffendingorganismsfromtheurinarybladderandtissues. ThemaintreatmentofUTIisbyantibiotics. Management of UTI dependson: Whetherinfectioniscomplicatedoruncomplicated. Whetherinfectionisprimaryorrecurrent. Typeofpatient(pregnant,child,hospitalizedornot,diabeticpatient, ..etc) Bacterialcount. Presence ofsymptoms.

Urinary Tract Infection Thetreatment duration is about7-14din mostcases Complicated Uncomplicated -Low-riskpatient(woman)forrecurrentinfection: -3daysantibioticwithouturinetest,andthecurerateis94%. -Thechoiceofantibioticdependonsusceptibilitypattern ofbacteria, whichincludes: Diabetesmellitus Aging Nitrofurantoin (forlongterm use)prophylaxis Spinal cordinjury Catheterization Amoxicillin (withor without clavulanic acid) Cephalosporins ( first orsecond generation) Comorbiditiesinpediatricpatients Kidsw/structureabnormality Fluoroquinolone(ciprofloxacinornorfloxacin): -(notforpregnantwomenorchildrenunder18year) -(firstchoiceifotherantibioticsareresistant.) TMP-SMX(tradenames:Bactrim,Septra, Cotrimoxazole)

Relapsing infection Recurrent infections Relapsemeansthatthere satreatmentfailure( ) Recurrent means that the patient will recover then get sick again. PatientswithtwoormoresymptomaticUTIswithin6monthsor3 ormoreoverayear. Need preventivetherapy Antibiotictakenassoonassymptomsdevelop. Ifinfectionoccurslessthantwiceayear, acleancatchurinetestshouldbetakenforcultureandtreatedas initialattackfor3days. Causedby: Treatmentfailure Structuralabnormalities Abscesses. Antibioticsusedattheinitialinfectiontreatmentfor7-14days. When to consult the doctor? If symptomspersist Achangeinsymptoms(likebloodinurineandpain) Pregnantwomen(pregnantwomenhavetoalwaysconsultadoctorbc sometimes they get Asymptomatic bacteriuria high count in urine butnosymptoms.Soifnottreatedcancausepyelonephritis) Morethan4infectionsperyear Impaired immunesystem Previous kidneyinfections Structuralabnormalitiesofurinarytract Historyofinfectionwithantibioticmultiresistantbacteria. Important! The difference between Relapsing and Recurrentinfectionsthatrelapsingmeansthe patient didn t recover completely and have the same bacteria. Recurrent means the patient recovered completely and then had reinfection.

Postcoital antibiotics Prophylactic antibiotics If recurrent UTI is related to sexual activity,andepisodesrecurmorethan 2timeswithin6months Asinglepreventivedosetaken immediatelyafter intercourse Antibiotics include:TMP-SMX, CephalexinorCiprofloxacin(forshort timetoavoidinfection) Optionalforpatientswhodonot respondtoothermeasures. Reducesrecurrencebyupto95% Low dose antibiotic taken continuouslyfor6monthsorlongerit includes: TMP-SMX, Nitrofurantoin,or Cephalexin Antibiotic taken at bedtimemore effective.(toprotectagainstrecurrent)

Moderatetoseverepyelonephritis Chronicpyelonephritis Uncomplicatedpyelonephritis Patientswithfever ,chillsandflank painbuttheyarehealthy, non-pregnant, female, without relevantcomorbiditiesandwithout structural or functional urinary tractabnormalities. Patients needhospitalization Thosepatientsneedlong-term antibiotic treatment even duringperiodswhentheyhave nosymptoms. chronic pyelonephritis is a rare condition and usually due to obstruction.Unlikeotherinfections, chronic pyelonephritis doesn t develop fromacutephaseitjust startsas chronic. Antibiotic given by IV route for 3-5daysuntilsymptomsrelieved for 24-48hrs. Iffeverandbackpaincontinue after72hrsof antibiotic,imagingtests(x-ray,ivu, ct scan) indicated to exclude abscesses, obstruction or other abnormality. Can be treated at home with oral antibioticsfor14dayswithoneof thefollowings: Cephalosporins Amoxicillin-Clavulanicacid Ciprofloxacin TMP-SMX. Fibrosis - Firstdosemaybegivenbyinjection. Dilated ureter

Treatment of specificpopulations Pregnantwomen UncomplicatedUTI Diabeticpatients HighriskforUTIandcomplications Similartopregnantwomen ForuncomplicatedUTI(any patient, not at pregnancy) need 3-5 days antibiotic treatment. ShouldbescreenedforUTI Havemorefrequentand more severeUTIs. Antibioticsduringpregnancyincludes:Amoxicillin, Ampicillin,Cephalosporins,andNitrofurantoin. Treatedfor7-14dayswith antibiotics even patients with uncomplicated infections PregnantwomenshouldNOTtakeQuinolonesor Tetracycline. Pregnant women with asymptomatic bacteriuria (evidenceofinfectionbutnosymptoms)have30%risk for acute pyelonephritis in the second or third trimester .Screeningand7-10daysantibioticneeded.

RememberwhenchildrenhaveUTIalwaystry toknowthecauseespeciallyinyoungboy. VeryImportant!!! Prof.hanansaidyoushouldknowthenameofthedrugs. Urethritisin Children Urethritis inMen VesicouretericReflux (VUR) Once a kid has recurrent UTI a congenitalabnormalitymightoccur. Sexually transmitteddisease Mostimportant causes: Neisseriagonorrheae Chlamydiatrachomatis Common in children with UTI (if not treated) can lead to pyelonephritis and kidney damage. Long-term (for months) antibiotic plus surgery used to correct VUR and preventinfections. Acute kidney infection (like fever, high bacteria count and pain): use Cefixime (oral) or IV Ceftriaxone or Gentamicin a one daily dose for 2-4 days followed by oral treatment eg. amoxicillin-clavulanic acid or TMP-SMX . Start with IV then continue w/ oral meditation for 14 days UsuallytreatedwithTMP-SMX orCephalexin. Treated with IM Ceftriaxone (work on Neisseria) + Doxycycline or Azithromycin (work on Chlamydia). Patientsshouldalsobetested for accompanyingSTD. SometimesgivenasIV. Gentamicin may be recommendedasresistanceto Cephalexin isincreasing.

Management of catheter-inducedUTI Thecatheterisaforeignbodysoitwill causeinfection Intermittent use ofcatheters: Ifcatheterisrequiredforlongperiods,itisbest tobeusedintermittently.( ) Verycommon Preventive measuresimportant. May bereplacedevery2weekstoreduceriskof infectionandirrigatingbladder*withantibiotics betweenreplacements. Catheter should not be used unless absolutelynecessaryandtheyshould beremovedassoonaspossible. irrigating of the bladder means that they enter sterile waterandsterileantibiotictowashandflushthebladder thenintroducetothenewcatheter. Dailyhygieneanduseofclosedsystemto preventinfection.

Catheter induced infections Itsnormalforpatientswhoareoncatheters tohaveaurinefullofbacteriasoitdoesn t meanthattheyhaveUTI. Wewillonlytreatpatientswithsymptoms. Antibioticuseforprophylaxisisrarely recommended since high bacterial counts present and patients do not develop symptomaticUTI. Catheterized patients who develop UTI withsymptomsoratriskforsepsis(feverand chill)shouldbetreatedforeachepisodewith antibioticsandcathetershouldberemoved, ifpossible. Antibiotictherapyhaslittlebenefitif thecatheteristoremaininplacefor longperiod. . Associatedorganismsareconstantly changing. Maybemultiplespeciesofbacteria.

Drs Notes vesicouretericreflux:*veryimportant* wheneverachildgetsUTIthanyoumustlookforacause.Mostofthemusuallyhavevesicouretericreflux. -whyisitimportant?Becauseitmayleadtoacutepyelonephritisandifnottreatedmayleadtorecurrentinfectionsleadingfinallytokidneydamage.yougive themantibioticsuntiltheygettheirsurgery,antibioticsincludeoralCefiximeorIVceftriaxone orGentamycinfollowedbyoraltreatment amoxicillin- clavulanic acid orTMP-SMX Case1:30yearoldw/ frequencyandpainfulurination.Urineanalysisshowed+leukocyteesteraseandnitrate.Microscopy revealedpresenceofWBCs& bacteria. -Diagnosis?Uncomplicatedacutecystitis -Durationoftreatment?Sinceit suncomplicated,thetreatmentshouldfrom3-5days. -Management?amoxicillinorTMP-SMXorCephalosporinfirstorsecondgenerationorciprofloxacinWhatifshewasdiabetic?itwouldbecomplicatedthusshe havetobetreatedfor7-14days. Case2: 30yearoldasymptomaticpregnantwoman.Culturewaspositivefor100,000CFU/mlEcoliSensitivetoalltestedabx. -Management?antibiotic:Amoxicillinoranarrowspectrumantibioticsinceshe spregnantandwedon ttoharmthefetus.otherantibioticsinclude Ampicillin, orCephalosporinsfirstorsecondgeneration( first:cephalexin,second:cefuroximeaxetil). Doctorasked:ifwehavethesamecasebutinsteadofpregnantwehavediabetic,whatwouldbethetreatment?Sinceshe sasymptomaticand non-pregnantthenyoudon ttreat. Another questionthedoctorasked:whichofthefollowingisanindicationtotreatanasymptomaticpatient?Pregnant Case3:30yearoldwithfrequencyandpainfulurination.Fever,flankpainandtendernessonexamofthearea.Urineanalysisshowed+leukocyteesteraseand nitrate.Microscopy revealedpresenceofWBCsandbacteria. -Diagnosis? Acutepyelonephritis -Management?InthiscasethepatientisnotthatsicksoyouwouldfavouroraltreatmentwithCiprofloxacinwhichisagoodchoice.Why?Becauseithashigh bioavailability;however,overuseofitmaycauseresistance IfthepatientwashighlysickyouwouldgowithIV2-4dayswithceftriaxone orgentamycinthenyouwouldstepdowntooral.

Drs Notes Case4:a4yearoldmalechildwithpyelonephritis. -Management?youcanusethirdgenerationcephalosporins(ifthepatientwasoldwecanstartw/ciprofloxacin) cefixime orfirstgeneration cephalexin or youcanstartwithGentamicinorIVCeftriaxonethenstepdowntooraltreatment(amoxicillin-clavulanicacidorTMP-SMX). (FoundtohaveVUR)thismightbementioneddirectlyinthecaseoritmightbementionedlaterinoneofthequestions -Management?Why?youshouldstartwithlong-termprophylacticantibioticuntiltheygettheirsurgery.Why?Becausemeanwhiletheyareprone to infectionswhichmayleadtokidneydamage. We mustknowtheconditionsofwhento consultthedoctor. Low-riskpatient(females)canbetreated withantibioticforthreedayswithouturineculture. AmoxicillinworkswellforE.coli. YoushouldwatchoutageandpregnancywhenusingFluoroquinolones.whenofthebadaspectsaboutusingprophylacticisthatresistancemaydevelop.Staph saprophyticusisoneofthecommonagentsthatcausePostcoitalUTI.inthecaseoflowerUTIsyoucanusenarrowspectrumantibiotic?Whynarrow spectrum? Because lower UTIs are not potentially harmful. Chronic pyelonephritis happens mostly whenever there s a structural or functional abnormality (ex: vesicoureteral reflux)inthesepatientyoushouldstartwithanantibioticuntiltheygetasugary. Inpregnantwomanyougowithanarrowspectrumbecausethetypeofantibioticmightharmtheinfant. Pregnantfemalesareatriskforpyelonephritis

Summary Relapsing infection Recurrent infections Uncomplicated pyelonephritis Moderate -sever pyelonephritis Chronic pyelonephritis Uncomplicated Complicated Low-riskpatient (woman) for recurrent infection 1-Aging 2-DM 2-Spinalcord injury 4-Catheterization 5-Comorbidities inchildren. two or more symptomatic UTIs within 6 monthsor3or more over a year. fever, chills and flank painbuthealthy,female non-pregnant, without comorbidities and without structural or functional UT abnormalities Patients need hospitalization need long-term antibiotic treatment even during periods whentheyhaveno symptoms. 1-treatment failure 2-structural 3-abnormalities 4-abscesses. Amoxicillin (with or without clavulanic acid) Cephlosporins(1or 2g) Fluoroquinolone TMP-SMX Nitrofurantoin ( forlongtermuse) Antibiotics used at the initialinfection Needpreventive therapy If infection occursless than 2 a year, aclean catch urine test should betaken for culture and treatedas initial attack for3d. at home with oral antibiotics: Cephalosporins, Amoxicillin-Clavulanic acid, Ciprofloxacin or TMP-SMX. Firstdosemaybegiven byinjection -Antibioticgiven by IVroute -If fever and back pain continue after 72 hrs of antibiotic, imaging tests to exclude abscesses, obstructionorother abnormality. c Antibioti - - Treatmentfor 7-14days Antibiotictaken as soon as symptoms develop 14days for3-5days 3 days antibiotic withouturinetest. e Tim - -

Pregnantwomen Urethritis inmen VUR Diabeti c patient s Have more frequent and moreseverUTIs. Childrenwith UTI Acutekidney infection -HighriskforUTIand should bescreened. -Pregnant women with asymptomaticbacteriuria have risk for acute pyelonephritis, Screening and 7-10 days antibiotic needed. Common in childrenwithUTI Can lead to pyelonephritis and kidney damage. Cefixime ( oral) or IV Ceftriaxone or Gentamicin a one daily dose for 2-4 days followedby oral treatment eg. amoxicillin-clav ulanic acid or TMP-SMX causes: 1-Neisseriagonorrheae 2-Chlamydia trachomatis Patients should be testedforotherSTD. Amoxicillin,Ampicillin, Cephalosporins, and Nitrofurantoin. NEVER Quinolones Fluoroquinolone ( ciprofloxacin ornorfloxacin) Treatedfor7-14 days with antibiotics even patients with uncomplicated infections TreatedwithIM Ceftriaxone + Doxycycline or Azithromycin. Long-term antibiotic+ surgery TMP-SMX Cephalexin. Gentamicin(if resistant for Cephalexin) Treatment Ifcatheterisrequiredforlongperiods,itisbesttobeusedintermittently,andirrigatebladderwith antibiotics. CatheterizedpatientswhodevelopUTIwithsymptomsoratriskforsepsisshouldbetreatedwith antibioticsandcathetershouldberemoved,ifpossible. Antibioticuseforprophylaxisisrarelyrecommendedsincehighbacterialcountspresentandpatientsdo notdevelopsymptomaticUTI.

Summary for antibiotic: Nitrofurantoi n Fluoroquinolone TMP-SMX Cephalexin Gentamicin Amoxicillin Cephalosporins - - ciprofloxacin norfloxacin - - - - 1-Uncomplicated UTI 2-Uncomplicated pyelonephritis- VUR(with Clavulanicacid) 3-Safewith pregnancy 1-Uncomplicated UTI 2-Uncomplicated pyelonephritis 3-Safewith pregnancy 1-Uncomplicated UTI 2-Postcoital antibiotics 3-Uncomplicated pyelonephritis Uncomplicated UTI firstchoice if otherantibiotics areresistant. 1-Uncomplicated UTI 2-Postcoital antibiotics(UTIis relatedtosexual activity) 3-Prophylactic antibiotics 4-Uncomplicated pyelonephritis 5-Childrenwith UTI 6-VUR 1-Uncomplicated UTI 2-Prophylactic antibiotics 3-Safewith pregnancy 1-Postcoital antibiotics 2-Prophylactic antibiotics 3-Childrenwith UTI 1-Childrenwith UTI 2-VUR Use in

3-Ayoungmarriedmanwasdiagnosedwithurethritis.To completeyourtestswhatdoyouhavetodonext? A)CTscan. B)Test him for STD.. C)Look for abscesses. D)Nothingshouldbedone. MCQs Thanks team 435-436 1-50yearolddiabeticmalecamewithfrequenturination andadysuria,hisdoctordiagnosedhimwithurethritis. Whichofthefollowingcanbeisthebestchoiceforhim? A-Azithromycinefor7days. B-Doxycyclinefor7days. C-Azithromycinefor7-14days. D-Doxycyclinefor7-14days. 4-A26yearoldfemalepresentedtotheclinicwitha recurrentdysuriaaftersexualactivity,whichofthe followingprocedurescanbenefitherbest? A-A singledoseofgentamicinbeforeintercourse. B-A singledoseof TMP-SMX before intercourse. C-Asingledoseofgentamicinafterintercourse. D-AsingledoseofTMP-SMXafterintercourse. 2-A10yearschildpresentedwithUTI,wasprescribed Cephalexin,secondurineanalysisafterafullcourseof Cephalexin shows same bacteria. What should you prescribeasalternativeantibiotic? A-norfloxacin B-Ciprofloxacin C-Nitrofurantoin D-Gentamicin 5-Afemalepatientwascomplainingofflankpain,chills and her temperature was high, she was diagnosed with pyelonephritis.Shehasnofurtherproblems.Whatisthe besttreatmentplanforthiscase? A-Gentamicinorallyfor7days. B-Ciprofloxacinorallyfor14days. C-Cefiximeorallyfor14days. D-Ceftriaxoneorallyfor7days 5-B 4-D 3-B 2-D 1-D

SAQ 1 thechoiceofantibioticdependon? susceptibility pattern of bacteria 2 Apregnantwoman surineanalysisshowbacteriuria,hergeneralappearanceis normal.Shecomplainofnothing,and shedenieshavingnauseaorvomiting. Whatshouldyoubeconcerned of? acutepyelonephritis Forhowlongwillyouputheronantibiotic? 7-10days whichantibioticwecannotgivetothispatient? Quinolones, Fluoroquinolone ( ciprofloxacin ornorfloxacin) 3-AmalepatientpresentedwithUrethritis,whatwouldyouprescribehim? IMCeftriaxone+DoxycyclineorAzithromycin.

Team Leaders Alanoud Almansour & OmarAlsuhaibani Please contact us if you have anysuggestion, correction, or question: Microbiology.med437@gmail.com Team Members Special thanks to: Reem AlQahtani Alanoud Alessa Dana Alrasheed Hadeel Awartani KhuloodAlwehaibi Nada Alobaid NorahAlkadi Nouf Alotaibi Noura Alothaim Reema Aldihan Reema AlEnezy Sara Alsultan ShouqAlqahtani AdelAlsuhaibani Hussien Alami KhaledAldosari MohammedAldwaghri SulaimanAlzomia