Urinary tract infection (UTI)

Dr. Salah Wageehuddein, Clinical

Pharmacy
 Definitions
1- A urinary tract infection (UTI) is defined
as the presence of microorganisms in the
urine that cannot be accounted for by
contamination.

Dr. Salah Wageehuddein, Clinical

Pharmacy
2- Lower tract infections:
cystitis (bladder), urethritis (urethra),
prostatitis (prostate gland), and
epididymitis.

Dr. Salah Wageehuddein, Clinical

Pharmacy
3- Upper tract infections:

involve the kidney and are referred to as

pyelonephritis.

Dr. Salah Wageehuddein, Clinical

Pharmacy
4- Uncomplicated UTIs:

are not associated with structural or

neurologic abnormalities that may interfere
with the normal flow of urine or the voiding
mechanism.

Dr. Salah Wageehuddein, Clinical

Pharmacy
5- Complicated UTIs:
Result from:
• Congenital abnormality.
• Distortion of the urinary tract.
• Stones.
• Indwelling catheter.
• Prostatic hypertrophy.

Dr. Salah Wageehuddein, Clinical

Pharmacy
6- Recurrent UTIs:

These infections are either due to

reinfection or relapse.

Dr. Salah Wageehuddein, Clinical

Pharmacy
6.1- Reinfections: 6.2- Relapse:

caused by a different represents the

organism and account development of
for the majority of repeated infections
recurrent UTIs. caused by the same
initial organism.

Dr. Salah Wageehuddein, Clinical

Pharmacy
 Pathophysiology
• The bacteria causing UTIs usually originate from
bowel flora of the host. UTIs can be acquired via
three possible routes: the ascending,
hematogenous, or lymphatic pathways.

• The bacteria are believed to enter the bladder

from the urethra. Once in the bladder, the
organisms multiply quickly and can ascend the
ureters to the kidney.

Dr. Salah Wageehuddein, Clinical

Pharmacy
 Virulence factors
1- Fimbriae: resulting in colonization of the urinary
tract, bladder infections, and pyelonephritis.

2- Hemolysin: a cytotoxic protein produced by

bacteria that lyses a wide range of cells
including erythrocytes, leukocytes, and
monocytes.

3- Aerobactin: which facilitates the binding and

uptake of iron by Escherichia coli.
Dr. Salah Wageehuddein, Clinical
Pharmacy
 Microbiology
The most common causes of uncomplicated
UTIs:
• E. coli (>85% of community-acquired
infections)
• Staphylococcus saprophyticus (coagulase-
negative staphylococcus) (5-15%).

Dr. Salah Wageehuddein, Clinical

Pharmacy
The urinary pathogens in complicated or
nosocomial infections may include:
• E. coli (<50%)
• Proteus spp
• Klebsiella pneumoniae
• Enterobacter spp
• Pseudomonas aeruginosa
• Staphylococci, and enterococci
• Candida spp (critically ill and chronically
catheterized patient).

Dr. Salah Wageehuddein, Clinical

Pharmacy
• The majority of UTIs are caused by a
single organism.

• Patients with stones, indwelling urinary

catheters, or chronic renal abscesses,
multiple organisms may be isolated.

Dr. Salah Wageehuddein, Clinical

Pharmacy
Signs and symptoms

Dr. Salah Wageehuddein, Clinical

Pharmacy
• The nitrite test can be used to detect the
presence of nitrate-reducing bacteria in the urine
(such as E. coli ).

• The leukocyte esterase test is a rapid dipstick

test to detect pyuria.

• A method to detect upper UTI is the antibody-

coated bacteria test, an immunofluorescent
method that detects bacteria coated with
immunoglobulin in freshly voided urine.

Dr. Salah Wageehuddein, Clinical

Pharmacy
 DESIRED OUTCOME
The goals of treatment:

1. Prevent or treat systemic consequences

of infection.

2. Eradicate the invading organism.

3. Prevent recurrence of infection.

Dr. Salah Wageehuddein, Clinical

Pharmacy
PHARMACOLOGIC TREATMENT
• Acute uncomplicated cystitis
• Symptomatic abacteriuria.
• Asymptomatic bacteriuria.
• Complicated UTIs.
• Recurrent infections.
• Prostatitis.

Dr. Salah Wageehuddein, Clinical

Pharmacy
 1- Acute Uncomplicated Cystitis
Microbiology:
• E. coli.
• S. saprophyticus
• K. pneumoniae and Proteus mirabilis.

Treatment:
Short-course therapy (3-day therapy) with:
• Trimethoprim–sulfamethoxazole or
• a fluoroquinolone (e.g., ciprofloxacin, levofloxacin, or
norfloxacin) is superior to single-dose therapy for uncomplicated
infection and should be the treatment of choice.

• Amoxicillin or sulfonamides are not recommended because of the

high incidence of resistant E. coli.

Dr. Salah Wageehuddein, Clinical

Pharmacy
• Follow-up urine cultures are not necessary
in patients who respond.

Dr. Salah Wageehuddein, Clinical

Pharmacy
 2- Symptomatic Abacteriuria
• Single-dose or short-course therapy with trimethoprim–
sulfamethoxazole has been used effectively.

• Prolonged courses of therapy are not necessary for the

majority of patients.

• If single-dose or short-course therapy is ineffective, a

culture should be obtained.

• If the patient reports recent sexual activity, therapy for

Chlamydia trachomatis should be considered
(azithromycin 1 g as a single dose or doxycycline 100
mg twice daily for 7 days).

Dr. Salah Wageehuddein, Clinical

Pharmacy
 3- Asymptomatic Bacteriuria
• The management of asymptomatic bacteriuria depends on the age
of the patient and, if female, whether she is pregnant.

• In children, treatment should consist of conventional courses of

therapy, as described for symptomatic infections.

• In the nonpregnant female, therapy is controversial; however, it

appears that treatment has little effect on the natural course of
infections.

• Most clinicians feel that asymptomatic bacteriuria in the elderly is a

benign disease and may not warrant treatment. The presence of
bacteriuria can be confirmed by culture if treatment is considered.

Dr. Salah Wageehuddein, Clinical

Pharmacy
 4- Complicated Urinary Tract
Infections
Acute Pyelonephritis:
• The presentation of high-grade fever (greater
than 38.3°C [100.9°F]) and severe flank pain
should be treated as acute pyelonephritis, and
aggressive management is warranted.

• Severely ill patients with pyelonephritis should

be hospitalized and IV drugs administered
initially.

Dr. Salah Wageehuddein, Clinical

Pharmacy
• Mild cases can be treated using oral
antibiotics that have shown efficacy in this
setting include trimethoprim
sulfamethoxazole or fluoroquinolones.

• If a Gram stain reveals gram-positive

cocci, Streptococcus faecalis should be
considered and treatment directed against
this pathogen (ampicillin).
Dr. Salah Wageehuddein, Clinical
Pharmacy
In the seriously ill patient:

1- IV fluoroquinolone, an aminoglycoside
with or without ampicillin. Or

2- an extended-spectrum cephalosporin
with or without an aminoglycoside.

Dr. Salah Wageehuddein, Clinical

Pharmacy
• If the patient has been:
• 1- hospitalized in the last 6 months,
• 2- has a urinary catheter, or
• 3- is in a nursing home,
• the possibility of P. aeruginosa and enterococci infection,
as well as multiply-resistant organisms, should be
considered. In this setting, ceftazidime, ticarcillin-
clavulanic acid, piperacillin, aztreonam, meropenem,
or imipenem, in combination with an aminoglycoside,
is recommended.

• If the patient responds to initial combination therapy, the

aminoglycoside may be discontinued after 3 days.

Dr. Salah Wageehuddein, Clinical

Pharmacy
• Follow-up urine cultures should be
obtained 2 weeks after the completion of
therapy to ensure a satisfactory response
and to detect possible relapse.

Dr. Salah Wageehuddein, Clinical

Pharmacy
 5- Recurrent Infections
• In patients with infrequent infections (i.e.,
fewer than three infections per year), each
episode should be treated as a separately
occurring infection.

• Short-course therapy should be used in

symptomatic female patients with lower
tract infection.

Dr. Salah Wageehuddein, Clinical

Pharmacy
• In patients who have frequent
symptomatic infections, long-term
prophylactic antimicrobial therapy may be
instituted (see Table 50-4). Therapy is
generally given for 6 months, with urine
cultures followed periodically.

Dr. Salah Wageehuddein, Clinical

Pharmacy
• In women who experience symptomatic
reinfections in association with sexual
activity, self administered, single-dose
prophylactic therapy with trimethoprim -
sulfamethoxazole taken after intercourse
has been found to significantly reduce the
incidence of recurrent infection in these
patients.

Dr. Salah Wageehuddein, Clinical

Pharmacy
• Women who relapse after short-course therapy
should receive a 2-week course of therapy.

• In patients who relapse after 2 weeks, therapy

should be continued for another 2 to 4 weeks.

• If relapse occurs after 6 weeks of treatment,

urologic examination should be performed, and
therapy for 6 months or even longer may be
considered.
Dr. Salah Wageehuddein, Clinical
Pharmacy
 SPECIAL CONDITIONS
1- Urinary Tract Infection in Pregnancy

• In patients with significant bacteriuria, symptomatic or

asymptomatic, treatment is recommended in order to
avoid possible complications during the pregnancy.

• Therapy should consist of an agent with a relatively low

adverse-effect (a sulfonamide, cephalexin,
amoxicillin, amoxicillin/clavulanate, nitrofurantoin)
administered for 7 days.

Dr. Salah Wageehuddein, Clinical

Pharmacy
• Tetracyclines should be avoided because of
teratogenic effects, and sulfonamides should not
be administered during the third trimester
because of the possible development of
kernicterus and hyperbilirubinemia.

• Also, the fluoroquinolones should not be given

because of their potential to inhibit cartilage and
bone development in the newborn.

Dr. Salah Wageehuddein, Clinical

Pharmacy
2- Catheterized Patients
• When bacteriuria occurs in the asymptomatic, short-term
catheterized patient (less than 30 days), the use of
systemic antibiotic therapy should be withheld and the
catheter removed as soon as possible.

• If the patient becomes symptomatic, the catheter should

again be removed, and treatment as described for
complicated infections should be started.

• The use of prophylactic systemic antibiotics in patients

with short-term catheterization reduces the incidence of
infection over the first 4 to 7 days.

Dr. Salah Wageehuddein, Clinical

Pharmacy
Dr. Salah Wageehuddein, Clinical
Pharmacy
 Prostitis
• Prostatitis is an inflammation of the
prostate gland and surrounding tissue as a
result of infection.

• It can be either acute or chronic.

Dr. Salah Wageehuddein, Clinical

Pharmacy
• The majority of patients can be managed with oral
antimicrobial agents, such as trimethoprim–
sulfamethoxazole or the fluoroquinolones
(ciprofloxacin, levofloxacin).

• When IV treatment is necessary, IV to oral sequential

therapy with trimethoprim–sulfamethoxazole or a
fluoroquinolone, such as ciprofloxacin or ofloxacin,
would be appropriate.

• The total course of therapy should be 4 weeks, which

may be prolonged to 6 to 12 weeks with chronic
prostatitis.

Dr. Salah Wageehuddein, Clinical

Pharmacy
• Parenteral therapy should be maintained
until the patient is afebrile and less
symptomatic.

• The conversion to an oral antibiotic can be

considered if the patient has been afebrile
for 48 hours or after 3 to 5 days of IV
therapy.

Dr. Salah Wageehuddein, Clinical

Pharmacy
• The choice of antibiotics in CBP should include
those agents that are capable of crossing the
prostatic epithelium into the prostatic fluid in
therapeutic concentrations and that also
possess the spectrum of activity to be effective.

• Currently, the fluoroquinolones (given for 4 to 6

weeks) appear to provide the best therapeutic
option in the management of CBP.

Dr. Salah Wageehuddein, Clinical

Pharmacy
Dr. Salah Wageehuddein, Clinical
Pharmacy