UTI

Adverse Effects

Treatment

Etiology/Pathophysiology

Goals of Therapy

Monitoring and Follow-Up

Signs and Symptoms

Acute Uncomplicated UTI

Acute Complicated UTI (pyelonephritis)

Acute simple cystitis (uncomplicated UTI) is when there is no concern that the infection has extended beyond the bladder.

Colonization of the vaginal introitus or urethral meatus by uropathogens from the fecal flora, followed by ascension via the urethra into the bladder.

Acute UTI accompanied by signs or symptoms that suggest extension of infection beyond the bladder (acute complicated UTI) :

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Fever (>99.9°F/37.7°C)¶

Chills, rigors, significant fatigue or malaise beyond baseline, or other features of systemic illness

Flank pain

Costovertebral angle tenderness

Pelvic or perineal pain in men

Eradicate the infection

Acute simple UTI

Hematuria

Urinary frequency and urgency

Dysuria

Suprapubic pain

Pyelonephritis (complicated UTI) is when there is concern the infection has extended beyond the bladder- kidney/upper urinary tract)

Prevent urosepsis

Control symptoms

Reduce the risk of renal damage

Patients who have persistent symptoms after 48 to 72 hours of empiric antimicrobial therapy or have recurrent symptoms:

urine culture
empiric treatment with another antimicrobial agent

Follow-up urine cultures are not needed in patients with acute simple cystitis whose symptoms resolve on antimicrobials. For patients who had hematuria on initial presentation, a urinalysis should be repeated several weeks following antimicrobial therapy to evaluate for persistent hematuria

Patients that DO NOT have risk factors for Multi-Drug Resistant gram negative organisms

Nitrofurantoin

Sulfamethoxazole-Trimethoprim

Fosfomycin

Dosing- 3 grams of powder mixed in water as a single oral dose

PK:

Mild to moderate pyelonephritis

critically ill patients empirical therapy

Fluoroquinolones (Ciprofloxacin or Levofloxacin)

Sulfamethoxazole-Trimethoprim

IV fluoroquinolone

IV aminoglycoside with or without ampicillin

IV extended-spectrum cephalosporins with or without an aminoglycoside

Dosing- 800/160 mg PO BID for 3 days (7 days for males)

Dosing- 100mg PO BID for 5 days (7 days for males)

Rapidly absorbed

Half- life: 3-8 hours, 50 hours in CrCl < 54 ml/min, 40 hours in CKD Stage 5

Renal excretion decreases to 11% with CrCl < 54ml/min

Rapid, completely absorbed

Half-life: 6-11 hours (TMP), 9-12 hours (SMX)

Renally excreted as metabolites and unchanged drug, dosage adjustment necessary

Renally excreted, contraindicated in CrCl < 60

Well absorbed

Half-life: 20-60 minutes, prolonged with renal impairment

MOA

Risk Factors

History of UTI

Patients who tend to hold their urine for long periods of time

Immunosuppressed clients

BPH diagnosis

Caused by E.coli and other gram-negative enteric organisms

Inhibits bacterial wall synthesis by inactivating pyruvyl transferase, which is critical in the synthesis of cell walls by bacteria

Excreted in urine (38% as unchanged) and feces (18% as unchanged)

Bioavailability: 37% [30% with food]

Interferes with bacterial folic acid synthesis and growth via inhibition of dihydrofolic acid formation as well as inhibit dihydrofolic acid reduction to tetrahydrofolate, resulting in further inhibition of the folic acid pathway

Metabolized via CYP2C9 (SMX)

Reduced by bacterial flavoproteins to reactive intermediates which inactivate or alter bacterial ribosomal proteins and other macromolecules

Protein binding: 60-90%

Bioavailability: increased with food by 40%

Adverse Effects

increased serum phosphate, flatulence, nausea, headache, C. diff, DILI, peripheral neuropathy, pulmonary toxicity

Special Populations

hypersensitivity reactions, dermatitis, skin photosensitivity, skin rash, hyperkalemia diarrhea, nausea, stomatitis, vomiting

Adverse Reactions

headache, pain, dizziness, skin rash, diarrhea, nausea, dyspepsia, rhinitis

Adverse Effects

Renal Impairment: Dose adjustment required in patients with renal impairment

Special Populations

Patient Counseling

Drug causes sun sensitivity. Pt should use sunscreen, cover skin with clothing and a hat, and avoid the sun/tanning beds.

Pt should maintain adequate hydration during therapy to prevent crystalluria and renal stone formation.

Patient should also report signs/symptoms of a severe skin reaction such as Stevens-Johnson syndrome (flu-like symptoms, spreading red rash, or skin/mucous membrane blistering) or toxic epidermal necrolysis (widespread peeling/blistering of skin).

Advise patient to immediately report signs/symptoms of fulminant hepatic necrosis (somnolence, confusion, jaundice, abdominal pain), blood dyscrasia, severe diarrhea, or shortness of breath.

Patient Counseling

Drug may cause brown-color urine.

Drug may cause loss of appetite, nausea, vomiting, or hemolytic anemia.

Tell patients on therapy for 6 months or longer to report signs of adverse pulmonary effects such as malaise, dyspnea on exertion, cough, or signs of diffuse interstitial pneumonitis or fibrosis.

Patient should take drug with food.

Instruct patient to report signs/symptoms of hepatic dysfunction, or neuropathy.

Pediatric: contraindicated in children < 1 month of age (increased risk of hemolytic anemia)

Elderly: avoid use in geriatric patients

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Special Populations

Elderly: Use with caution, greater risk for more severe side effects

Use with caution in people with potential for folate deficiency

Contraindicated in people with sulfa allergy

Immediately report s/sx of Clostridium difficile associated diarrhea (severe, watery, or bloody diarrhea)

Mix drug with 3-4 oz water (not hot) before ingesting. Do not ingest dry powder form of the drug, it must be dissolved in water first.