UTI
Complicated
Uncomplicated
Risk factors
Treatment
Examples
sexual intercourse
new sexual partner
history of a UTI in a first-degree female relative
Cystitis
Presentation
frequency
Urgency
Urinalysis and culture are not typically needed
dysuria
Pyelonephritis
Treatment
Presentation
Diagnosis
fever
chills
flank pain
requires testing
Use results from urinalysis and urine culture to confirm diagnosis and guide therapy
Treatment
inpatient: non-pregnant women with acute pyelonephritis
outpatient: non-pregnant women with acute pyelonephritis
fluoroquinolones
ciprofloxacin 500 mg PO BID x7d
ciprofloxacin ER 1000 mg PO qd x7d
levofloxacin 750 mg PO qd x5d
folate inhibitors
TMP/SMX 160mg/800mg PO BID x14d
initial
step-down: same as outpatient
ciprofloxacin 400 mg IV BID
levofloxacin 250-500 mg IV qd
ceftriaxone 1000 mg IV qd
aminoglycoside 5 mg/kg IV qd
imipenem/cilastatin 500 mg IV q6h
Infections occurring despite the presence of anatomical protective measures
UTI in males are by definition complicated
Infections occurring due to anatomical abnormalities, for example, an obstruction, hydronephrosis, renal tract calculi, or colovesical fistula
Infections occurring due to an immune compromised state
Atypical organisms causing UTI
Recurrent infections despite adequate treatment
Infections occurring in pregnancy
Infections in renal transplant patients
hospitalized with critical illness warranting intensive care or urinary tract obstruction
vancomycin + antipseudomonal carbapenem
other hospitalized patients
risk for MDR
yes: pip-tazo or antipseudomonal carbapenem
no: ceftriaxone or pip-tazo or fluoroquinolones
outpatient
risk for MDR
no, and no concerns with fluoroquinolone: ciprofloxacin or levofloxacin
yes: ertapenem FOLLOW BY ciprofloxacin or levofloxacin
no, but with concerns with fluoroquinolone: ceftriaxone or ertapenem or gentamin or tobramycin FOLLOWED BY TMP-SMX or amoxcillin/clavulanate or cefpodoxime or cefdinir or cefadroxil
First line agents
Macrobid
Trimethoprim/sulamethoxazole
MOA: inactivates or alters bacterial ribosomal proteins leading to inhibition of protein synthesis, aerobic energy metabolism, DNA, RNA, and cell wall synthesis
PK/PD:60-90% protein binding, half-life 20-60min (prolonged with renal impairment), renal excretion
Avoid in CrCl <30 mL/min and patients on dialysis
Indications: acute uncomplicated cystitis, prophylaxis for recurrent infection in cystitis
Special populations: avoid in elderly and children <1 month of age; can cross placenta and is present in breast milk
Indicated if it has not been used for urinary tract infection in prior 3 months and local resistance for Escherichia coli known to be < 20%
Dosing: then use 160 mg/800 mg orally twice daily for 3 days
Monitoring: S/Sx of pulmonary reaction, numbness or tingling in extremities, CBC, periodic LFTs, renal function
Warnings: Risk of pulmonary toxicity, peripheral neuropathy and hepatic reactions.
Dosing: 100 mg BID for 5-7 days
Drug Interactions:
Special Populations:
Warnings: hypersensitivity to sulfa drugs, severe rash (SJS).
PK/PD:
Drug Interactions:
Monitoring:
Adverse Reactions:
Adverse Reactions: Rash, GI discomfort, hyperkalemia, hyponatremia, myalgia
Headache (6%) Nausea (8%) Hyperphosphatemia (5%) Anemia (5%)
dapsone, eplerenone, nitric oxide, prilocaine
CBC, electrolytes, renal function
ACEis, ARBs, digoxin, dofetilide, eplerenone. dapsone, cyclosporine, antidiabeic agents, nitric oxide, phenytoin, prilocaine, rifampin
CL of TMX is 19% lower in elderly patients. Use with caution in pts with decreased CrCl. Can cross placenta and is present in breast milk
A: rapid oral absorption - 90-100% D: Vd ~1.3L/kg M: hepatic via CYP2C9
E: excreted as metabolites and unchanged drug