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PASIN HASSADUM
B. Pharm., M. Pharm. (community pharmacy) Pharm. D
Content
Introduction
Classification of UTIs
Uncomplicated UTIs in Adults
Complicated UTIs in Adults
INTRODUCTION
Pathogenesis
INTRODUCTION
Pathogenesis
ascent from the urethra : most common pathway
organisms of enteric origin : E. coli and other Enterobacteriaceae
Women > men
increased risk of infection : bladder catheterisation or instrumentation
haematogenous or lymphatic spread: primary infections elsewhere in the
body
INTRODUCTION
Based on :
clinical symptoms
laboratory data
microbiological findings
Divided :
Uncomplicated
complicated UTIs
sepsis
Anatomical level of infection
Anatomical level of infection
Urethra: urethritis (UR)
Urinary bladder: cystitis (CY)
Kidney: pyelonephritis (PN)
Blood stream: sepsis (US).
10
Urine excretion system
B
11
Urine excretion system
Classification of UTIs
Classification of UTIs
Definition
Acute uncomplicated UTIs :
Acute cystitis
Pyelonephritis
Mostly in women
Without structural and functional abnormalities urinary tract, kidney
diseases, or comorbidity
Uncomplicated UTIs in Adults
Pathogen
E. coli 70-95%
Staphylococcus saprophyticus 5-10%
Occasionally : Enterobacteriaceae : Proteus mirabilis and Klebsiella sp.
Acute uncomplicated cystitis
Acute uncomplicated pyelonephritis
Recurrent (uncomplicated) UTIs in women
UTIs in pregnancy
UTIs in postmenopausal women
Acute uncomplicated UTIs in young men
Asymptomatic bacteriuria
Acute uncomplicated cystitis
Diagnosis
Clinical diagnosis
irritative symptomatology
dysuria, frequency and urgency
absence of vaginal discharge
no other risk factors for complicated UTIs
Laboratory diagnosis
Urine dipstick testing
Urine cultures are recommended
suspected acute pyelonephritis
symptoms : not resolve or recur within 2-4 wk after the complete tx
women who present with atypical symptoms
A colony count of > 103 cfu/mL + symptoms of acute uncomplicated cystitis
Follow-up Routine post-tx UA or UC in asymptomatic pt. not indicated
Acute uncomplicated cystitis
Introduction
Acute uncomplicated cystitis
Tx IDSA
Acute uncomplicated pyelonephritis
Diagnosis
Clinical diagnosis
flank pain
nausea and vomiting
fever (> 38 C)
costovertebral angle tenderness
+/- symptoms of cystitis
Acute uncomplicated pyelonephritis
Acute uncomplicated pyelonephritis
Acute uncomplicated pyelonephritis
Follow-up
Routine post-tx. UA/UC asymptomatic: not be indicated
Not improve within 3 days, or resolve and then recur within 2
weeks, repeated UA/UC
Appropriate investigation: ultrasound, CT etc
R/O any complicating factors
Uncomplicated UTIs in Adults
Duration :
Short courses of antimicrobial therapy (3 days)
Follow-up
UA/UC 1-2 weeks after completion Tx: asymptomatic bacteriuria and symptomatic
UTI in preg
Prophylaxis Postcoital prophylaxis : preg. history of frequent UTIs before
onset of preg.
UTIs in pregnancy
Treatment of pyelonephritis
After clinical improvement parenteral therapy can be switched to oral
therapy for a total treatment duration of 7-10 days
Complicated UTI: Appropriate antimicrobial therapy for 7-10 days
Uncomplicated UTIs in Adults
A complicated UTI:
structural or functional abnormality of the genitourinary tract
presence of an underlying disease
Pathogen
Enterobacteriaceae: E. coli (most common)
Depending on the underlying conditions
Non-fermenters :Pseudomonas aeruginosa
G+ cocci : Staphylococci and Enterococci
Complicated UTIs in Adults
Treatment strategy : 3 goals
management of the urological abnormality,
antimicrobial therapy
supportive care
The duration of Tx
usually 7-14 days
May be prolonged for up to 21 days
Until predisposing factors are completely removed
True cure without recurrent infection
UA/UC: 5-9 days after completion Tx and also 4-6 weeks later
Complicated UTIs in Adults
Complicated UTIs in Adults
Clinical presentation
+/- typical symptoms : dysuria, urgency, frequency, flank pain, costovertebral
angle tenderness, suprapubic pain and fever
Severe obstructive acute pyelonephritis
Urosepsis
Especially lower urinary tract symptoms (LUTS) : not UTIs
Benign prostatic hyperplasia (BPH)
Transurethral resection of the prostate (TURP)
Urological abnormalities : concomitant medical conditions
Diabetes mellitus (10%) and
Renal failure
Immunosuppression
Complicated UTIs in Adults
Urine cultures
> 105 cfu/mL and > 104 cfu/mL MSU of women and men,
catheter urine sample > 104 cfu/mL
Pyuria > 10 WBC/hpf
Dipstick
Leukocyte esterase test
Haemoglobin
Nitrite
Complicated UTIs in Adults
Complicated UTIs associated with urinary stones
E. coli and enterococci (less important pathogens)
82% of patients infected with urease-producing organisms
Proteus and Pseudomonas sp
The duration of Tx
usually 7-14 days
May be prolonged for up to 21 days
Until predisposing factors are completely removed
Before and after the completion tx. UA/UC must be.
Complicated UTIs in Adults
Content
Introduction
Classification of UTIs
Uncomplicated UTIs in Adults
Complicated UTIs in Adults
Urosepsis
Ref. EAU guideline 2013
Case study 1:community pharmacy
CC:Thai female 30 yrs dysuria, frequency, pyuria
PI: 2 day
PMH: no
PE: BP100/70 mmHg HR 80 bt/min RR 20 bt/min T 37C
Med: Cyproterone acetate 2.000 mg - EE 35 cmg 1 tab x 1 hs
Problem :
S: O: A: P:
Case study 2
CC: Thai female 60 yrs dysuria, frequency, pyuria
PI: 2 day
PMH: 2 wks stroke
PE: BP140/90 mmHg HR 80 bt/min RR 20 bt/min T 38C
Med:
losartan 50 mg 1 x od
ASA 81 mg 1 x od
atorvastatin 40 mg 1 x od
metformin 500 mg 2 x bid
Case study 2
Problem:
S:
O:
A: PK/PD , IESAC
P:
Ceftazidime
Strength x g/vial
Reconstitution solution : SWFI , D5W ,NSS,
Administration : IV push IV drip IM
C max
T1/2
PK