Lecture 24 - UTIs Part 2

what are the usual pathogens of uncomplicated UTI

Escherichia coli

Staphylococcus saprophyticus

Other Enterobacterales

what is the first go to treatment for uncomplicated UTI

nitrofurantoin

what are alternative options for uncomplicated UTI

fosfomycin

cephalexin

TMP/SMX (can use only TMP if sulfa allergy)

pivmecillinam

cefixime (broader spectrum, less ideal to use)

fluoroquinolone**

(should choose an agent not used in the last 6 months)

why is nitrofurantoin the ideal choice for uncomplicated UTI

excreted in urine - good local effect

very little effect on gut bacteria

little resistance - many different mechanisms against bacteria

why are fluoroquinolones not ideal to use for uncomplicated UTI

higher side effect risk compared to other antimicrobials

more broad spectrum which is unnecessary

what are the usual pathogens of complicated UTI (no risk factors)

Escherichia coli

Staphylococcus saprophyticus

Other Enterobacterales

what is outpatient treatment for pyelonephritis - outpatient

ceftriaxone IV x 1 dose followed by oral therapy or

gentamicin IV x 1 dose followed by oral therapy

what are oral therapy options for pyelonephritis - outpatient

cefixime

amoxi-clav

fluoroquinolone

TMP-SMX

why are nitrofurantoin or fosfomycin not used for pyelonephritis

do not achieve very high levels in the kidneys or bloodstream

what are treatment options for pyelonephritis - hospitalized/septic

ceftriaxone IV

gentamicin IV

what are the usual pathogens for complicated UTI with risk factors (e.g. recent ABX, immunocompromised, obstructive uropathy, previous resistant organism)

Escherichia coli

Other Enterobacterales

Enterococcus spp

Pseudomonas aeruginosa

Others

what are treatment options for complicated UTI - Septic and obstructive uropathy, recent instrumentation, immunocompromised, or cephalosporins in last 3 months

piperacillin-tazobactam IV ± gentamicin IV

what are treatment options for complicated UTI - Septic and previous ceftriaxone/piperacillin-tazobactam resistant Gram-negative organism

meropenem IV ± gentamicin IV

what are usual pathogens for catheter associated UTI

Escherichia coli

Other Enterobacterales

Enterococcus spp

CoNS

Others

what is treatment for catheter associated UTI - Afebrile and systemically well

cefixime

amoxi-clav

fluoroquinolone

TMP-SMX

what is treatment for catheter associated UTI - Febrile and/or systemically unwell

ampicillin IV PLUS [ceftriaxone IV or gentamicin IV]

(ampicillin provides coverage against enterococcus)

what is the treatment for catheter associated UTI - Septic and obstructive uropathy, recent instrumentation, immunocompromised, cephalosporins in last 3 months, or previous ceftriaxone/piperacillin-tazobactam resistant Gram-negative organism

treat as complicated UTI

how soon do symptoms improve after starting ABX

48-72 hours

what symptoms should you always ask about for UTI follow up

systemic symptoms (or factors concerning for pyelonephritis, including nausea and vomiting)

is a repeat urine C&S recommended after completion of therapy

generally not recommended unless treatment failure

(or pregnant patients, for whom ongoing screening and treatment of ASB is indicated)

What is your approach to this patient?

Urine C&S is not necessary

Treat with: Nitrofurantoin BID x 5 days

Follow up in a couple of days

What is your approach to this patient?

Is he having any symptoms - no

• Why was urine culture sent - part of routine physical

• No treatment necessary - asymptomatic bacturia (unless patient is going to be having an invasive procedure)

What is your approach to this patient if he was having symptoms?

Nitrofurantoin or cephalexin (narrower spectrum)

what are the usual pathogens for UTI in pregnant patients

Escherichia coli

Streptococcus agalactiae

Staphylococcus saprophyticus

Other Enterobacterales

what are treatment options for cystitis in pregnancy

nitrofurantoin (not to be used in 3rd trimester)

cephalexin

cefixime

fosfomycin

TMP/SMX (not to be used in 1st or 3rd trimester)

pivmecillinam

what are treatment options for pyelonephritis in pregnancy

ceftriaxone IV

ampicillin IV

is a urine C&S recommended post-treatment for pregnant patients

yes after 1 week follow by monthly follow-up cultures during remainder of pregnancy

what is the definition of relapse

Same organism

typically within 2-4 weeks after completion of therapy

Consider investigation for pyelonephritis or renal abscess

what is the definition of re-infection

Same or different organism

Over 90% of recurrences are due to this

how can UTIs be prevented

Avoid the use of spermicides or spermicide-coated condoms

Adequate hydration (e.g., additional 1.5 L of water daily)

Post-coital voiding

Cranberry products (cranberry juice → cranberry + hydration)

Topical vaginal estrogen (postmenopausal women)***

• E.g., vaginal cream, vaginal rings, etc

E. coli vaccine in development

what is considered frequent recurrences

≥ 3 episodes/year or ≥ 2 episodes/6 months

when should prophylactic treatment be considered in females with recurrent UTIs

should confirm eradication of UTI with negative urine culture 1-2 weeks post-treatment before initiating prophylaxis

pericoital prophylaxis or continuous prophylaxis, patient initiated treatment

what are options for pericoital prophylaxis

TMP-SMX

nitrofurantoin

cephalexin

what are treatment options for continuous prophylaxis

TMP-SMX (low dose)

what is prostatitis

infection, inflammation, or pain in the prostate gland

what is acute bacterial prostatitis

urinary symptoms and pain (which may be suprapubic, perineal, rectal, or in external genitalia). May include fever and urosepsis.

what is chronic bacterial prostatitis

lasting for > 3 months.

(Recurrent infections of prostate caused by same organisms – intermittent symptoms)

what are the usual pathogens in bacterial prostatitis

E. coli

Other Enterobacterales (e.g., Klebsiella, Proteus spp, etc.)

Enterococcus

Pseudomonas (moreso in nosocomial)

what are less common causes of bacterial prostatitis

Staphylococci and Streptococci

STIs

what is treatment for acute bacterial prostatitis - mild-moderate

ciprofloxacin

TMP-SMX

ceftriaxone IV → switch to po agents when clinical improvement

what is treatment for acute bacterial prostatitis - severe

Piperacillin-tazobactam → switch to PO agent when clinical improvement to complete 4 weeks

what is treatment for chronic bacterial prostatitis

ciprofloxacin

TMP-SMX

doxycycline