UTIs

List different types of UTIs

Asymptomatic Bacteriuria

Uncomplicated Cystitis

Pyelonephritis

Criteria for Asymptomatic Bacteriuria

Lack of urinary symptoms

1 >/= bacterial species in urine with >10^5 CFUs/mL

± Pyuria (WBCs in urine) of >10 WBC/mm³

What patient populations are NOT recommended for routine urine screenings

Non-pregnant women

DM

Older adults

Long-term care facility patients

Spinal cord injury

Indwelling catheter patients

What patient populations are recommended for routine urine screenings

Pregnant women

Urologic procedures

Kidney transplants

Criteria for Uncomplicated Cystitis

Infection confined to bladder

NO fever, flank pain, or tenderness

Pyuria (>10 WBCs/mm³)

Positive uropathogen >1,000 CFU/mL (not required for diagnosis)

T/F: Presence of Leukocyte esterase in a Urinalysis corresponds to Pyuria

True

T/F: if Leukocyte esterase is negative in an UA, we can rule out infection

False

For empiric therapy selection factors, which organ function should be considered for

Kidneys

For empiric therapy selection factors, we should consider local resistance patterns for which bacteria

E. Coli

List of medications for Uncomplicated Cystitis treatment

Bactrim

Nitrofurantoin (Macrobid)

Fosfomycin

Oral Beta-Lactams (amoxicillin/clavulanic acid, cefpodoxime, cefixime)

Fluoroquinolones (Ciprofloxacin, Levofloxacin)

What is the recommended dosing for Bactrim (Trimethoprim/Sulfamethoxazole) to treat Uncomplicated Cystitis

160mg/800mg tablet PO BID for 3 days

Factors to not recommend Bactrim for Tx

Sulfa allergy

High resistance rate (>20%) in the community

Recent prior treatment of med in the last 3 months

Which medication is First Line for Uncomplicated Cystitis if the patient how low resistance

Bactrim

What medication is First Line for Uncomplicated Cystitis if patient is has low baseline resistance, especially if they have high resistance to Bactrim

Nitrofurantoin (Macrobid)

Which medication is First Line for Uncomplicated Cystitis if community has high Bactrim resistance and is a single dose therapy

Fosfomycin

T/F: Oral Beta-Lactams can be first line agents for Uncomplicated Cystitis

False; avoid use unless other agents are not appropriate

What is the dosing for Nitrofurantoin for Uncomplicated Cystitis

100mg PO BID for 5 days

Factors to not recommend Nitrofurantoin for Uncomplicated Cystitis

CrCl < 40 mL/min

Pyelonephritis

What is the dosing for Fosfomycin for Uncomplicated Cystitis

3 grams powder packet PO once

Factors to not recommend Fosfomycin for Uncomplicated Cystitis

Expensive

Pyelonephritis

What is the duration of treatment for Oral Beta-Lactams for Uncomplicated Cystitis

3-7 days

T/F: Fluoroquinolones should be avoided unless other agents are appropriate for Uncomplicated Cystitis due to ADRs

True

Bactrim ADEs

Maculopapular rash

Urticaria

N/V

Hematologic

Nitrofurantoin ADEs

N / HA

Fosfomycin ADEs

N / V / HA

Fluoroquinolones ADEs

N / V / D / HA

Insomnia

Beta-Lactams ADEs

N / V/ D

Rash

Indications for Pyelonephritis

Lower UTI symptoms

Positive UA

N/V

Fever / Chills

Flank pain

Signs of hydronephrosis on imaging (inflammation)

What should be obtained in order to switch from Empiric Abx to more selective Abx for Pyelonephritis

Urine Culture and Susceptibility testing

Four-Step approach choosing Empiric Abx for Pyelonephritis (complicated UTI)

Severity of Illness

Risk factors for resistance

Patient-specific considerations

Antibiogram (if patient is septic)

What is the initial treatment for unknown local resistance patterns for Pyelonephritis

IV long-acting, broad spectrum parenteral antimicrobial (Meropenem or Carbapenem)

How is severity of Pyelonephritis measured

Lack or Presence of Sepsis ± Shock

What SOFA score indicates Sepsis in Pyelonephritis patients

Increase of 2 or more points

General symptoms of Sepsis

Hypotension

Tachycardia

Fever

Elevated Respiratory Rate

Confusion

Leuko-cytosis/penia

List of IV Abx classes for Pyelonephritis and Sepsis

3rd Gen Cephalosporins

4th Gen Cephalosporins

Carbapenems (oral)

Fluoroquinolones (oral; 5-7 days)

Piperaccil-Tazobactam (4.5g q 8H)

Amoxicillin-Clavulanate (oral)

What IV 3rd Gen Cephalosporins are recommended for Pyelonephritis and Sepsis

Ceftriaxone (1-2g daily)

Ceftazidime

Cefotaxime

What IV 4th Gen Cephalosporins are recommended for Pyelonephritis and Sepsis

Cefepime (1-2g q 8-12H)

What IV Carbapenems are recommended for Pyelonephritis and Sepsis

Meropenem (1g q 8H)

Ertapenem

Imipenem-Cilastatin

What is the duration of treatment for Pyelonephritis (non-fluoroquinolones)

7 days TOTAL

IV Ciprofloxacin dosing for Pyelonephritis with Sepsis

400mg IV q8-12h

IV Levofloxacin dosing for Pyelonephritis with sepsis

500-750mg IV SID

Considerations if patient is not clinically improving from Pyelonephritis

Assess for drug-drug mismatch

Reassess diagnosis

Assess for unresolved source

Plan for longer therapy course