Pharmacologic Management of Urinary Tract Infections

Pharmacologic Management
of Urinary Tract Infections
Sue Butcher, APRN, CNS
April 16, 2016
Objectives
Differentiate between UTIs and asymptomatic bacteriuria
Review evaluation and treatment of complicated,
uncomplicated, recurrent, and relapsing UTIs
Select antibiotic and other pharmacologic and nonpharmacologic treatments based on urine culture, and
patient factors including age, symptoms, comorbities,
and financial restrictions
Definitions
Uncomplicated UTI
Complicated UTI
Asymptomatic Bacteriuria
Recurrent UTI
Relapsing UTI
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UTI definitions
CDC-Urine cultures >100k colonies of <2
types bacteria and one signs/symptoms
with no other known cause
Alternative- 2 signs/SX with no other
cause AND
Urine dip with leuk esterace and/or nitrate
OR pyuria (>3 WBC/HPF or 10KWBC/cc
OR organisms on micro of spun urine
Uncomplicated UTI
Mild, self-limiting
Healthy women without physiologic or
anatomic urinary tract abnormalities or
recent surgery, or instrumentation
Complicated
Opposite of previous, or poor response to
therapy
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Asymptomatic Bacteriuria
Specimen collection
Women – 2 consecutive voided specimens
with same bacteria >100k or single cath
with one bacteria >100k
Men – single clean catch >100k one
bacteria
Recurrent UTI (symptomatic)
>2 q 6 months or >3 in 1 year
OR different pathogens
10% women >60 years old will have
recurrent UTI
Relapsing UTIs-symptomatic
Original UTI never cleared
3 reasons antibiotics fail:
– Not a bug
– Not treating the bug
– Not reaching the bug
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Scope of problem
In women, 12% a year
4-8 million clinic visits per year
Most common cause of ambulatory visits
Costs > $1.6 billion per year
15% community prescribed antibiotics
Acute UTI
SX: Dysuria, urgency, frequency,
nocturia, suprapubic pressure, hematuria
Differential Diagnosis : vaginitis, OAB,
STDs, Interstitial Cystitis
UA dipstick
Leukocyte esterase – immune response to
infection. Trace to many
Nitrite – produced by degradation of gramnegative bacteria
Specificity if both positive: 98-99% IF
good specimen
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Culture and Sensitivity
Bacteria:
– E coli
– Staph saprophyticus
– Klebsiella
– Enterobacter
– Serratia
– Proteus (think stones)
– Pseudomonas (instrumentation)
MIC - MBC
MIC – Minimum Inhibitory Concentration
Lowest concentration of drug that
inhibits growth
S – sensitive I- intermediate
R-Resistant
MBC – Minimal Bactericidal concentration
Kills bug-important in immunocomp
Antibiotics – Infectious Disease Society of
America (IDSA) 2010 update
Acute uncomplicated UTI
1st line: Nitrofurantoin 100 mg bid X 5 days
OR SMZ-TMP 800/160 mg bid X 3 days
OR Fosfomycin 3 GM 1 dose
2nd line:
Cipro 500 mg bid X 3 days
Levaquin 500 mg QD X 3 days
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Complicated UTI
– 1st Line
Nitrofurantoin 100 mg bid X 7-14 days
SMZ TMP 800/160 mg bid X 7-14 days
– 2nd Line
Fluoroquinolones 7-14 days
Pyelonephritis
Initial Ceftriaxone 1 GM OR
Aminoglycoside 80 mg
THEN
– Cipro 500 mg BID for 7 days
– OR Cipro ER 1 GM daily for 7 days
– OR Levaquin 750 mg for 5 days
Nitrofurantoin
Macrobid, Furadantin
Many Gram Negative and Positive
Proteus usually resistant
Concentrated and Excreted in urine
Avoid longterm suppression
Soon off Beers list
S.E. Anorexia, N/V, HA, periph neuropath
Contraindicated Pregnancy at term
Contraindicated CrCl <60
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Sulfonamides
Bactrim Septra
Gram negative and positive
Resistance in some areas
Side effects: rashes, photosensitivity, N/V, diarrhea
Interactions- potentiates warfarin, phenytoin, digoxin, MTX
Pregnancy Category D
Renal dosing: Not recommended with CrCl <15 ml/min, CrCl 15-30,
reduce dose by 1/2
Fosfomycin
Monurol
Gram negative and positive
Single 3 Gm dose (sachet) Dilute 4 oz
H2O
Safe in pregnancy (Category B)
Side effects – GI, HA
Fluoroquinolones
Cipro, Levaquin
Gram negative and some gram positive
Side effects – N/V, diarrhea, HA, rash,
photosensitivity, arthropathy, achilles
tendon rupture, C diff
Pregnancy Category C
Potentiates anticoagulants, monitor
antidiabetes drugs, no Cipro with Zanaflex
Separate dosing with antacids by 2 hours
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Quinilone Renal Dosing
Cipro: CrCl 30-50 250-500 mg bid; CrCl 529 250-500 mg q 18 hours; HD or PD:
250-500 mg q 24 hours after dialysis
Levaquin: CrCl <20-49 500 mg initial dose,
then 250 mg q 24 hours; CrCl 10-19 500
mg initial dose, then 250 mg q 48 hours;
HD or PD 500 mg initial dose, then 250 q
48 hours
Beta Lactams
Amoxicillin 500 mg tid
Augmentin (Amoxicillin/potassium
Clavulanate) 500mg/125 mg tid
Side effects – GI, yeast, blood dyscrasias
Pregnancy Category B
Check renal dosing based on CR CL –
lowers seizure threshold
Allergy – 5-8% claim
Renal Dosing
Amoxicillin: GFR 10-30 10-30 250-500 mg
q 12 hours; GFR <10 or HD, 250-500 mg q
24 hours giving additional dose at end of
HD
Augmentin: CrCl 10-30 250-500 mg q 12
hours; CrCl <10 250-500 mg q 24; HD give
additional doses during and after
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Cephalosporins
Gram positive
Often e coli and proteus sensitive
Urine concentration high
SE: GI, Yeast
Potentiates metformin
Cross allergy with PCN 5-10%
Cephalexin (Keflex) Ceftriaxone
(Rocephin IM)
Antibiotic Resistance
Overuse
No new drugs
Unclear of relationship with antibiotics in
meats, etc
Recurrent UTIs
Risk Factors
post menopausal
Intercourse Spermicides
New partner
Previous UTIs
Family History
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Recurrent UTIs
NOT associated with:
Pre or postcoital voiding patterns
Wiping
Beverage consumption
Douching
Tampons
Underwear type
Bath vs shower, hottub
Prevention
Behavioral changes
Low risk, so reasonable
Don’t fluid restrict
Probiotics
– Inconsistent efficacy
– Product stability a concern
Cranberry – juice, capsules, tablets
DBPC showed no benefit
Vaginal Estrogen
Normalizes vaginal flora
Promotes “good” bacteria
Clinical Trials support
ACOG now supports in women with breast
cancer
Vagifem – twice weekly
Estrace/Premarin Cream 3 times weekly
Estring - quarterly
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Urinary Antiseptic
(Methenamine)
Releases formaldahyde @pH <5.5, which
is antibacterial
Excreted unchanged in urine
Methenamine Hippurate 1 Gm bid with
500 mg Vitamin C to acidify urine
DO NOT GIVE with SULFA –forms
insoluble compound with formaldahyde
released
Antibiotic Prophylaxis
Postcoital – 2-3 times weekly
– Bactrim DS or SS
– Trimethoprim 100 mg if sulfa allergic
– Macrobid
– RARELY daily suppression
When to Refer
Poor response to antibiotics
Proteus
History of calculi
Potential obstruction
Suspected urethral diverticulum
Concern for cancer
Suspected mesh or foreign body
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CAUTI
CDC (2009) Criteria for Catheter insertion:
Acute retention or bladder outlet obstruction- check PVR
To improve comfort for end-of-life care if needed
Critically ill and need for accurate hourly I&O
GU or some colorectal surgery
Healing of open sacral or perineal wound in
incontinence- NEVER for incontinence alone
Need for intraoperative monitoring of I&O
Prolonged immobilization (unstable spine, multiple
trauma such as pelvic fractures
CAUTI
Use smallest cath (14 fr 5-10cc balloon)
Aseptic technique
Secure tube
Bag below bladder
Closed system
Empty into patient specific container
Nurse protocol for removal
QUESTIONS?
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