Uti

Urinary Trace Infection
PASIN HASSADUM
B. Pharm., M. Pharm. (community pharmacy) Pharm. D
Content
Introduction
Classification of UTIs
Uncomplicated UTIs in Adults
Complicated UTIs in Adults
INTRODUCTION
In the USA, UTIs over 7 million physician visits/year

15% of all community-prescribed antibiotics for UTI
more than 100,000 hospital admiss/year : pyelonephritis
40% of all hospital acquired infections : majority of cases, catheter
associated
25% of pt. who require a urinary catheter for one week : Bacteriuria
Increase resistant strains
INTRODUCTION
Increase resistant strains
extended-spectrum b-lactamase (ESBL) producing :resistance to most
antibiotics, except carbapenem group
faecal bacteria carrying the ESBLCARBA enzyme : New-Dehli metallo-b-
lactamase NDM-1:resistant to all available antibiotics including the
carbapenem group.
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
Microbiological and other laboratory findings

In 1960 : significant bacteriuria > 105 cfu/mL
> 103 cfu/mL MSU: acute uncomplicated cystitis in women.
> 104 cfu/mL MSU: acute uncomplicated pyelonephritis in women.
> 105 cfu/mL MSU in women :complicated UTI.
> 104 cfu/mL MSU in men: complicated UTI.
in straight catheter urine in women: complicated UTI.
MSU: mid-stream sample of urine

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).
Male accessory gland or genital infections (MAGI) orchitis, epididymitis and

prostatitis are not included.
Anatomy and Physiology Quick Review
Male VS Female urinary tract

Urine excretion system
Male VS Female
10
Kidney Upper Blood circulation

K
Ureter
Bladder Lower Nerve syst.

U
Uretha
B
11
Definition
Acute uncomplicated UTIs :
Acute cystitis
Pyelonephritis
Mostly in women
Without structural and functional abnormalities urinary tract, kidney
diseases, or comorbidity
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
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
Introduction
Tx IDSA
Diagnosis
Clinical diagnosis
flank pain
nausea and vomiting
fever (> 38 C)
costovertebral angle tenderness
+/- symptoms of cystitis
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

UTIs in pregnancy
Diagnosis Recurrent UTIs are common among young

Healthy women
Anatomically and physiologically normal urinary tracts
Recurrent UTIs need to be diagnosed by urine culture
Prevention Different therapeutic options can be recommended to the
patient.
Antimicrobial prophylaxis
UTIs in pregnancy
UTIs in preg./asymptomatic bacteriuria : common during preg.
asymptomatic bacteriuria before pregnancy
20-40% of women C asymptomatic bacteriuria develop pyelonephritis during preg.
Diagnosis
Healthy pregnant women/ non-pregnant women: similar criteria
Cystitis : PE, UA, UC
Pyelonephbritis : ultrasound
UTIs in pregnancy
UTIs in pregnancy
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

UTIs in pregnancy
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
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
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
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 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.
Content
Introduction
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
Current Tx: continuous med PTA

Ceftriaxone 2 gm iv od
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

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Urinary Trace Infection

In the USA, UTIs over 7 million physician visits/year

Microbiological and other laboratory findings

MSU: mid-stream sample of urine

Male accessory gland or genital infections (MAGI) orchitis, epididymitis and

Male VS Female urinary tract

Kidney Upper Blood circulation

Bladder Lower Nerve syst.

Uncomplicated UTIs in Adults

Recurrent (uncomplicated) UTIs in women

Diagnosis Recurrent UTIs are common among young

Recurrent (uncomplicated) UTIs in women

Current Tx: continuous med PTA

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