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Infeccao Urinaria

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Infeccao do trato urinario - caso clinico hipotetico e discussao

Infeccao do trato urinario - caso clinico hipotetico e discussao

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Infeccao Urinaria Infeccao Urinaria Presentation Transcript

  • Infecções urinárias
  • Caso clínico PACIENTE VAI AO SERVIÇO DE EMERGÊNCIA
  • Caso clínico Mulher de 49anos, sem antecedentes prévios , vai ao consultório com queixa de disúria e polaciúria, sem febre. Você suspeita de uma provável cistite. Você coleta culturas? (1) sim (2) não
  • Scottish Intercollegiate Guidelines Network
  • Testes rápidos Dipstick tests should only be used to diagnose bacteriuria in women with limited symptoms and signs (no more than two symptoms). Women with limited symptoms of UTI who have negative dipstick urinalysis (LE or nitrite) should be offered empirical antibiotic treatment. The risks and benefits of empirical treatment should be discussed with the patient and managed accordingly. If a woman remains symptomatic after a single course of treatment, she should be investigated for other potential causes. Scottish Intercollegiate Guidelines Network
  • Caso clínico E se fosse um homem? (1) sim (2) não
  • Scottish Intercollegiate Guidelines Network
  • Caso clínico Qual antibiótico você prescreveria? (1) nitrofurantoina (2) sulfametoxazol-trimetoprim (3) norfloxacina (4) ciprofloxacina (5) levofloxacina
  • Increased resistance to first-line agents among bacterial pathogens isolated from urinary tract infections in Latin America: time for local guidelines? Andrade - Mem Inst Oswaldo Cruz, Rio de Janeiro, Vol. 101(7): 741-748, November 2006
  • Increasing resistance in community-acquired urinary tract infections in Latin America, five years after the implementation of national therapeutic guidelines Bours - International Journal of Infectious Diseases 14 (2010) e770–e774
  • Caso clínico Por quanto tempo você trataria esta paciente? (1) Dose única (2) Três dias (3) Sete dias (4) 14 dias
  • Duração do tratamento da ITU não complicada em idosos ITU persistente Dose única x 3 a seis dias Mais persistência precoce (OR=2,01; 1,05-3,84) Sem diferenças a longo prazo (OR= 1,18; 0,59-2,32) Cochrane collaboration
  • Short- Versus Long-Course Antibiotic Therapy for Acute Pyelonephritis in Adolescents and Adults: A Meta-Analysis of Randomized Controlled Trials Kyriakidou - Clinical Therapeutics/Volume 30, Number 10, 2008
  • Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America Duration of Treatment 47. Seven days is the recommended duration of antimicrobial treatment for patients with CA-UTI who have prompt resolution of symptoms (A-III), and 10–14 days of treatment is recommended for those with a delayed response (A-III), regardless of whether the patient remains catheterized or not. i. A 5-day regimen of levofloxacin may be considered in patients with CA-UTI who are not severely ill (B-III). Data are insufficient to make such a recommendation about other fluoroquinolones. ii. A 3-day antimicrobial regimen may be considered for women aged 65 years who develop CA-UTI without upper urinary tract symptoms after an indwelling catheter has been removed (B-II). Hooton - Clinical Infectious Diseases 2010; 50:625–663
  • Caso clínico Você coletaria urocultura de controle? (1) sim (2) não
  • Potential complaint Outcomes of treatment Microscopic examination From: Urinary Tract Infections Bacteria + pyruria Calvin Kunin 1997 Cultures ISBN 0-683-18102-5 Therapy Asymptomatic Eradication Suppression Failure Cure Reinfection Relapse Persistance
  • Persistence of Uropathogenic Escherichia coli in the Face of Multiple Antibiotics Blango & Mulvey - ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, May 2010, p. 1855–1863 Vol. 54, No. 5
  • Significant Risk Factors for Developing Bacteriuria in PatientsWith an Indwelling Urinary Catheter Increasing duration of catheterization Not receiving systemic antibiotictherapy Female sex Older age Azotemia Diabetes mellitus Rapidly fatal underlying illness Nonsurgical disease Faulty aseptic management of the indwelling catheter Bacterial colonization of the drainage bag Catheter not connected to a urine meter Periurethral colonizationwith uropathogens Saint - Arch Intern Med. 1999;159:800-808
  • Caso clínico Se o resultado viesse positivo, você trataria com antibióticos? (1) sim (2) não
  • Significant Risk Factors for Developing Bacteremia in Patients With Bacteriuria Male sex Infection with Serratia marcescens Older age Noninfectious urinary tract disease (eg, nephrolithiasis or prostatic hypertrophy) Presence of an indwelling urinary catheter Saint - Arch Intern Med. 1999;159:800-808
  • Clinical Infectious Diseases 2005; 40:643–54
  • Caso clínico E se fosse diabético? (1) sim (2) não
  • Long-Term Escherichia coli Asymptomatic Bacteriuria among Women with Diabetes Mellitus Dalal - Clinical Infectious Diseases 2009; 49:491–7
  • Caso clínico E se fosse homem? (1) sim (2) não
  • Caso clínico E se o paciente fosse sondado? (1) sim (2) não
  • Tempo de uso de sonda urinária está associado ao risco de ITU Pós-operatório Wald - Arch Surg. 2008;143(6):551-557
  • European and Asian guidelines on management and prevention of catheter-associated urinary tract infections 14. Routine urine culture in asymptomatic catheterised patients are not recommended (B). 15. Urine, and in septic patients also blood for culture must be taken before any antimicrobial therapy is started (C). 16. Febrile episodes are only found in less than 10% of catheterised patients living in a long-term facility. It is therefore extremely important to rule out other sources of fever (A). Tenke - International Journal of Antimicrobial Agents 31S (2008) S68–S78
  • Caso clínico Paciente retorna após 40 dias com as mesmas queixas. Você coleta urocultura? (1) sim (2) não
  • Caso clínico Qual esquema você iniciaria? (1) nitrofurantoina (2) sulfametoxazol-trimetoprim (3) norfloxacina (4) ciprofloxacina (5) levofloxacina
  • Caso clínico Você investigaria a paciente? (1) sim (2) não
  • Predicting the Need for Radiologic Imaging in Adults with Febrile Urinary Tract Infection Nieuwkoop - Clinical Infectious Diseases 2010; 51(11):1266–1272
  • Predicting the Need for Radiologic Imaging in Adults with Febrile Urinary Tract Infection História de urolitíase pH urinário >7,0 Filtração glomerular <40 mL/min/1,73m2 VPP=24% VPN=93% Nieuwkoop - Clinical Infectious Diseases 2010; 51(11):1266–1272
  • ITU recorrente Mais do que dois episódios por ano em mulheres não grávidas Investigar condições predisponentes Discutir profilaxia
  • Recurrent urinary tract infections in non- pregnant adult women Henn - SA Pharmaceutical Journal – July 2010
  • Fatores implicados na persistência da Escherichia coli uropatogênica (UPEC) Bactéria Hospedeiro Fímbria (pili): adesão Defesas naturais (fluxo Fímbria tipo I: adesão e urinário, produção de inflamação glicosaminas) Fímbria tipo P Proteína de Tamm- Fímbria tipo Dr Horsfall (níveis baixos Sideróforo – adesão estimulam adesão) Hemolisina Defensinas (peptídeos Fator de necrose com ação antimicrobiana) citotóxico Estado de secretor de Protectinas grupo sanguineo P Kucheria - Postgrad Med J 2005;81:83–86.
  • Fatores implicados na persistência da Escherichia coli uropatogênica (UPEC) Colonização vaginal Deficiência de C3 Formação de biofilme em epitélio (?) Reservatórios exógenos Kucheria - Postgrad Med J 2005;81:83–86.
  • Temporal Changes in the Prevalence of Community- Acquired Antimicrobial-Resistant Urinary Tract Infection Affected by Escherichia coli Clonal Group Composition Smith - Clinical Infectious Diseases 2008; 46:689–95
  • Molecular Analysis of Escherichia coli from Retail Meats (2002–2004) from the United States National Antimicrobial Resistance Monitoring System Johnson - Clinical Infectious Diseases 2009; 49:195–201
  • Food Reservoir for Escherichia coli Causing Urinary Tract Infections Vincent - Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 1, January 2010
  • Pet animals as reservoirs of antimicrobial- resistant bacteria Guardabasi - Journal of Antimicrobial Chemotherapy (2004) 54, 321–332
  • Canine Feces as a Reservoir of Extraintestinal Pathogenic Escherichia coli Johnson - INFECTION AND IMMUNITY, Mar. 2001, p. 1306–1314
  • Antimicrobial-resistant pathogens in animals and man: prescribing, practices and policies Hunter - J Antimicrob Chemother 2010; 65, Suppl. 1, i3–i17
  • RECURRENT URETHRITIS (MALE) POTENTIAL CAUSES Bacterial Neisseria gonorrhoeae (GC) Chlamydia trachomatis (CT) Mycoplasma genitalium Trichomonas vaginalis Ureaplasma urealyticum Viral Adenovirus HSV (herpes simplex virus) Non-STI secondary to catheterization or other instrumentation, or trauma of the urethra in association with other factors that contribute to urinary tract infection underlying urology conditions
  • Prostatite crônica Shoskes - The Canadian Journal of Urology; 8(Supplement 1); June 2001
  • Caso clínico Como você investigaria? (1) urografia excretora (2) estudo urodinamico (3) cistoscopia (4) ressonância magnética da pelve
  • Clinical effectiveness and cost-effectiveness of tests for the diagnosis and investigation of urinary tract infection in children: a systematic review and economic model Localisation of UTI (37 studies, 82 evaluations) Imaging techniques investigated included ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), intravenous pyelography (IVP), cystography and various scintigraphic techniques. Scintigraphic techniques, generally regarded as the reference standard, were the only investigations able to localise UTI accurately. Health Technology Assessment 2006; Vol. 10: No. 36
  • Clinical effectiveness and cost-effectiveness of tests for the diagnosis and investigation of urinary tract infection in children: a systematic review and economic model Detection of reflux (34 studies, 57 evaluations) Standard ultrasound techniques were found to have poor performance for the detection of reflux. Contrast-enhanced ultrasound techniques were accurate for both ruling in and for ruling out reflux. Other tests investigated were IVP, indirectvoiding radionuclide cystography, N- acetylglucosaminidase/creatinine ratio, scintigraphy and a clinical risk scoring system. Although IVP and indirect voiding radionuclide cystography were both accurate for ruling in reflux, none of these tests was found to be useful for both ruling in and ruling out disease. Health Technology Assessment 2006; Vol. 10: No. 36
  • Caso clínico Você prescreveria um creme estrogênico? (1) sim (2) não
  • Creme vaginal estrogênico Após menopausa: epitélio atrófico, maior colonização bacteriana Estudos clínicos mostram redução nas recorrências Kucheria - Postgrad Med J 2005;81:83–86.
  • Caso clínico Você recomendaria produtos à base de cranberries? (1) sim (2) não
  • Produtos à base de Cranberries Diminuição da adesão Frutose Composto polimerisado Kucheria - Postgrad Med J 2005;81:83–86.
  • Produtos à base de cranberries 200mg de cranberries ou 5000mg de cranberries frescos ITU crônica – evidência de redução de eventos – um a menos nos primeiros seis meses Interação com warfarina Scottish Intercollegiate Guidelines Network
  • Caso clínico Você prescreveria um probiotico? (1) sim (2) não
  • Probióticos Lactobacillus acidophilus Substituição do lactobacilo não produtor de ácido Dificulta crescimento de E.coli Redução de episódios em 43% (um estudo) Kucheria - Postgrad Med J 2005;81:83–86. Reid - Postgrad Med J 2003;79:428–32.
  • Probiotic Prophylaxis in Pediatric Recurrent Urinary Tract Infections Gerasimov – Clin Pediatr Volume 43(1), January/February 2004, pp 95-98
  • Urogenital infections in women: can probiotics help? [Review] L. rhamnosus ação maior sobre enterobactérias e resistência a espermicidas L fermentum B-54 ou RC-14 Produção de H2O2 Bruce - British Medical Journal 2003. Volume 79(934), pp 428-432
  • Estudos clínicos Baerheim et al. Sem redução Reid et al Recorrências: 21% x 47% Reid et al Um ano; compara antes e após uso 6,0 x 1,6 episódios/ano Andreu - REV. MED. MICROBIOL., Volume 15(1).January 2004.1-6
  • Caso clínico Você iniciaria profilaxia antimicrobiana? (1) sim (2) não
  • Antibiotic Prophylaxis and Recurrent Urinary Tract Infection in Children Craig - N Engl J Med 2009;361:1748-59.
  • Antibiotic Prophylaxis and Recurrent Urinary Tract Infection in Children Craig - N Engl J Med 2009;361:1748-59.
  • Antibiotic Prophylaxis and Recurrent Urinary Tract Infection in Children Craig - N Engl J Med 2009;361:1748-59.
  • Profilaxia
  • Caso clínico Você iniciaria profilaxia antimicrobiana em paciente com uso crônico de sonda urinária? (1) sim (2) não
  • Maki & Tambyah - Emerging Infectious Diseases 2001; 7(2):1
  • Risco de ITU febril em pacientes sondados Population Incidence Male, veteran 0.21/patient-month, 0.69/100 d Women, 65 y 1.1/100 patient-days Male and female, mean age 82.3 y 0.80/100 patient-days Female, mean age 71 y 0.9-1.2/100 d Obstructed catheter 8.1/100 d Non-obstructed catheter 1.1/100 d Nicolle - Infect Control Hosp Epidemiol 2001;22:316-321
  • Antimicrobial Prophylaxis for Catheter-Associated Bacteriuria ANTIMICROBIAL AGENTs AND CHEMOTHERAPY, Feb. 1977, P. 240-243Vol. 11, No. 2
  • Profilaxia ITU crônica/lesão medular : meta-análise Infecções sintomáticas em pacientes não-agudos Morton - Arch Phys Med Rehabil Vol 83, January 2002
  • Profilaxia ITU crônica/lesão medular : meta-análise Infecções sintomáticas em pacientes agudos Morton - Arch Phys Med Rehabil Vol 83, January 2002
  • Profilaxia ITU crônica/lesão medular : meta-análise Infecções assintomáticas em pacientes agudos Morton - Arch Phys Med Rehabil Vol 83, January 2002
  • Profilaxia ITU crônica/lesão medular : meta-análise Infecções assintomáticas em pacientes não-agudos Morton - Arch Phys Med Rehabil Vol 83, January 2002
  • Management of bacterial UTI in patients with catheters A ntibiotic prophylaxis is not recommended for the prevention of symptomatic UTI in patients. Antimicrobial prophylaxis may be considered in patients for whom the number of infections are of such frequency or severity that they chronically impinge on function and well- being. Antibiotic prophylaxis in catheterised patients may reduce the occurrence of asymptomatic bacteriuria but at the risk of increasing antibiotic resistance. Scottish Intercollegiate Guidelines Network
  • Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America Prophylaxis with Systemic Antimicrobials 29. Systemic antimicrobial prophylaxis should not be routinely used in patients with short-term (A-III) or long-term (A-II) catheterization, including patients who undergo surgical procedures, to reduce CA- bacteriuria or CA-UTI because of concern about selection of antimicrobial resistance. Hooton - Clinical Infectious Diseases 2010; 50:625–663
  • Infecção urinária em pacientes com trauma medular: guia de prevenção e tratamento Cranberries Acidificação com sais de metenamina: provavelmente úteis Probióticos: sem evidência Antibióticos: Evidência negativa Everaert - Acta Clinica Belgica 2009; 64(4): 335
  • European and Asian guidelines on management and prevention of catheter-associated urinary tract infections 9. Topical antiseptics or antibiotics applied to the catheter, urethra or meatus are not recommended (A). 10. Benefits from prophylactic antibiotics and antiseptic substances have never been established, therefore they are not recommended (A). 11. Removal of the indwelling catheter after non-urological operation before midnight may be beneficial (B). 12. Long-term indwelling catheters should be changed in intervals adapted to the individual patient, but must be changed before blockage is likely to occur (B), however there is no evidence for the exact intervals of changing catheters. 13. Chronic antibiotic suppressive therapy is generally not recommended (A). Tenke - International Journal of Antimicrobial Agents 31S (2008) S68–S78
  • CAN ANTIBIOTIC USE DURING ROUTINE REPLACEMENT OF LONG-TERM URINARY CATHETER PREVENT BACTERIURIA? Firestein - Infectious Diseases in Clinical Practice, 2001:10:133–135
  • Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America Prophylactic Antimicrobials at Time of Catheter Removal or Replacement 40. Prophylactic antimicrobials, given systemically or by bladder irrigation, should not be administered routinely to patients at the time of catheter placement to reduce CA-UTI (AI) or at the time of catheter removal (B-I) or replacement (AIII) to reduce CA-bacteriuria. i. Data are insufficient to make a recommendation as to whether administration of prophylactic antimicrobials to such patients reduces bacteremia. Hooton - Clinical Infectious Diseases 2010; 50:625–663
  • Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America Routine Catheter Change 39. Data are insufficient to make a recommendation as to whether routine catheter change (eg, every 2–4 weeks) in patients with functional long-term indwelling urethral or suprapubic catheters reduces the risk of CA-ASB or CA-UTI, even in patients who experience repeated early catheter blockage from encrustation. Hooton - Clinical Infectious Diseases 2010; 50:625–663
  • Caso clínico Após dois meses, paciente apresenta quadro de infecção urinária acompanhada de febre e calafrios. Que culturas você coletaria?
  • Caso clínico Quais os agentes esperados?
  • Caso clínico Qual esquema você iniciaria? (1) nitrofurantoina (2) ceftriaxona (3) ertapenem (4) ciprofloxacina (5) piperacilina-tazobactam
  • ITU resistente Fatores de risco para resistência à cefalotina e gentamicina em E. coli Fator OR (IC95%) Paciente acamado 8,67(1,68-17,04) ITU prévia 4,14 (1,23-4,96) Sonda vesical 6,56 (1,39-14,75) Casa de repouso 6,36 (1,13-21,52) Lau - J Microbiol Immunol Infect 2004; 37:185
  • E. coli Resistência ao SMX-TMP em ITU SMX- Variável OR p Uso recente de ATB 2,37(1,14-4,95) 0,02 exceto SMX-TMP Uso recente de SMX-TMP 16,74(2,90-96,95) 0,002 3 ITUs nos últimos 1,65(0,55-4,92) 0,37 12 meses Brown - CID 2002; 34:1061
  • Fatores de risco para ITU causada por E.coli resistente à ciprofloxacina na comunidade Variável OR p Doença crônica 22,4 (3-128) 0,03 Uso prévio de quinolona 80,7 (11-613) <0,001 Chaniotaki - CMI 2004; 10: 70
  • Multirresistência na comunidade Resistência a cipro no Brasil (CREC): >20% E.coli produtora de CTX-M na comunidade Co-resistência frequente Ciprofloxacina: até 66% SMX-TMP, tetraciclina e gentamicina Valverde – Produtoras de CTX-M9 ou –M14 mais resistentes à ciprofloxacina e tetraciclina que as produtoras de TEM-4 ou SHV-12 Os genes blaCTX-M estão associadas a integrons da classe 1 Cassetes responsáveis por resistência a betalactâmicos, sulfas, aminoglicosídeos, cloranfenicol e com menor impacto, rifampicina.
  • Klebsiella pneumoniae e E.coli Antimicrobiano Habitual ESBL Ampicilina R R Amoxi-clav S R Cefalotina S R Cefoxitina S S Ceftazidima S R Ceftriaxona S S Cefepima S R Pip-Tazo S S Ciprofloxacina S S Imipenem S S
  • Prevalence of ESBL phenotypes SENTRY Programme: Latin America (2003) % ESBL phenotypes; three substratesa (No. tested) Country E. coli Klebsiella spp. Argentina 2.9 (139) 48.1 (52) Brazil 4.1 (292) 31.8 (143) Chile 4.9 (225) 29.7 (37) Mexicoc 37.3 (51) 54.5 (77)b Venezuela 3.7 (109) 22.7 (22) aAztreonam, ceftazidime and ceftriaxone. Greatest percentage of isolates with MIC ≥2 µg/mL was used. E-test was used to confirm phenotype bAll isolates showed low MICs for ceftazidime cIsolates from 2004 only
  • E.coli em uroculturas ESBL 10 8 6 % 4 4 2 2 2 0 0 2002 2003 2004 2005
  • Infecções causadas por Klebsiella sp e E.coli Evento ESBL+ ESBL- P Sucesso 83,0% 80,0% 0,67 Letalidade atribuível 5,2% 12,5% 0,15 Letalidade 20,7% 22,5% 0,81 A letalidade está diretamente ligada à terapia inicial apropriada Recomenda-se identificação precoce de pacientes suspeitos e início rápido de terapia empírica apropriada Bhavani – Diagn Microbiol Infect Dis 2006; 54:231
  • ESBL na comunidade País Infecção Organismo FR Irlanda, 1998 ITU E.coli ATB prévio/inf. Repetição Arábia Saudita, 2000 - K.pneumoniae - França,1000 ITU E.coli - Polônia, 2001 ITU E.coli Inf. Complicada Espanha, 2001 ITU E.coli - Israel, 2001 ITU E.coli - EUA,2002 ITU E.coli Ambulatório Cingapura, 2002 Bacteremia E.coli Um caso, ATB prévio Israel, 2002 Bacteremia E.coli, Enterobacter ATB prévio, casa repouso K.pneumoniae sonda Pitout - J Antimicrob Chemother 2005; 56:52-59
  • Risk Factors for community-acquired CREC Variável OR (IC95%) p Uso prévio de quinolona 30,35(5,82-158,42) <.0001 ITU recorrente 8,13 (2,95-22,37) <.0001 Killgore, March & Guglielmo - Ann Pharmacother 2004; 38: 1148
  • Quinolonas São fatores de risco para emergência de cepas produtoras de ESBL Se houver sensibilidade, podem ser utilizadas A resistência pode ocorrer Perda de porina Co-resistência: alteração da topoisomerase
  • Antibiotic resistance in community-acquired urinary tract infections: Prevalence and risk factors
  • Risk factors for extended-spectrum b-lactamase positivity in uropathogenic Escherichia coli isolated from community acquired urinary tract infections Azap - Clin Microbiol Infect 2010; 16: 147–151
  • Tratamento da Klebsiella sp produtora de ESBL Infecções Complicadas Não complicadas Escolha Carbapenêmicos Carbapenêmicos Tigeciclina Aminoglicosídeos quinolonas Alternativa Tigeciclina: promissora Pip-tazo Aminoglicosídeos e Cefepime=? quinolonas de acordo com a sensibilidade
  • Carbapenêmicos Ertapenem •Amplo espectro •Sem ação sobre gram-negativos não fermentadores Imipenem •Amplo espectro Meropenem •Infecções adquiridas no hospital
  • Organismo Ertapenem Imipenem Meropenem MIC50 MIC90 MIC50 MIC90 MIC50 MIC90 E. faecalis 8 ≥16 2 4 8 8 E. faecium >16 ≥16 ≥16 ≥16 32 64 MSSA 0.25 0.5 0.03 0.12 0.06 0.5 MRSA >16 ≥16 16 ≥16 8 32 S. pneumoniae 0.03 0.03 0.016 0.03 0.008 0.5 Acinetobacter spp 16 ≥16 0.5 2.0 0.25 2.0 Citrobacter spp 0.016 0.25 0.5 2.0 0.02 0.06 Enterobacter spp 0.03 0.5 1.0 2.0 0.03 0.13 E. coli 0.016 0.06 0.25 0.5 0.06 0.06 P. aeruginosa 4-8 ≥16 2 4 0.25 4
  • Propriedades Ertapenem Imipenem - Meropenem Cilastatina Metabolismo Renal I: Hepático Renal C: Renal Ligação ~94% 20% <10% proteica Meia vida 4h 1h 1h
  • Ertapenem Human Pharmacokinetics Healthy Volunteers Single 1g dose [Total Ertapenem]PL (mg/L) 1000 IV IM 100 Ertapenem Half-life ~ 4h 10 2 mg/L 1 0 2 4 6 8 10 12 14 16 18 20 22 24 Bioavailability of IM Ertapenem > 90% Time, hr
  • Ertapenem Dose 1g uma vez ao dia Insuficiência hepática Não é necessária correção Depuração <30mL/min 500mg uma vez ao dia Via IM ou EV
  • Fosfomycin in the treatment of extended spectrum beta-lactamase-producing Escherichia coli-related lower urinary tract infections Congresso ABIH - 02 de setembro de 2010 - 17h % 100 90 80 70 60 94,3 50 78,5 40 30 20 10 0 109 Sucesso clínico Sucesso microbiológico Pullukcu - International Journal of Antimicrobial Agents 29 (2007) 62–65
  • Fosfomycin for the treatment of multidrug-resistant, including extended-spectrum β-lactamase producing, Enterobacteriaceae infections: a systematic review Congresso ABIH - 02 de setembro de 2010 - 17h 110 Falagas - Lancet Infect Dis 2010; 10: 43–50
  • Infecção do trato urinário Suspeita de infecção urinária Sintomática Alteração nova do estado de consciência ou sinais de pielonefrite ou sepse ITU sem sinais Não Sim ITU com sinais Conceito sistêmicos sistêmicos Coletar urina I e cultura Coletar urina I e cultura, Em geral, tratamento duas hemoculturas, Investigação ambulatorial. hemograma e creatinina; Considerar internação. Norfloxacina 1 cp VO Hospitalização recente, 12/12h infecção de repetição? Ou Nitrofurantoína 1 cp VO Tratamento 8/8h Ou Cefuroxima 500mg VO 12/12h Sim Por 7-10 dias Não Ciprofloxacina 200mg EV a cada 12 h ou Ciprofloxacina 500 mg Ertapenem VO a cada 12h ou ceftriaxona 1g EV 12/12h
  • Algumas referências Best Practice Policy Statement onUrologic Surgery: Antimicrobial Prophylaxis http://www.auanet.org/content/media/antimicroprop08.pdf Scottish Intercollegiate Guidelines Network: Management of suspected bacterial urinary tract infection in adults http://www.sign.ac.uk/pdf/sign88.pdf Best Practice Statement on Urinary Catheterisation & Catheter Care http://www.nhshealthquality.org/nhsqis/files/CATHURIN_BPS_J UN04.pdf