urinary tract infections management

1. URINARY TRACT
INFECTIONS IN CRITICAL
CARE
Ahmed Mohamed Abdelazeem
Critical Care Medicine Department
Benha University
2017

2. INTRODUCTION
 UTIs Are The Leading Cause Of Gram-negative
Bacteremia In Patients Of All Ages

3. MICROBIOLOGICAL DATA

4. THE MODIFIED CLASSIFICATION
OF URINARY TRACT INFECTION

5. FACTORS SUGGESTIVE OF COMPLICATED
URINARY TRACT INFECTION
 Male Sex
 Advanced Age
 Hospital Acquired Infection
 Pregnancy
 Functional Or Anatomic Abnormality Of The Urinary Tract
 Recent Antimicrobial Use
 Diabetes Mellitus
 Indwelling Urinary Catheter
 Recent Urinary Tract Instrumentation
 Renal Transplant
 Immunosuppression

6. ASYMPTOMATIC BACTERIURIA
 Pregnancy( Amoxicillin Or Nitrofurantoin Or Oral
Cephalosporin Or TMP-SMX Or Trimethoprim
Alone) X 3-7 Days
 Invasive Urologic Proceduretmp-smx DS 1 Tab Bid
X 3 Days
 No Therapy For Asymptomatic Bacteriuria In The
Following Patient Populations:
 Premenopausal, Nonpregnant Women
 Diabetic Women
 Older Persons Living In The Community
 Elderly, Institutionalized Subjects
 Persons With Spinal Cord Injury
 Catheterized Patients While The Catheter Remains In

7. UNCOMPLICATED CYSTITIS
 Primary Regimens :
 TMP-SMX -DS 1 Tab Bid X 3 Days
 Nitrofurantoin 100 Mg Po Bid X 5 Days
 Alternative Regimens :
 Ciprofloxacin 250 Mg Bid Or Ciprofloxacin Extended
Release 500 Mg Q24h X 3 Days
 Levofloxacin 250 Mg Q24h X 3
 Amoxicillin-clavulanate 875/125 Mg Bid X 5-7 Days

8. UNCOMPLICATED PYELONEPHRITIS
 Primary Regimens
 Ciprofloxacin 400 mg IV q12h or Gatifloxacin 400 mg IV
q24h or Levofloxacin 750 mg IV q24h x 5-7 days
 ( Ampicillin 2 gm IV q6h + Gentamicin 5 mg/kg q24h) or (
Ceftriaxone 1-2 gm IV q24h or Piperacillin-tazobactam 3.375
gm IV q4-6h x 14 days
 Alternative Regimens
 Ampicillin-Sulbactam 3 gm IV q6h or Piperacillin-tazobactam
3.375 gm IV q4-6h
 Ertapenem 1 gm IV q24h or other carbapenem for suspected
or proven ESBL-producing organism Duration: 14 days

9. COMPLICATED URINARY TRACT
INFECTIONS
 Primary Regimens :
 Ampicillin + Gentamicin
 Piperacillin-tazobactam 3.375 Gm IV Q4-6h
 Imipenem 0.5 Gm IV Q12h (Max 4 Gm/Day)
 Meropenem 1 Gm IV Q8h
 Alternative Regimens :
 Ciprofloxacin 400 Mg IV Q12h
 Levofloxacin 750 Mg IV Q24h
 Ceftazidime 2 Gm IV Q8h
 Cefepime 2 Gm IV Q12h

10. PERINEPHRIC ABSCESS
 E. Coli, Proteus Spp., And Staphylococcus
Aureus Are The Common Causative
Organisms
 The Mainstay Of Treatment Is Drainage

11. RECURRENT URINARY TRACT
INFECTIONS
 Young Women: Treat As Uncomplicated UTI
Then Trial Of One Of The Following To Prevent
Recurrences :
 TMP-SMX 80mg/400mg (Single Strength Tab)
Po Q24h Or 3x/Week
 Cephalexin 250 Mg Once Daily
 Post-menopause: Treat As Complicated UTI
Then Consider One Of The Above

12. CANDIDIASIS
 Primary Regimens
 Asymptomatic Candiduria:
Most Cases Do Not Warrant Treatment But Consider
Treatment In Patients With Neutropenia, Low Birth-weight
Premature Infants, Pregnant Women, And Patients
Undergoing Urologic Procedures. Pre-procedure
Treatment Options Include:
• Fluconazole 200-400 Mg (3-6 Mg/Kg) Po/IV Once Daily
A Few Days Before And After The Procedure
• Amphotericin B 0.3-0.6 Mg/Kg Daily A Few Days Before
And After The Procedure

13.  Symptomatic Infection:
• Cystitis:
Fluconazole 200 Mg/Day (3 Mg/Kg) X 14 Days
• Ascending Pyelonephritis:
Fluconazole 400 Mg/Day X 14 Days
• Pyelonephritis Via Hematogenous Seeding:
Caspofungin 70 Mg IV Loading Dose, Then 50 Mg IV Qd
Ormicafungin 100 Mg IV Qd Oranidulafungin 200 Mg IV
Loading Dose, Then 100 Mg IV Qd

14.  Alternative Regimens
Treatment Of Fluconazole-resistant Candida
Species Or Fluconazole Intolerance:
 Cystitis:
• Amphotericin B 0.5 Mg/Kg X 1-7 Days
• Orflucytosine 25 Mg/Kg Qid X 7-10 Days
 Ascending Pyelonephritis:
• Amphotericin B 0.5-0.7 Mg/Kg X 14 Days
• Orflucytosine 25 Mg/Kg Qid X 14 Days

15. EMPIRIC THERAPY

16. CONCLUSION
 Urinary tract infections can occur in all age groups and
produce an exceptionally broad range of clinical
syndromes ranging from asymptomatic bacteriuria to
acute pyelonephritis with Gram negative sepsis to septic
shock
 Early recognition of symptoms followed by appropriate
investigations, accurate diagnosis and early goal
directed therapy is essential to improve outcomes.
Comprehensive management requires team approach
with timely inputs from microbiologists, radiologists,
surgeons and intensive care physicians

17. CASE
A 26-year-old Sexually Active Woman Presents With A 6-
day History Of Fevers, Chills,dysuria, Frequency, And
Flank Pain. She Also Reports Nausea And Has Repeatedly
Vomited And Been Unable To Maintain Oral Intake.
Her Past Medical History Is Remarkable Only For The
Normal Vaginal Delivery Of A Daughter 3 Years Ago. She
States That She Is Not Currently Pregnant.
Vital Signs Are As Follows: A Temperature Of 38.7°C, A
Recumbent Blood Pressure Of 98/66 And Pulse Of 88, A
Standing Blood Pressure Of 88/55 And Pulse Of 101, And
A Respiratory Rate Of 13.

18. Physical Examination Is Otherwise Remarkable For
Costovertebral Angle Tenderness To Palpation On The Left
Side.
Laboratory Analysis Shows A Peripheral Blood Leukocyte
Count Of 26,200 Cells/Mm3 With 82% Neutrophils And 15%
Band Forms. Electrolytes Are Within Normal Limits, And
Glucose Is 93 Mg/Dl. A Urine Sample Shows Pyuria And
100,000 Bacteria.
Questions
A. What Is Your Diagnosis?
B. Is This A “Complicated” Or “Uncomplicated” Infection?
C. Which Antibiotic(s) Would You Use To Empirically Treat This
Patient?