Uti policy-lec

1. UTI policy
BY
Seham Moustafa Fetouh
BCPS,Master of clinical pharmacy , Pharm D

2. Titles
 UTI in adults
 Catheter related UTI infection
 UTI in patients with renal impairment
 UTI in renal transplant
 UTI in pregnancy
 recurrent infection
 In adults
 during pregnancy
 In woman
 In renal transplant
 MRSA , Psudomomas , Candiduria risk factors

3. UTI protocol
contents referance by
UTI in adults Uptodate
IDSA guidelines
John hoppiken2015
Clinical ph Eman Anan
Recurrent UTI in adults Uptodate Clinical ph Seham Moustafa
Catheter related UTI infection Uptodate
Dynamed
sanford
Clinical ph Eman El-fakhrany
UTI in patients with renal failure Uptodate
lexicomp
Clinical ph Seham Moustafa
UTI in renal transplantation ( KTX) Uptodate
European Association of
Urology 2015
Clinical ph Seham Moustafa
UTI in pregnancy Uptodate Clinical ph Seham Moustafa
recurrent infection in woman Uptodate
2011 Canadian
Urological Association
Clinical ph Seham Moustafa

4. UTI IN ADULTS

5. Typical organism
Community acquiredNosocomial
E.coli
Klebsiella .pneumoniae
Proteus mirabillis
Enterococcus
S. auerua
E .coli
Klebsiella.pneumoniae
Proteus mirabillis
Enterococcus
S. auerua
S. saprophyticusP. aeruginosae
Other Gram –ve baclli
fungal
The choice of empiric antimicrobial agent for lower or upper UTI
1- The choice of between agents based on local resistance data ,
availability ,cost and patient circumstances .
2-Recent urine cultures should inform the choice of an empiric
regimen.
3- The regimen should be tailored on the basis of susceptibility
results .

6. Urine analysis finding in UTI
pH >7-7.5 (Infection with urease producing bacteria )
Nitrites *rapid indirect test for asymptomatic bacteriruia.
*E Coli, Klebsiella and Proteus produce nitrite from nitrate,
Pseudomonas, enterococci and S Saprophyticus do not.
Leukocyte
esterase
≥6 WBC/hpf.
*false-positive results are common when the urine is contaminated
with bacteria present in vaginal fluid
*urine culture is necessary if nitrite negative.
Proteinuria is a common finding in UTI
WBCs > 5-10
RBCs >3/hpf associated with cystitis or urethritis
*first-voided specimens (early morning) that have been stored in the
bladder for 2-4 hours
*absence of leukocytes and nitrites in a fresh urine sample confirms
its sterility

7. acute pyelonephritis
dysuria, frequency, urgency, suprapubic pain and/or hematuria
fever (>38ºC)
chills, flank pain
costovertebral angle tenderness
nausea/vomiting
mimic pelvic inflammatory disease.
Sepsis
multiple organ system dysfunction
Shock
acute renal failure
weeks to months of malaise, fatigue, nausea, or abdominal pain.
acute cystitis
dysuria, frequency, urgency, suprapubic pain and/or hematuria
CLINICAL MANIFESTATIONS
acute cystitis or pyelonephritis who have persistent symptoms after 48 to 72 hours of
appropriate antimicrobial therapy or recurrent symptoms within a few weeks of
treatment should have evaluation for complicated infection

8. UTI treatment in adults
Asymptomatic
bacteriuria in adults
symptomatic UTI in
adults
Uncomplicated UTI Complicated UTI Recurrent UTI
cystitis
pyelonephritis
cystitis
pyelonephritis
1-Mild to moderate Severe

9. 1-Asymptomatic bacteriuria (ABU ) in adults
the presence of high quantities of an uropathogen in the
urine of an asymptomatic person.
(No treatment unless the patient is one of the following catogery )
Catogery
1- Pregnant
2- Undergo Urological procedure(TMP/SMZ 3-5 days ttt before
surgey)
3-Renal transplant recipient within three months of transplant.
4- Neutropenia
5- colony counts ≥100,000/mL on at least two occasions (manual of
nephrology)

10. 2-ttt Uncomplicated acute cystitis in adults
Acute, sporadic lower UTI
CommentDurationDoseOption (all po)
3 days800/160 mg q12 hrSMZ / )TMP DS ( PO )
5 days100 q 12hrNitrofurantoin PO
Reserve fosfomycin
for MDRO
1 day3 gm Single doseFosfomycin (po)
Short course
therapy are more
effective than
single dose
3 days250 q 24 hr
Fluroquniolone PO
Levofloxacin
3 days250 q 12 hrCiprofloxacin
3-7 days200 mg q 12 hrOfloxacin
3- 7 days857 /125q 12 hr
Beta lactam PO
Amoxacillin/ clavulante
5-7 days500 q 12 hrCephalaxin

11. 2-Uncomplicated acute pyelonephritis (outpatient )
Acute, sporadic or upper UTI
CommentDurationDoseOption (all po)
- If hypersensitivity or known
resistance, other choices
include SMZ/ TMP (160/800
mg) or an oral beta-lactam, if
the uropathogen is known to
be susceptible.
10 days500 mg q 12 hr
Fluoroquinolone PO
Cipro floxacin
5 days750 once dailyLevofloxacin
3-7 days200 q 12Ofloxacin
14 days160/800 mgq12hrSMZ / TMP DS Po
14 days875/125mg q 12hr
β-Lactam po
Amoxacillin/ clavulant
7 days100 mg q 12 hrCefpodoxime

12. 4-Uncomplicated Acute pyelonephritis (Inpatient)
CommentDurationDoseOption
- In patients presenting
with signs of urosepsis
empiric antimicrobial
coverage for extended-
spectrum beta-lactamases
(ESBL)-producing
organisms is warranted .
7-14 days400 mg q12 hr
Fluoroquninolone IV
Ciprofloxacin
5 days750 mg once dailyLevofloxacin
14 days1-2 gm q 24 hr
Extended spectrum
cephalosporin IV
Ceftrixone
10 days2 gm q 12 hr
( sever infection )
Cefepime
14 days3 gm IV q 6hr
Extended spectrum
pencillin IV
Ampicillin / sulbctam
14 days3.375 q 6-8 hrPipracillin / tazobactam
For suspect or proven ESBL
producing organism14 days500q 6 hr
Carbapenem
Imipenem IV
14 days500 q 8 hrMeropenem IV

13. Complications of UTIs
suppurative complications, such as paraurethral abscesses,
renal or peri-renal abscess, and metastatic infection
including bone and joint infection or endocarditis.
urinary infection occurring in a patient with a structural or
functional abnormality of the genitourinary tract
Risk of potentially life-threatening infectious sequelae such
as bacteremia and sepsis infected cyst or treatment failure
or even death.

14. Risk factors
associated with
acute complicated UTIs

15. Suspected organisms for complicated UTI
organisms comments
Escherichia coli (ESBL) Predominant (as in uncomplicated)
Proteus mirabilis
Klebsiella pneumonia
Staphylococcus saprophyticus
occasional (as in uncomplicated)
Pseudomonas
Serratia,
Providencia species
Enterococci
staphylococci
fungi

16. Diagnosis for complicated UTI
1-Clinical manifestations
2-urinalysis
Pyuria its absence suggests an alternative diagnosis
White cell casts  renal origin for pyuria
pyuria and bacteriuria may be absent.
3-Urine Gram stain  choice of empiric therapy pending culture results
4-urine culture
5-Radiographic imaging for:
-persistent clinical symptoms after 48 to 72 hours of appropriate antibiotic
-severely ill or who also have symptoms of renal colic or history of renal
stones, diabetes, history of prior urologic surgery, immunosuppression,
repeated episodes of pyelonephritis, or urosepsis
CT scanning detect anatomic or physiologic factors associated with
complicated urinary tract infection
Renal ultrasound for patients whom exposure to contrast or radiation is
undesirable
Magnetic resonance imaging when avoidance of contrast dye or ionizing
radiation is warranted

17. 5-ttt Complicated cystitis in adults
CommentDurationDoseOption
If tolerate oral7 - 14 days500 mg q 12 hrCiprofloxacin po
5 days750 q 24 hrLevofloxacin po
-use Parentral If not tolerate oral
Or if infection suspected to be
resistant organism
5 days750 mg once daily
Fluoroquinolone IV
Levofloxacin
10 days400 mg q 12 hrCiprofloxacin
1- 2 gm q 24 hr
Extended spectrum
cephalosporine IV
ceftrixone
Monitoring of aminoglycoside levels is
warranted in the setting of unstable
renal function
7-10 days3mg /kg /day in
equally divided
doses every 8hr
Aminoglycoside
Gentamycin
In the case that a serious urinary tract
infection is documented or suspected
to be caused by an extended-
spectrum beta-lactamase (ESBL)
producing organism (based on prior
cultures )
14 day
500 q6 hr
Carbabenem
Imipenem IV
500 q 8 hrMeropenem IV

18. 6-ttt Complicated pyelonephritis in adults
1-Mild to moderate complicated pyelonephritis
CommentDurationDoseOption
7- 14 days
1 gm q 24 hr
3rd generation cephalosporin
Ceftrixone IV
400 mg q 12 hrQuniolone
Ciprofoxacin IV
750 mg q 12 hrLevofloxacin IV
2-Sever Complicated pyelonephritis
CommentDurationDoseOption
-If p. aeruginosa is suspected
higher doses
-*The resistance pattern of the ESBL
strain should guide empirical
therapy.
*If MRSA suspect or history or
gram + ve cocci in gram stain add
vancomycin
14 days2 gm q 12 hrCefepime
3.375 q 6 hrPipracillin / tazobactam
500 q 8 hrCarbapenem
Meropenem
500 q 6 hrImipenem

19. Ttt Recurrent UTI in adults
Two uncomplicated infections within 6 months or three infections
within a year and are often considered reinfections.
 Recurrent cystitis
Drug dose duration
nitrofurantoin 100 mg 6–12 months
trimethoprim-sulfamethoxazole 40 mg/200 mg 6–12 months
cephalexin 250 mg 6–12 months
 Recurrent pyelonephritis
Drug dose
Trimethoprim-sulfamethoxazole 160 mg/800 mg tablets twice daily
nitrofurantoin 50 to 100 mg once or twice daily
 Chronic Bacterial Prostatitis
Drug dose duration
trimethoprim-sulfamethoxazole 160 mg/800 mg twice daily 12 weeks
fluoroquinolone 12 weeks
nitrofurantoin 50 or 100 mg once or twice daily 6 to 12 months

20. CATHETER RELATED UTI INFECTION

21. Symptomatic bacteriuria UTI
• Culture growth of ≥10^3 colony forming units (cfu)/mL of
uropathogenic bacteria in the presence of symptoms or
signs compatible with UTI without other identifiable
source in a patient with indwelling urethral, indwelling
suprapubic, or intermittent catheterization.

22. Pathogen %
E. coli 27 %
Enterococcus spp 15 %
Candida spp 13 %
P. aeruginosa 11%
Klebsiella spp 11%
Symptoms ≥ 1 of the following with no other recognized cause
Fever > 38 ° c
Suprapubic tenderness
Costovertebral angle pain or tenderness
unexplained systemic symptoms  altered mental status, hypotension, or evidence
of a systemic inflammatory response syndrome.

23. Treatment
• removal of catheter.
Mild - Moderate Patient stable with no evidence of upper tract disease
Ceftriaxone 1 g iv /24 hr
Cefotaxime 1g iv/8 hr
Fluoroquinolone :
Levofloxacin750 mg iv/24 hr(5days) or250-500/24hr(10days)
Ciprofloxacin 400 mg iv /12 hr or 500 po/12 hr
(avoid in pregnancy and in patients with prior
exposure to quinolones)
Sever (MDR)
Or
If P. aeruginosa is
suspected
evidence of upper tract disease, or hospitalized > 48 hr
Ciprofloxacin
cefepime 1 g iv /12 hr
ceftazidime 1 g iv / 8 hr
If an extended-spectrum
beta-lactamase (ESBL)
producing organism is
suspected
Consider :
Meropenem 500 mg iv / 8 hr
Imipenem /cilastatin 500 mg iv / 6 hr
If gram- positive
infection is suspected
Consider :
Vancomycin 15 -20 mg /kg /dose every 8 to 12 hours

24. If candiduria
healthy patients with asymptomatic
candiduria
urinary catheter change and may not require
antifungal therapy.
candiduria and without
evidence of disseminated infection
the removal of the urinary
catheter and discontinuation of antibiotics.
disseminated candidiasis systemic therapy
fluconazole (200 mg the first day, then 100 mg for 4
days),
Continuous bladder irrigation with amphotericin B
(50 mg/1,000 mL of sterile water
through a three-way catheter for 5 days),
or low-dose intravenous therapy with
amphotericin (0.3 mg/kg in a single dose).
Duration of ttt :
7 days 10 -14 days 5 days
resolution of symptoms delayed response levofloxacin if the patient is not severely ill

25. UTI in patients with renal impairment

26. Treatment of UTIs in patients with renal failure
*fluoroquinolone is the drug of choice for ttt pyelonephritis in renal
dysfunction also appropriate for ttt cystitis.
*Nitrofurantoin should not be used in patients with significant renal
dysfunction. Prolonged use of nitrofurantoin in CRF is associated with
increased risk of neuropathies due to systemic drug accumulation.
*the use of gentamicin is not recommended in patients with CRF due
to an increased risk of nephro- and ototoxicity.
*ceftriaxone , Fosfomycin have no dosage adjustments
* ceftriaxone , Fosfomycin , vancomycin are non dialyzable
* The presence of pyuria, including white blood cell casts, without
bacterial infection is common in dialysis patients.
* pyuria is a marker for urinary tract infection, even in asymptomatic
dialysis-dependent patients

27. Doses adjustment in renal impairment
Drug Route Adjustment in renal
impairment
Adjustment in intermittent
HD
ceftrixone IV no dosage adjustments,
maximum daily dose should
not exceed 2 g.
Poorly dialyzed; no
supplemental dose or
dosage adjustment
necessary
Cefepime IV Need adjustment administer after
hemodialysis on dialysis
days
ceftazidime IV Need adjustment administer after
hemodialysis on dialysis
days , Dialyzable (50% to
100%)
Cefpodoxime Need adjustment Dose 3 times/week
following dialysis.
cephalexin Need adjustment Oral: 250 to 500 mg every
12 to 24 hours; moderately
dialyzable (20% to 50%);
give dose after dialysis
session.

28. Drug Route Adjustment in renal
impairment
Adjustment in intermittent HD
Amoxacillin/
clavulante
IV, Oral Need adjustment 250 to 500 mg amoxicillin every 24
hours; administer dose both during
and after dialysis. Do not use 875
mg tablet or extended-release
tablets.
Ampicillin / sulbctam IV, Oral Need adjustment administer after hemodialysis on
dialysis days, 1.5 to 3 g every 12 to
24 hours
Vancomycin IV Need adjustment Poorly dialyzable by intermittent
hemodialysis
use of high-flux membranes and
continuous renal replacement
therapy (CRRT) increases
vancomycin clearance, and
generally requires replacement
dosing
Aztreonam IM, IV Need adjustment Dialyzable (20% to 50%)

29. Drug Route Adjustment in renal
impairment
Adjustment in intermittent
HD
Meropenem IV Need adjustment administer after
hemodialysis on dialysis
days,Meropenem and its
metabolite are readily
dialyzable:
Imipenem /cilastatin IV CrCl <15 mL/minute: Do not
administer imipenem and
cilastatin unless
hemodialysis is instituted
within 48 hours.
administer dose after
dialysis session and at
intervals timed from the
end of that dialysis
session or 250 to 500 mg
every 12 hours
Ertapenem Need adjustment When the daily dose is
given within 6 hours prior
to hemodialysis, a
supplementary dose of 150
mg is required following
hemodialysis.
Doripenem Need adjustment Dialyzable (~52% of dose
removed during 4-hour
session in ESRD patients)

30. Drug Route Adjustment in renal impairment Adjustment in
intermittent HD
Levofloxacin IV, Oral Need adjustment supplemental doses are
not required following
hemodialysis
ciprofloxacin IV, Oral Need adjustment administer after
hemodialysis on dialysis
days , Minimally
dialyzable (<10%)
Ofloxacin Oral Need adjustment 100 to 200 mg after
dialysis
norfloxacin oral CrCl ≤30 mL/minute/1.73 m2:
400 mg once daily
Fosfomycin Oral No adjustment No adjustment
Pipracillin /
tazobactam
IV Need adjustment Hemodialysis removes
30% to 40% of
dose. Administer
scheduled doses after
hemodialysis on dialysis
days or administer an
additional dose of 0.75 g
after the dialysis session

31. Drug Route Adjustment in renal
impairment
Adjustment in
intermittent HD
SMZ / TMP Oral CrCl <15: Use is not
recommended
-contraindicated in severe
renal disease if renal function
cannot be monitored.
Or GFR < 10 : Not
recommended;
if used, 5 to 10 mg TMP/kg
every 24 hours
Not recommended;
if used, 5 to 10 mg
TMP/kg every 24
hours (dose after
hemodialysis on
dialysis days)
fluconazole Need adjustment 100% of daily dose
after each dialysis
session; on
nondialysis days,
patient should
receive a reduced
dose according to
their CrCl.

32. Drug Route Adjustment in renal
impairment
Adjustment in
intermittent HD
nitrofurantoin oral CrCl <60 : contraindicated.
Alternate dosing: Limited data
suggest nitrofurantoin is safe
and effective for short-term
treatment of uncomplicated
UTI in patients with decreased
renal function.
The Beers Criteria
recommends avoiding use in
geriatric patients ≥65 years
with a CrCl <30 mL/minute
Gentamycin IV Need adjustment administer after
hemodialysis on
dialysis days) ,
Dialyzable (~50%;
variable; dependent
on filter, duration, and
type of IHD):

33. UTI in renal transplantation ( KTX)

34. Interaction with immunosuppression must be considered
calcineurin inhibitors +
* TMP-SMZ  increased nephrotoxicity
* Nephrotoxic antibiotics (e.g. aminoglycosides, amphotericin)
 synergistic effects with CNIs, increasing renal damage.
*Ciprofloxacin  increase calcineurin inhibitor (CNI) levels,
but levofloxacin and ofloxacin usually do not
*Erthryomycin and antifungal agents  increase CNI levels.
*Rifampin, imipenim , cephalosporins  reduce CNI levels.

35. causative organism
Escherichia coli dominant causative organism
Pseudomonas aeruginosa
Enterobacter cloacae
Klebsiella pneumonia
Klebsiella oxytoca
Staphylococcus saprophyticus
Streptococcus species
Corynebacterium urealyticum
rare causes

36. Diagnosis
investigations comments
BK and/or CMV infection should be excluded
C-reactive protein, leucocytes differentiating between infection and rejection in a
dysfunctional graft.
level of immunosuppression to exclude over-immunosuppression
- imaging (ultrasonography) exclude post-renal causes of infection (urolithiasis, urinary
tract obstruction, forgotten’ ureteric stent, etc.)
Fever associated with UTI
Tenderness over the allograft is also more commonly observed with
complicated UTI.
urine analysis with microscopy
(dipstick/sediment)
at 2, 4, 8, and 12 weeks
posttransplantand
urine dipstick that is positive for leukocyte esterase, nitrites,
blood, and protein and urine microscopy that shows pyuria
(ie, at least 10 white blood cells per high-power field of
unspun urine)
urinary culture

37. UTI Prophylaxis in ( KTX)
Removal of the catheter as early as 36–48 h after KTX
drug dosage route frequency duration notes
TMP /SMZ 160 mg/800 mg oral daily 6 -12 months or
indefinitely
after KTX
cephalexin 500 mg orall twice
daily
three months For TMP/SMZ
allergy
alternative agent will depend on the patient’s current and past microbiology data
and on resistance patterns at the transplant center.

38. UTI treatment in ( KTX)
Asymptomatic
bacteriuria in ( KTX)
symptomatic UTI in
( KTX)
Uncomplicated UTI
Complicated UTI
Recurrent UTI

39. Asymptomatic bacteriuria (ABU) in ( KTX)
The presence of >10^5 bacterial colony forming units per
milliliter (CFU/mL) of urine on urine culture with no local
or systemic symptoms of UTI.
Screen for asymptomatic bacteriuria up until three months
after transplantation.
Do not regularly screen for asymptomatic bacteriuria after
three months posttransplant
treat asymptomatic bacteriuria within three
months of transplant in order to prevent
symptomatic UTIs. Symptomatic UTIs have
been associated with early graft dysfunction

40. drug dosage route frequency duration
ciprofloxacin 250 mg oral twice daily 5 days
amoxicillin 500 mg oral three times
daily
5 days
nitrofurantoin 100 mg oral twice daily 5 days
For candiduria, treatment is always recommended to
prevent local fungal complications.

41. symptomatic UTI in ( KTX)
* First excluded BK virus infection
* Any febrile renal transplant patient with an abrupt
deterioration of renal function should be treated as UTI
(Unless another source of fever is readily apparent) with
empiric antibacterial therapy aimed at gram-negative
bacteria, including Pseudomonas aeruginosa, after blood
and urine samples have been obtained

42. Ttt Uncomplicated UTI in ( KTX)
the presence of >10^5 CFU/mL on urine culture with local
urinary symptoms, such as dysuria, frequency, or urgency,
but no systemic symptoms, such as fever or allograft pain.
* The duration of treatment :
<6 months posttransplant 10 to 14 days.
>6 months posttransplant 5-7 days
drug dosage route frequency notes
ciprofloxacin 250 mg oral twice daily
levofloxacin 500 mg oral once daily
amoxicillin 500 mg oral 3 times
daily
IF Enterococcus species are
suspected
nitrofurantoin 100 mg oral twice daily IF Enterococcus species are
suspected

43. Complicated UTI in ( KTX)
the presence of >10^5 CFU/mL on urine culture with fever and either
one of the following: allograft pain, chills, malaise , nausea and
fatigue. or bacteremia with the same organism in urine, or biopsy
with findings consistent with pyelonephritis.
drug dosage route frequency Duration
piperacillin-
tazobactam.
4.5 g IV every 6 hr 14 to 21 days
meropenem 1 g IV every 8 hr 14 to 21 days
Vancomycin
+ cefepime
15 mg/kg
1 g
IV
IV
every 12hr
every 8hr
14 to 21 days
switch to Oral agents once the patient is free of symptoms except for
flouroquinones switch once the patient is able to take oral medications

44. Recurrent UTI in ( KTX)
three or more episodes of UTI in one year
if recurrent UTIs +indwelling source (such as infected cysts in native
kidneys) therapy duration required to be four to six weeks .
or , therapy for recurrent UTIs can be discontinued after a shorter
period, and the patient can be transitioned to prophylactic
antibiotics.
Surgical therapy of recurrent UTI after KTX  treatment of obstructed
transplant ureters, urolithiasis, and BOO from causes like BPH.
Nephrectomy of native kidneys for refluxive kidneys is the ‘last
option’ treatment and for hereditary polycystic kidneys (autosomal
dominant polycystic kidney disease)but not for acquired polycystic
kidneys in patients with renal insufficiency

45. UTI in pregnancy

46. Asymptomatic bacteriuria and cystitis
pyelonephritis
Mild to moderate pyelonephritis
Severe
persistent bacteriuria
recurrent infection
UTI ttt in pregnancy

47. Asymptomatic bacteriuria and cystitis in pregnancy
Antibiotic Dose route frequency Duration Notes
Nitrofurantoin 100 mg orally every12hr 5-7 days Avoid use during the first
trimester and at term if
other options are
available.
Amoxicillin 500 mg
or
875 mg
orally
orally
every 8hr
every12hr
3-7 days Resistance may limit its
utility among gram-
negative pathogens.
Amoxicillin-
clavulanate
500 mg
or
875 mg
orally
orally
every 8hr
every12hr
3-7 days
Cephalexin 500 mg orally every 6hr 3-7 days
Cefpodoxime 100 mg orally every12hr 3-7 days
Fosfomycin 3 g orally single
dose
TMP/SMZ 800/160
mg
every12hr 3 days Avoid during the first
trimester and at term.

48. pyelonephritis in pregnancy
Antibiotic Dose route frequency Notes
Mild to moderate pyelonephritis
Ceftriaxone 1 g IV every 24hr
Cefepime 1 g IV every 12 hr
Aztreonam 1 g IV every 8 hr Alternative in the setting of beta lactam
allergy.
Ampicillin
+
Gentamicin
1-2 g +
1.5
mg/kg
IV
IV
every 6 hr
every 8 hr
Gentamicin associated with fetal
ototoxicity; this regimen should be used
only if intolerance precludes the use of
less toxic agents
Severe pyelonephritis with an impaired immune system and/or incomplete urinary drainage
Piperacillin-
tazobactam
3.375 g IV every 6 hr
Meropenem 1 g IV every 8 hr history of infections with extended-
spectrum beta-lactamase (ESBL)-
producing Enterobacteriaceae (or other
risk factors)
Ertapenem 1 g IV every 24hr
Doripenem 500 mg IV every 8 hr
Once afebrile for 48 hours, pregnant patients can be switched to oral therapy to
complete 10 to 14 days of treatment , Oral options beta-lactams or, if in the
second trimester, trimethoprim-sulfamethoxazole.

49. persistent bacteriuria in pregnancy
* first follow-up culture (test of cure) is positive for
bacterial growth [≥10^5 cfu/mL] with the same species
*Use the same antimicrobial in a longer course (eg, seven
days, if a three-day regimen was used previously) or a
different antimicrobial in a standard regimen
* Suppressive therapy may be appropriate for women
with bacteriuria that persists after two or more courses
of therapy.

50. Ttt recurrent infection during pregnancy
For the duration of pregnancy
persistent bacteriuria Suppressive therapy
Nitrofurantoin (50 to 100 mg orally at bedtime)
recurrent
asymptomatic
bacteriuria
do not recommend antibiotic prophylaxis
recurrent cystitis postcoital prophylaxis with low dose nitrofurantoin
(50 to 100 mg PO postcoitally or at bedtime)
or cephalexin (250 to 500 mg PO postcoitally or at
bedtime) can be used.
6–12
months
Recurrent
pyelonephritis
nitrofurantoin (50 to 100 mg orally at bedtime) or
cephalexin (250 to 500 mg orally at bedtime)
Prevention in woman
with history of
recurrent UTI prior to
pregnancy
If recurrent UTIs appear to be related to sexual
intercourse. postcoital dose of either cephalexin (250
mg) or nitrofurantoin (50 mg)

51. recurrent infection in woman
three or more episodes of UTI in 12 months or two or more
episodes of lower UTI in 6 months
*Encourage better hydration (1.6L/day recommended) to ensure
more frequent urination
*For postmenopausal women with risk factors such as atrophic
vaginitis consider prescribing intra-vaginal or oral oestrogens
*Cranberry juice (300 mL/day) was effective in decreasing
asymptomatic bacteriuria with pyuria in postmenopausal women

52. Continuous antimicrobial prophylaxis regimens
for women with recurrent urinary tract
infection
Post-coital antimicrobial
prophylaxis regimens for women
with recurrent urinary tract
infection
Trimethoprim-sulfamethoxazole 40 mg/200 mg
once daily
Trimethoprim-sulfamethoxazole
40 mg/200 mg
Trimethoprim-sulfamethoxazole 40 mg/200 mg
thrice wkly
Trimethoprim-sulfamethoxazole
80 mg/400 mg
Nitrofurantoin 50 mg once daily Nitrofurantoin 50 mg or 100 mg
Nitrofurantoin 100 mg once daily
Cefaclor 250 mg once daily
Cephalexin 125 mg once daily
Cephalexin 250 mg once daily Cephalexin 250 mg
Norfloxacin 200 mg once daily Norfloxacin 200 mg
Ciprofloxacin 125 mg once daily Ciprofloxacin 125 mg
Ofloxacin 100 mg

53. Risk factors for methicillin-
resistant Staphylococcus aureus (MRSA)
colonization
Health care-associated risk factors include:
•Recent hospitalization
•Residence in a long-term care facility
•Recent surgery
•Hemodialysis
Additional risk factors for MRSA infection include:
•Human immunodeficiency virus (HIV) infection
•Injection drug use
•Prior antibiotic use
Factors associated with MRSA outbreaks include:
•Incarceration
•Military service
•Sharing sports equipment
•Sharing needles, razors, or other sharp objects

54. P. aeruginosa risk factors
 hospital-acquired P. aeruginosa UTI
● impaired host defenses
● recent urinary tract instrumentation
● chronic indwelling urinary catheters.
● male sex
● longer hospitalization prior to UTI
● prior use of penicillins, third generation cephalosporins, carbapenems,
aminoglycosides, and vancomycin
 Community-acquired P. aeruginosa UTI
● Urinary tract obstruction
● Chronic prostatitis
● Prolonged courses of antibiotic therapy
● Recurrent infections

55. Candiduria risk factors
hospitalized patients risk factors
prior antibiotic therapy ,and malignancy .
Complicated  Urinary tract infections associated with drainage devices,
diabetes, or urinary tract abnormalities are considered.
Community risk factors
diabetes, antimicrobial use, indwelling bladder catheters
intensive care units risk factors
older age, diabetes mellitus, length of stay, ventilator support, and parenteral
nutrition
Ascending Candida infection of the kidney Predisposing urinary tract
abnormalities :
●Renal stones causing obstruction
●Renal stone manipulation with percutaneous lithotripsy or ureteroscopy
●Nephrostomy tubes
●Prostatic hypertrophy
●Neurogenic bladder
●Infected penile prosthesis
●Chronic bladder catheterization

56. HOME MESSAGE
 WHO TO BE TTT?
• All symptomatic pt cystitis , pyelonephritis
• Asymptomatic pt Pregnant woman , Post renal transplant within three
months of transplant , Prior urological surgery , colony counts ≥100,000/mL on
at least two occasions , Neutropenia
 WHO TAKE PROPHYLAXIS?
• recurrent cystitis and pyelonephritis in adults
• Chronic Bacterial Prostatitis in adults
• Prevention in Post renal transplant .
• Recurrent UTI in KTX
• persistent bacteriuria in pregnancy
• Recurrent cystitis and pyelonephritis in pregnancy
• Prevention in pregnant woman with history of recurrent UTI prior to
pregnancy
• Recurrent UTI in woman

57. REFERANCES
Uptodate
Manual of nephrology Robert W. Schrier, Eighth Edition 2015
Pearl recommendations and reviewed by HealthPartners Physician Leadership
2013.
European Association of Urology 2015
Canadian Urological Association 2011
IDSA guidelines
John hoppiken2015
Dynamed
sanford
lexicomp