A 19 year old female patient was admitted to the female medicine ward with complaints of abdominal pain, fever, headache, weakness since 2 days.

1. A Case Study on UTI with
Iron Deficiency Anaemia
- Ajita Sadhukhan
- Pharm D. 4th year
- Roll No. : 1
- Enrolment No. : 150821207001
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2. Patient Demographics:
• IPD No.: 18011675
• OPD No.: 18100453
• Age: 19 years
• Sex: Female
• Department: Female Medicine Ward
• Unit: 2
• Date of Admission: 29.06.18
• Date of Discharge: 04.07.18
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3. Reason for admission:
• C/O: – abdominal pain (epigastric pain)
- fever all since 2 days
- headache
- weakness
• CMP- 2nd day
• Past History: NAD
• Family History : NAD
• Personal History:
- appetite: normal
- Bowel habit: regular
- Addiction: none
- Sleep: sound
• ALLERGIES : NKA3/26/2020 3

4. OBJECTIVES:
• General Examination:
- Built: average
- Nutrition: average
- Clubbing: not seen
- Jaundice: not seen
- Pallor: ++
- Bowel habits: regular
- Bladder habits: normal
- Oedema: not seen
- Skin, hair, nails: NAD
- Tongue: pale
- Eyes: pale
- Lymphnodes: not palpable
- Temperature: normal
- Pulse: 86/min
- B.P.: 110/70 mm Hg
- Respiration: normal
• Systemic Examination:
- R.S.: AEBE clear
- C.V.S.: NAD
- C.N.S.: conscious, oriented
- P/A: soft
- G.U.S.: adequate UOP
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5. Lab. Investigation reports [first day]
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LABORATORY PARAMETERS OBSERVED VALUE NORMAL RANGE UNIT
Hb 7.5 12.5-16 g/dL
WBC 16850 4000-10500 /mcgL
Neutrophils 82 50-70 %
Eosinophils 01 0-7 %
Lymphocytes 12 20-40 %
Monocytes 05 <10 %
Basophils 00 <1 %
RBC 3.88 4.20-5.40 Millions/mcgL
MCH 19.3 27-31 pg
Platelets 247000 1.5-4.5*10^5 /mcgL
MCV 64.4 78-100 fL
Hematocrit (PCV) 25.0 37-47 %
MCHC 30.0 32-36 g/dL
RDW-CV 18.0 11-14.6 %

6. Contd…
• PS for MP: malarial parasite not seen
• Urine analysis:
- Colour: reddish
- Appearance: turbid
- Reaction: 6.5
- Specific gravity: 1.015
• Chemical examination:
- Protein: 2+
- Blood: 3+
• Microscopic examination:
- RBC: plenty/HPF (0-10/HPF)
- Epithelial cells: 2-3/HPF (absent)
• Radiology report: no significant abnormality detected3/26/2020 6

7. Assessment:
• Provisional Diagnosis: Fever under investigation
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8. ASSESSMEN
T
Justification:
• A 19 year old female patient was admitted to
female medicine ward unit 2 with complaints of
abdominal pain in the epigastric region, fever,
headache and weakness since 2 days.
• Based on lab investigations, patient was
presented with:
- Low Hb, Low RBC, Low MCV, Low PCV, Low
MCHC, high RDW-CV levels → anaemia
- High WBC, High neutrophil, Low lymphocyte
levels → infection/ inflammation
- Low MCH level → iron deficiency anaemia
- Reddish urine → hematuria caused by UTI
- Turbid urine → due to presence of epithelial cells
in urine caused due to UTI
• Hence, the patient was diagnosed with UTI with
iron deficiency anaemia.
Final Diagnosis: UTI
with iron deficiency
anaemia.
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9. GOALS OF TREATMENT:
• For UTI:
- to eradicate the invading microorganisms causing the infection
- prevent complications or treat systemic consequences of
infections
- provide symptomatic relief to patients
- Prevent the recurrence of infection
- Prevent antimicrobial resistance
- early treatment is recommended to reduce the risk of
progression to pyelonephritis
• For iron deficiency anaemia:
- To treat anaemia or to fully replace iron stores
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10. Day 1:
• c/o mild chills
• Temp.: 102.6 F
• P: 96/min
• B.P.: 110/70 mm Hg
• SPO2: 98%
• R.S.: NAD
• C.V.S.: NAD
• Urine: passed
• Stool : passed
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Adv.:
-CBC, PSMP, Urine –R & M, USG (abd. &
pelvis)
-Inj. NS (100 ml) + 2 amp. Febrinil
(paracetamol) IV stat over 30 mins
-Solid diet (SD)

11. Day 1 Medication chart:
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone + 500
ml NS
1 g I.V. 1-0-1 To treat UTI
Inj. Paracetamol 1 amp I.V. 1-1-1 Fever
Inj. pantoprazole 40 mg I.V. BD Gastric disturbance
Inj. DNS/RL 1 pint @ 80 ml/hr I.V. - To maintain
electrolyte balance

12. Day 2
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• Fever spike at 10 a.m.
• Temp.: 102 F
• GC stable
• B.P.: 110/70 mm Hg
• P: 114/min
• SPO2: 99% @ RA
• Stool: not passed
• Urine: passed
• R.S.: NAD
• C.V.S: NAD
• C.N.S.: NAD
• P/A: soft

13. Day 2 Medication chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone + 500
ml NS
1 g I.V. 1-0-1 To treat UTI
Inj. Paracetamol 1 amp I.V. 1-1-1 Fever
Inj. pantoprazole 40 mg I.V. BD Gastric disturbance
Inj. DNS/RL 1 pint @ 80 ml/hr I.V. - To maintain
electrolyte balance

14. Day 3
• T: normal
• P: 82/min
• B.P.: 90/60 mm Hg
• SPO2: 99%
• R.S.: NAD
• C.V.S: NAD
• C.N.S.: NAD
• Urine: passed
• Stool: passed
• No fresh complaints
• Continue same treatment3/26/2020 14

15. Day 3 Medication chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone + 500
ml NS
1 g I.V. 1-0-1 To treat UTI
Inj. Paracetamol 1 amp I.V. 1-1-1 Fever
Inj. pantoprazole 40 mg I.V. BD Gastric disturbance
Inj. DNS/RL 1 pint @ 80 ml/hr I.V. - To maintain
electrolyte balance

16. Day 4
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• B.P.: 110/70 mm Hg
• P: 115/min
• SPO2: 99%
• Stool: passed
• Urine: passed
• R.S.: NAD
• C.V.S: NAD
• C.N.S.: NAD
• No fresh complaints
• Adv.: CBC, iron profile,
sickling
•Hb: 5.5 g/dL
•Total WBC count: 7530/mcgL
•Platelet: 189000/mcgL

17. Day 4 Medication chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone + 500
ml NS
1 g I.V. 1-0-1 To treat UTI
Inj. Paracetamol 1 amp I.V. 1-1-1 Fever
Inj. pantoprazole 40 mg I.V. BD Gastric disturbance
Inj. DNS/RL 1 pint @ 80 ml/hr I.V. - To maintain
electrolyte balance

18. Day 5
• T: 96.7 F
• P: 117/min
• B.P.: 100/60 mm Hg
• SPO2: 96%
• R.S.: NAD
• C.V.S: NAD
• C.N.S.: NAD
• Urine: passed
• Stool: passed
• No fresh complaints
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• Adv.:
- Inj. Febrinil (paracetamol) IV SOS
- Tab. Pantop (pantoprazole) 40
mg BD PO
- Tab. Tonofolic Z 1-0-1

19. Day 5 Medication chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Paracetamol 1 amp I.V. SOS Fever
Tab. pantoprazole 40 mg P.O. BD Gastric disturbance
Tab. Ferrous
fumarate + folic acid
+ zinc sulphate
325 mg + 500 mcg +
50 mg
P.O. 1-0-1 Iron deficiency
anaemia

20. Day 6
• Temp.: 95.2 F
• P: 103/min
• B.P.: 110/70 mm Hg
• SPO2: 99%
• R.S.: NAD
• C.V.S.: NAD
• C.N.S.: NAD
• Urine: passed
• Stool : passed
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Adv.:
-Tab. Pantop (pantoprazole) 40 mg BD PO
-Tab. Tonofolic Z 1-0-1
-Tab. MBSon SL (cyanocobalamine) 1-0-1
X-ray chest (PA) view → not done (patient
could not afford it)
Discharge patient, follow-up after 7 days

21. Discharge Medication chart
• Follow up after 7 days
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab.
cyanocobalamine
1500 mcg P.O. 1-0-1 Anaemia
Tab. pantoprazole 40 mg P.O. BD Gastric disturbance
Tab. Ferrous
fumarate + folic acid
+ zinc sulphate
325 mg + 500 mcg +
50 mg
P.O. 1-0-1 Iron deficiency
anaemia

22. Treatment:
• Ceftriaxone is a 3rd generation cephalosporin beta lactam antibiotic. It’s a bactericidal
antibacterial that inhibits bacterial wall synthesis of the actively dividing cells by
binding to one or more penicillin binding proteins, thus inhibiting bacterial wall
synthesis resulting in cell death. It is used to treat UTI.
• Paracetamol, or acetaminophen, is a centrally acting analgesic and anti-pyretic with
minimal anti-inflammatory properties. It relieves fever by inhibiting the formulation and
release of prostaglandin in the CNS and by inhibiting the endogenous pyrogens at the
hypothalamic thermoregulatory centre. It is prescribed to reduce fever.
• Pantoprazole is a proton pump inhibitor. It accumulates in the acidic compartment of
the parietal cells and is converted to an active form, a sulphonamide that binds to
hydrogen-potassium-ATPase at the secretory surface of the gastric parietal cells.
Inhibition of hydrogen-potassium-ATPase blocks the final step of gastric acid
production, leading to inhibition of both basal and stimulated acid secretion.
• Ferrous fumarate: Used as iron supplement to treat iron deficiency anaemia.
• Folic acid: It is a nutritive agent used to treat anaemia.
• Zinc sulphate: Used as a source of zinc as supplement.
• Cyanocobalamine: used to treat low vitamin B 12.
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23. Monitoring Parameters:
Disease Related:
• UTI:
• Urine analysis
• USG, CT scan or MRI of urinary tract
• Cytoscopy (recurrent UTIs)
• IDA:
• Full blood examination
• Serum ferritin
• Total iron binding capacity (TIBC) and
transferrin saturation
• Soluble transferrin receptor (sTfR)
• Bone marrow examination
• Monitored therapeutic trial of iron
Drugs Related:
• Ceftriaxone: RFT, white blood cell
count, differential count.
• Paracetamol: fever reduction
• Pantoprazole: Se. Mg2+, Vitamin B12
• Ferrous fumarate + Folic acid + Zince
sulphate:
• Cyanocobalamin: Hematocrit,
reticulocyte count, vitamin B12, folate,
iron levels

24. Treatment:
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25. POINTS TO BE INTERVENED WITH THE
DOCTOR
• Drug-drug interaction:
- Pantoprazole + ferrous fumarate → monitor closely (moderate)
pantoprazole will decrease the level or effect of ferrous fumarate by
increasing gastric pH. Applies to oral form of both agent. Use caution/monitor.
- Ferrous fumarate + zinc sulphate → monitor closely (moderate)
concurrent use of iron and zinc will decrease the level or effect of ferrous
fumarate/zinc by increasing gastric pH. Applies to oral form of both agent. Use
caution/monitor. Separate use of iron or zinc by at least 2 hours is
recommended.
• Serum ferritin not done.
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26. Patient Counselling:
• About disease:
• UTI: Urinary tract infections are the most commonly occurring
bacterial infections especially in females of childbearing age.
Approximately 60% females develop UTI in their lifetime. UTI is
treatable and curable with proper medications and adherence to
therapy. It has high morbidity and low mortality.
• Iron deficiency anaemia: IDA is characterized by decreased levels
of ferritin and serum iron, as well as decreased transferrin
saturation. It can affect both length and quality of life if proper
care is not taken. It results in decreased iron carrying capacity of
blood.it can be cured easily with proper diet.
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27. • About medications:
▪ Pantoprazole: 40 mg orally once daily for up to 8 weeks or in two
divided doses twice a day. The adverse effects include abnormal ECG,
peripheral oedema, itching, rash, etc.
▪ Ferrous fumarate + folic acid + zinc sulphate: Take with or without food
twice a day.
▪ Cyanocobalamine: Take twice a day after food.
▪ In cases of missed dose, take the dose as soon as possible.
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28. • Life Style Modifications:
• Drink plenty of water and keep yourself hydrated.
• Drink cranberry juice to prevent UTI.
• Lactobacillus probiotics are also helpful in preventing UTIs in females.
• Iron is best absorbed from meat, fish and poultry.
• Ready to eat cereal (100% fortified) ¾ cup, instant plain oatmeal (fortified) 1
cup, wheat germ, broccoli, baked potato, raw tofu ½ cup, lentils ½ cup,
pomegranate are some iron rich foods.
• Orange juice and other ascorbic acid rich foods can be included in meals to
increase iron absorption whereas milk and tea reduce its absorption and should
be consumed in moderation.
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29. References:
• Pharmacotherapy: A Pathophysiologic Approach, 9th edition, by
Joseph T. Dipiro
• Micromedex
• Medscape
• Mayoclinic.com
• Australian Red Cross Blood Service
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