A 20-year-old female presents with urinary frequency, bleeding, dysuria, and foul-smelling urine. She has a history of urinary tract infections (UTIs) and obesity. A urinalysis confirms the presence of bacteria, white blood cells, and blood in the urine consistent with uncomplicated cystitis. She is prescribed a course of antibiotics to treat the infection and prevent recurrence, with close follow-up in case symptoms persist or worsen.

2.  CC: 20 yr old AA female presents on
June 10, 2015 complaining of urinary
freq, bleeding, dysuria, and foul-smelling
urine
 HPI: sx first appeared at end of April
 Allergies: ciprofloxacin (rash)
 (-) pregnancy/lactation/sexual activity

3.  PMH: UTI (2013), obesity
› No hx of gynecological
abnormalities/menstrual issues
 FH: non-contributory
 SH:
› Diet: juice fast
 Veggie/fruit juices a couple times daily
› (-) ethanol, nicotine, drug use
› (+) exercise

4.  Temp wnl
 BP 124/83
 Wt 204 lbs (BMI 33.9)
 HR 80
 RR 18
 SPO2 99%

5.  ROS
› (+) urinary freq, bleeding, dysuria
› (-) suprapubic pain, fever/chills
 Gen: well-appearing/NAD
 Lungs: CTA BL
 Heart: RRR, no murmurs
 Abd: soft, non-tender, (+) BS
 Back: (-) CVA tenderness
 Extr: (-) edema

6.  Color: yellow
 Clarity: cloudy
 pH 6.0
 Specific gravity ≥1.030
 (+) WBCs, blood
 (-) glucose, bilirubin, protein, nitrites
 Trace: ketones

7.  May 5: Dx with uncomplicated cystitis
› Rx: cipro 500 mg po bid x 10 days
› D/c after third day because of rash
 May 11: Bactrim® DS po bid x 10 days
 May 28: residual sx; no med prescribed
 June 10: urinary sx persist
› Doxycycline 100 mg po bid x 10 days

8.  Definition
› Bladder infection caused by bacteria
› "Lower" UTI
 Premenopausal, non-pregnant females
› No urological abnormalities/comorbidities
 Prognosis
› Generally good with prompt tx
› Relapse is common in some individuals
› Growing resistance against many abx

9.  Dysuria
 Urinary freq/urgency
 Suprapubic pain
 Cloudy, bloody, foul-smelling urine
 *Elderly may present differently
› altered mental status, change in eating
habits, GI distress

10.  History confirmed by UA
 Dipstick UA
› Bacteriuria
› Pyuria (WBC ≥10/mm3)
 Leukocyte esterase test
› Gross hematuria
› Nitrites
 with nitrate reducers like E. Coli

11.  Eradicate infection
 Prevent or tx infection-related
complications
 Prevent infection recurrence

12.  Acute pyelonephritis
 Vaginitis
 Urethritis
 Structural urethral abnormalities
 Interstitial cystitis
 Pelvic inflammatory disease
 Nephrolithiasis

13.  "Upper" UTI (kidney infection)
 Cystitis sx may be present
› Duration > 5-7 days
 Additional sx
› Fever/chills, N/V, Flank pain/CVA tenderness
› Rarely: sepsis, shock, acute renal failure
 Dx: Urine culture and susceptibility
› Tailor tx to pathogen

14.  FQ resistance ≤ 10%
› Cipro 500 mg po bid x 7 days
› Cipro 1000 mg XL po daily x 7 days
› Levo 750 mg po daily x 5 days
 If FQ resistance > 10%
› Initial IV dose (1 g ceftriaxone or 24 hr
aminoglycosidez) is recommended
 Bactrim DS po bid x 14 days
› Susceptible pathogen
› Add IV dose if susceptibility unknown

15.  Escherichia coli (75-95%)
 Staphylococcus saprophyticus (5-20%)
› Less common
› More likely to cause pyelonephritis and recur
 Klebsiella, Enterococci, or Proteus
mirabilis (<5%)
› More common in older women

16.  Pathogens in rectal flora --> transfer to
urethra --> colonize and ascend to
bladder
 Imbalance in vaginal flora (Lactobacilli) -
-> increased pH --> greater risk of E. Coli
infection
 More common in women
› Urethral proximity to rectal area
› Shorter urethra --> easy access to bladder

17.  Female gender
 Menopause --> loss of estrogen
 Frequent sexual intercourse
 Spermicide/diaphragm use
 Abx use --> disruption in gut flora
 Immunocompromised status
 Diabetes
› High urine glucose content
› Hyperglycemia --> neutrophil dysfunction

18.  Unsweetened cranberry juice
› D-Mannose may prevent bacterial
attachment to urinary tract
 Increase water intake
› May help "flush out" bacteria
 Drink water and empty bladder after
intercourse
› May help flush out bacteria
 Consider probiotics during abx tx

19.  Avoid scented feminine
products/douches
› Cause irritation
› Disrupt vaginal flora
 Limit sugar intake
› May disrupt vaginal flora
› Especially for diabetics
 Wipe from front to back after BM
› Prevents transfer of bacteria to urethra

20.  100 mg po bid x 5 days
 Minimal resistance
 ADRs: N/D, anorexia, flatulence, urine
discoloration
 Avoid
› Suspected pyelonephritis
› CrCl < 40 mL/min
 Cost: $32 for 5 days

21.  1 DS (800/160) tablet po bid x 3 days
 ADRs: rash, N/V, hematologic supp.
 Avoid
› Resistance rate > 20%
› If used for cystitis tx in past 90 days
› Sulfa allergy
 Cost: $4 at Walmart, free at Publix

22.  3 g single dose in 4 oz of water
 Not absorbed systemically
› Less likely to alter gut flora and cause C. diff
infection
› Concentrates in urine
 Useful in multi-drug resistance
› Active against ESBL gram (-) rods, VRE, MRSA
 Avoid if pyelonephritis suspected
 Cost: $72.61 per tx

23.  Not discussed in 2010 IDSA guidelines
 Per DiPiro
› Azithromycin 1 g po single dose
 $29.13 per tx
› Doxycycline 100 mg po bid x 7 days
 Effective, but resistance develops rapidly
 Used primarily for chlamydial infections
 Avoid in pregnancy and children
 $77.45 for 14 capsules

24.  FQ (3 days)
› *Concerns about resistance
 Ciprofloxacin (free at Publix)
 Levofloxacin
 Ofloxacin
 B-lactams (3-7 days)
› Lower efficacy, more ADRs
 Amoxicillin-clavulanate 500 mg po tid x 5-7
days
 Cefdinir, cefaclor, cefpodoxime-proxetil

25.  Nitrofurantoin 50 mg po daily x 6 months
› Monitoring
 CBC, LFTs, SCr, BUN
 Signs of pulmonary toxicity/peripheral
neuropathy
 Bactrim® SS 1/2 tablet po daily x 6
months
› Monitoring: CBC, K, SCr, BUN

26.  Automatically classified as "complicated"
 Tx if significant bacteriuria
› Pyuria (>10 WBC/mm3) + sx
 7 day regimens
› Cephalosporin
› Amoxicillin/clavulanate
› Bactrim (first and second trimesters)
 Avoid tetracyclines and FQ

27.  Tested efficacy of various abx against
urinary E. Coli isolates
› Samples from 2010-2013
› 12 cities, 8 Canadian provinces
 99.4% of 868 urinary E. Coli isolates were
susceptible to fosfomycin
› Least resistance (5 isolates)
› Active against ESBL, AmpC, MDR pathogens

28.  Resistance rates
› Fosfomycin 0.1%
› Bactrim 25.3%
› Nitrofurantoin 1.5%
› Cipro 22.5%
› Amoxicillin-clavulanate 5.7%
 High resistance to Bactrim and FQ
 Fosfomycin and nitrofurantoin are better
options for empiric tx

29.  May 5: Dx of uncomplicated cystitis
› Rx: Cipro 500 mg po bid x 10 days
› D/c after third day because of rash
 May 11: Bactrim® DS po bid x 10 days
 May 28: residual sx; no med prescribed
 June 10: urinary sx persist
› Doxycycline 100 mg po bid x 10 days

30.  Initial tx: cipro 500 mg po bid x 10 days
› Wrong drug
 Bactrim® DS po bid x 3 days would have been a
better choice
 FQ not first-line due to resistance
› Wrong dose
 Appropriate for complicated cystitis
 Correct dose of cipro: 250 mg po bid x 3 days
› Since pt d/c drug after 3 days of tx, resistance
must have already been present

31.  If sx persisted after Bactrim® DS po bid x 3
days
› Azithromycin 1 g po single dose ($29.13)
› Doxycycline 100 mg po bid x 7 days ($77.45)
 Large gap in tx (May 21-June 9)
› Allowed for development of resistance
› On May 28, pt returned, complaining of
residual sx, but no med was prescribed
› Doxy was finally prescribed on June 10

32.  Efficacy
› Resolution of s/sx
› Optional UA
 Safety
› Discuss common ADRs
› Lab monitoring not required for short-term
abx tx

33.  Take abx as prescribed
› Finish even if sx resolve
 Return to clinic if sx recur or worsen
 Stop juice fast (too high in sugar)
› Resume normal diet and watch sugar intake
 Wipe from front to back after BM
 Consider probiotics during abx tx
› May help restore vaginal flora balance

34.  Mehnert-Kay SA. Diagnosis and management of
uncomplicated urinary tract infections. Am Fam
Physician. 2005 Aug 1;72(3):451-456.
 University of Maryland Medical Center website. Urinary tract
infection. Accessed June 23, 2015 at
http://umm.edu/health/medical/reports/articles/urinary-
tract-infection.
 Gupta K, Hooton TM, Naber KG, et al. International clinical
practice guidelines for the treatment of acute
uncomplicated cystitis and pyelonephritis in women: a 2010
update by the Infectious Diseases Society of America and the
European Society for Microbiology and Infectious Diseases.
CID. 2011;52(5):e103-e120.

35.  Lexicomp website. Accessed on June 22, 2015 at
http://online.lexi.com.proxy.pba.edu/.
 UptoDate website. Accessed on June 22, 2015 at
http://www.uptodate.com.proxy.pba.edu/.
 Wells BG, DiPiro JT, Schwinghammer TL, DiPiro CV.
Pharmacotherapy Handbook. 8th edition. McGrawHill
Medical: New York, 2012.
 Karlowsky JA, Denisuik AJ, Lagace-Wiens PRS, et al. In vitro
activity of fosfomycin against Escherichia coli isolated from
patients with urinary tract infections in Canada as part of the
CANWARD surveillance study. Antimicrobial Agents and
Chemotherapy. 2014;58(2):1252-1256.