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Uti policy-lec

This document outlines a UTI policy and protocol. It discusses various types of UTIs including those in adults, patients with renal impairment, catheter-related infections, and pregnancy. It provides typical organisms, symptoms, diagnostic criteria, and treatment recommendations for uncomplicated and complicated UTIs. Treatment options are provided for different severities of infection. It also discusses dosing adjustments needed for antibiotics in patients with renal impairment and on dialysis. Recurrent UTIs are addressed as well as specific organisms like MRSA, Pseudomonas, and Candida.

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UTI policy BY Seham Moustafa Fetouh BCPS,Master of clinical pharmacy , Pharm D
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
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
UTI IN ADULTS
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 .
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
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
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
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)
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
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
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
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.
Risk factors associated with acute complicated UTIs
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
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
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
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
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
CATHETER RELATED UTI INFECTION
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.
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.
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
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
UTI in patients with renal impairment
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
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.
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%)
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)
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
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.
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):
UTI in renal transplantation ( KTX)
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.
causative organism Escherichia coli dominant causative organism Pseudomonas aeruginosa Enterobacter cloacae Klebsiella pneumonia Klebsiella oxytoca Staphylococcus saprophyticus Streptococcus species Corynebacterium urealyticum rare causes
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
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.
UTI treatment in ( KTX) Asymptomatic bacteriuria in ( KTX) symptomatic UTI in ( KTX) Uncomplicated UTI Complicated UTI Recurrent UTI
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
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.
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
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
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
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
UTI in pregnancy
Asymptomatic bacteriuria and cystitis pyelonephritis Mild to moderate pyelonephritis Severe persistent bacteriuria recurrent infection UTI ttt in pregnancy
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.
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.
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.
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)
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
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
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
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
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
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
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
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Uti policy-lec

  • 1.
    UTI policy BY Seham MoustafaFetouh BCPS,Master of clinical pharmacy , Pharm D
  • 2.
    Titles  UTI inadults  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 referanceby 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.
  • 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 findingin 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 inadults 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 acutecystitis 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 suppurativecomplications, 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.
  • 15.
    Suspected organisms forcomplicated 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 complicatedUTI 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 cystitisin 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 pyelonephritisin 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 UTIin 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.
  • 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. coli27 % 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 ofcatheter. 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 patientswith 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 patientswith renal impairment
  • 26.
    Treatment of UTIsin 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 inrenal 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 Adjustmentin 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 Adjustmentin 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 Adjustmentin 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 Adjustmentin 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 Adjustmentin 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 renaltransplantation ( KTX)
  • 34.
    Interaction with immunosuppressionmust 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 colidominant causative organism Pseudomonas aeruginosa Enterobacter cloacae Klebsiella pneumonia Klebsiella oxytoca Staphylococcus saprophyticus Streptococcus species Corynebacterium urealyticum rare causes
  • 36.
    Diagnosis investigations comments BK and/orCMV 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 routefrequency 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 UTIin ( 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.
  • 46.
    Asymptomatic bacteriuria andcystitis pyelonephritis Mild to moderate pyelonephritis Severe persistent bacteriuria recurrent infection UTI ttt in pregnancy
  • 47.
    Asymptomatic bacteriuria andcystitis 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 AntibioticDose 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 inpregnancy * 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 infectionduring 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 inwoman 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 prophylaxisregimens 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 formethicillin- 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 riskfactors  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 hospitalizedpatients 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  WHOTO 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 nephrologyRobert 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