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Urinary tract infection

Urinary tract infection. Piroon Mootsikapun M.D. Infectious Dis Unit Department of Medicine, KKU. Urinary Tract Infection. Acute uncomplicated cystitis in women Acute uncomplicated pyelonephritis Acute complicated UTI Recurrent UTI Asymptomatic bacteriuria Prostatitic syndrome.

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Urinary tract infection

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  1. Urinary tract infection Piroon Mootsikapun M.D. Infectious Dis Unit Department of Medicine, KKU

  2. Urinary Tract Infection • Acute uncomplicated cystitis in women • Acute uncomplicated pyelonephritis • Acute complicated UTI • Recurrent UTI • Asymptomatic bacteriuria • Prostatitic syndrome

  3. Urinary Tract Infection Acute uncomplicated cystitis in women • Common 40-50% of adult women had at least 1 UTI in lifetime Microbial cause • E. coli 80% • S. saprophyticus 5-20% • Other: Klebsiella, Proteus, Enterococci

  4. Urinary Tract Infection Acute uncomplicated cystitis in women • Clinical • Dysuria, urgency, frequency, suprapubic pain • No urinary symptoms within 4 weeks before • Laboratory • >10 WBC/mm3 • >103 cfu/mm3

  5. Urinary Tract Infection Acute uncomplicated cystitis in women Differential Dx • acute urethritis • acute vaginitis

  6. Acute uncomplicated cystitis Treatment • Single dose therapy effective < 3 day regimen but = longer duration • TMP/SMX is standard ATB • Quinolones =TMP/SMX efficacy as 3 dayRx Ampicillin less effective than TMP/SMX • Expected eradication of bacteriuria > 90%

  7. Acute uncomplicated cystitis Treatment Drug Dose Days Eradication rate 2-wk > 2-wk • Norfloxacin 400 BID x3d 95% 87% • Ofloxacin 100 BID x3d 89% - • Ciprofloxacin 100 BID x3d 92% 83% • TMP/SMX 480BID x3d 94% 84% • B-lactam x3d 82% 75%

  8. Acute uncomplicated cystitis Treatment Drug Dose Days Eradication rate 2-wk > 2-wk • Norfloxacin 800 mg 80% 76% • Ofloxacin 400 mg 93% - • Ciprofloxacin 500 mg 89% 81% • TMP/SMX 480 mg 89% 81% • B-lactam 66% 72%

  9. Recurrent cystitis Treatment • Urine culture • Longer course of Rx with quinolones if not used initially • Prophylatic ATB

  10. Recurrent cystitis • Prophylactic ATB • Long term low dose • TMP/SMX ½ tab (80/400) OD • Norfloxacin 200 mg x3/wk • Ciprofloxacin 250 mg x3/wk • Post intercouse • TMP/SMX ½ tab (80/400) • Norfloxacin 200 mg • Ciprofloxacin 250 mg • Ofloxacin 200 mg

  11. Urinary Tract Infection Acute uncomplicated pyelonephritis • Almost all cases occur in women Pathogenesis • ascending • dissemination Microbial cause • E. coli • GNR • S. saprophyticus, Enterococci

  12. Urinary Tract Infection Acute uncomplicated pyelonephritis • Clinical • Fever, chill, flank pain • No urological abnormality by clinical, X-ray, ultrasound • Laboratory • > 10 WBC/mm3 • > 104 cfu/mm3

  13. Urinary Tract Infection Acute uncomplicated pyelonephritis • Treatment • as soon as possible to prevent renal parenchymal damage and scarring • In-patients – IV antibiotic • Out-patient – oral ATB

  14. Urinary Tract Infection Acute uncomplicated pyelonephritis • In-patient treatment • Inability to maintain oral hydration • Uncertain compliance • Uncertain diagnosis • Severe symptoms/toxicities • Unable to return for follow up • Pregnant

  15. Acute uncomplicated pyelonephritis GNR found only • Ceftriaxone 1-2 gm iv q 24 hr • Gentamicin 3-5 mg/kg iv q 24 hr • Cefepime 1 gm iv q 12 hr • Gatifloxacin 400 mg iv q 24 hr • Levofloxacin 500 mg iv q 24 hr • Ciprofloxacin 200-400 mg iv q 12 hr

  16. Acute uncomplicated pyelonephritis GPC also found -> enterococci? • Add Ampicillin 1 gm iv q 6 hr • Or Ampicillin/Sulbactam 1.5 gm iv q 6 hr

  17. Urinary Tract Infection Quinolones Dose Total 24 hr Cmax urine excretion urine Levofloxacin 500 70.7% 579 Gatifloxacin 400 69.7% 400 Moxifloxacin 400 16.9% 55 Ciprofloxacin 500 40.8% 585

  18. Acute uncomplicated pyelonephritis Transitional therapy (IV to oral ATB) • When • Significant clinical improvement (S&S) • No fever at least 24 hour • Stable vital sign (BP, PR,RR) at least 48 hr • CBC - WBC return to normal

  19. Acute uncomplicated pyelonephritis Transitional therapy (IV to oral ATB) • Switch therapy • Step down therapy

  20. Acute uncomplicated pyelonephritis • Oral antibiotic (GNR only) • Ofloxacin 200 mg po q 12 hr • Levofloxacin 300 mg po q 24 hr • Ciprofloxacin 500 mg po q 12 hr • Gatifloxacin 400 mg po q 24 hr • Cefipime 200 mg po q 12 hr (alternative) • Cefdinir 200 mg po q 12 hr (alternative) • Cefpodoxime 200 mg po q 12 hr (alternative)

  21. Acute uncomplicated pyelonephritis • Oral antibiotic (enterococci) • Amoxycillin 500 mg po q 8 hr • Amoxycillin/clavulanate 1 gm po q 12 hr • Cotrimoxazole 80/400 mg po q 12 hr

  22. Urinary Tract Infection Duration of treatment • Conventional Rx –10 -14 days • Short course Rx - 7days • Mild to moderate case, rapid response • Longer course Rx 3 - 4weeks • Severe case, slow response • Prolonged treatment • Focal abcess

  23. Persistent febrile UTI Possible cause • ATB resistant pathogen, before or after • Multiple pathogens • Azotemia -> indequate drug delivery • Papillary necrosis, • Abscess – intrarenal, perirenal • Obstruction – intraluminal, extraluminal • Underlying dis that Impaired host defense

  24. Recurrent acute pyelonephritis Treatment • Within 2 weeks • Urine culture • Ultrasound KUB • Rx with another new class ATB • > 2 weeks after previous episode • Rx with ATB as previous episode

  25. Complicated UTI Complicated factor • Catheter use • > 100 cc residual urine– spinal cord ds • Obstructive uropathy • Vesicoureteral reflux • azotemia due to intrinsic renal dis • renal transplantation

  26. Complicated UTI Complicated factor • Men • Children • Nosocomial MDR infection • Pregnancy • Comorbid – diabetes, analgesic use

  27. Complicated UTI • Clinical • Persistent febrile UTI after 3 days • Recurrence UTI • Renal colic • Gross hematuria • Infection with urea splitting pathogen (Proteus)

  28. Complicated UTI • Approach • Repeat urine culture • Ultrasound KUB • (Men) – prostatic massage urine C/S

  29. Acute UTI with stone obstruction and hydronephrosis • Management other than ATB • Consult urosurgeon • Cystoscope –> ureteral stent -> infection cleared -> stone removal • If stent placement not possible -> percutaneous nephrostomy tube (PNT)

  30. UTI in patients with spinal cord injury • Often without classic symptoms • May present with back pain, abdominal pain, lethargy, malodorous urine • Usually polymicrobial with rapid and constant change • Pyuria – unclear significance

  31. UTI in patients with spinal cord injury Management • Asymptomatic bacteriuria – not Rx • Except • Immunocompromised • Before urinary instrumentation • Proteus spp. infection

  32. UTI in patients with spinal cord injury Management of symptomatic UTI • UA, Urine C/S • Remove long indwelling cath and insert the new one to eliminate colonization • Start broad spectrum ATB cover NI • Rx duration 7-14 days, episodic Rx only • Follow up urine culture to determine cure

  33. Recurrent UTI in women • Clinical • > 3 episodes of acute UTI in a year • No urinary tract abnormalities • Laboratory • < 103 cfu/mm3 of uropathogen

  34. Asymptomatic bacteriuria • Clinical • No urinary symptoms • Laboratory • > 10 WBC/mm3 • > 105 cfu/mm3 of same organism in 2 consecutive urine MSU cultures > 24 hours apart

  35. Asymptomatic bacteriuria Sceening and treatment benefit only in • Pregnancy • Undergoing urological instrumentation • Renal transplantation - unclear

  36. Prostatitis syndrome NIH/NIDDK system classification Category Description • I Acute bacterial prostatitis • II Chronic bacterial prostatitis • III Chronic pelvic pain syndrome • III A Inflammatory • III B Non-inflammatory • IV Asymptomatic inflammatory prostatitis

  37. Acute bacterial Prostatitis Clinical • Flu like symptoms • Urinary symptoms • Tense and tender prostate • Most isolated E. coli • Other GNR: Klebsiella, Proteus • Prostate massage should not performed

  38. Chronic bacterial Prostatitis Clinical Pain • slow, gradual onset, perineal, testicular, tip of penis, urethral, pain on ejaculation, worsening by prolonged sitting Urinary • dysuria, frequency, urgency, hematuria • Decrease libido, Lethargy

  39. Chronic bacterial Prostatitis Treatment Source Drug Dose Duration No. Cure rate FU mo Schaeffer 1990 Norfloxacin 400 BID 28 14 64 6 Pust 1989 Ofloxacin 200 BID 14 21 67 8 Naber 2000 Ciprofloxacin 500 BID 28 34 76 6

  40. Thank you

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