Urinary Tract Infections

(UTI’s)
Urinary Tract Infections
& Prostatitis

Gisela I. Robles, Pharm. D.

rgisela@.nova.edu
PHA 6630: TP III
February 12, 09

Learning Objectives UTI’s Background

Upon completion of this lecture, the
student should have an understanding of
the following facts about urinary tract
infections (UTI’s) and prostatitis :
• Define the different types
• Describe the pathophysiology and etiology
• List common pathogens
• Recognize clinical features and presentation
• List the different diagnostic tools
• Recommend appropriate therapy
• Identify clinical pharmaceutical interventions
• UTI’s result from the presence of
microorganisms in the urine (not related to
contamination) that has the potential to invade
the urinary tract and adjacent tissues
• One of the most common bacterial infections (~
8 million patient visits/year in the U.S.)
• Prevalence:
– Women > men while young
– Women = men at the age of 65
• Localized vs. systemic

UTI Types

• Lower Tract – Infection in lower

portion of UT. Can include bladder
(cystitis), urethra (urethritis), prostate
gland (prostatitis), and epididymitis.
• Upper Tract – Infection in upper
portion of UT. Can include kidneys
(pyelonephritis) and ureters.
 UTI Types Male UT
• Uncomplicated:
Infection present in individuals with normal UT
anatomy and no alterations in urine flow or
voiding mechanism.
• Complicated:
Infection resulting from a predisposing lesion such
as congenital abnormalities, distortion of UT,
stone, indwelling catheter, prostatic hypertrophy
and neurogenic deficits. Affect both genders
similarly, and can involve the upper and lower UT.
Men UTI’s are considered complicated.

UTI Etiology UTI Pathophysiology

• Bowel Flora A. Route of entry: C. Host Defense
• Uncomplicated UTI’s: 1. Ascending Mechanisms:
– E. coli (85%)- MOST COMMON pathogen 2. Hematogenous – Low urine pH
– S. saprophyticus (5 – 15%) 3. Lymphatic – Extreme osmolality
– K. pneumoniae, Proteus spp., P. aeruginosa, and – High [urea]
Enterococcus spp. (5 – 10%) – High [organic acid]
– S. epidermidis- repeat cultures to r/o contamination B. Factors that impact – Prostatic secretions
• Complicated UTI’s: infection development: – Micturition
– Pathogens w/ ↑ resistance to antibiotics 1. Size of inoculum – Anti-adherence mechanism:
– E. coli (< 50%) and E. faecalis (frequently isolated in – Urinary mucus
hospitalized patients) 2. Virulence of – Tamm-Horsfall protein
microorganism – Inflammatory response
• Candida spp.
3. Natural host defense – Lactobacillus and estrogen
• Single organism vs. multiple organisms levels
• Community acquired vs. hosp. acquired

Clinical Presentation:
UTI Predisposing Factors UTI and Prostatitis
• Age • Vesicoureteral reflux • Lower UTI • Acute Bacterial
• Dysuria Prostatitis
• Gender • Immunocompromised • Urgency/frequency • Perineal, sacral, or
suprapubic pain
• UT structural patients • Nocturia
• Urinary retention
• Suprapubic discomfort
abnormalities • Instrumentation • Upper UTI • Dysuria
– Obstruction • Urgency/frequency
• Pregnancy •
•
Fever
Chills
• Nocturia
• BPH
• Sexual intercourse / • Malaise • Chronic Bacterial
• Urethral strictures Prostatitis
• N/V
– Caliculi diaphragm use • Flank pain • Voiding difficulties
– Tumors
• Menopause • Abdominal pain • Perineal and suprapubic
pain
• Incomplete bladder • Costovertebral tenderness
emptying
 Urinalysis
Laboratory Findings
Parameter UTI Normal
Markers Values
• Urine collection:
• Midstream clean catch Appearance Cloudy Yellow
• Catheterization pH Alkaline 4.5 – 8.5
• Supra-pubic bladder aspiration
Protein Positive Negative
• Urinalysis (dipstick for leukocyte
esterase or nitrite, $ and fast) Nitrite Positive Negative

• Urine microscopy (40x power) Leukocyte esterase Positive Negative

• Urine Culture ($$ and lengthy) RBC Positive Negative
• Bacterial susceptibility testing WBC > 10/mm3 0 – 5 /hpf
Bacteria Many None

Urine Culture UTI Antimicrobial Treatment

Characteristic Finding A. Goals:
C. Duration of Therapy:
• Treat and prevent systemic infection
• Conventional:
Symptomatic female ≥ 102CFU coliforms/mL or • Eradicate invading organism – 7-14 days (women)
≥ 105 non coliforms/mL • Prevent recurrent infections – 10-14 days (men)
• Prevent ADR • Short Course
B. Antimicrobial Therapy: – Three-Five Day
Symptomatic male ≥ 103 CFU bacteria/mL • TMP/SMX , fluoroquinolones, – Single Dose
nitrofurantoin and beta lactam agents
• Recurrent/Prophylactic
Asymptomatic individual ≥ 105 CFU bacteria/mL X 2 • Susceptibility testing
• Prostatitis
specimens • Patient drug allergies
• Patient adherence
Catheterized individual ≥ 102 CFU bacteria/mL • Cost of therapy
• Refer to Antimicrobial Table (114-3) in
Chapter 114, page 2087
* Positive bacteria growth on supra-pubic
catheterization in a symptomatic patient is
considered a UTI.

Uncomplicated UTIs (Lower UTI) Pyelonephritis (Upper UTI)

1. Prevalence/Etiology:
- Most common type
- Sexual intercourse
2. Pathogens:
- E. coli
- S. saprophyticus
- Klebsiella
- Proteus
3. Clinical Presentation:
- (+/-) dysuria, frequency,
urgency and suprapubic
discomfort
4. Antibiotics: 1. Prevalence/Etiology:
- TMP/SMX - Complicated UTI
- Nitrofurantoin 2. Pathogens:
- Fluoroquinolones - Gram (-): E. coli, Klebsiella, Proteus
- Gram (+): E. faecalis, S. saprophyticus
5. Duration of Therapy:
- Long term hosp. patients: P. aeruginosa,
- Conventional
enterococci and multiple-resistant pathogens
- Three-Five Day
3. Clinical Presentation:
- Single Dose (one-day)
- (+/-) dysuria, frequency, urgency and supra-pubic
discomfort
 Pyelonephritis (Upper UTI) cont’d Symptomatic Abacteriuria (Urethral Syndrome)
Calculate CrCl to determine
4. Antibiotics: appropriate antibiotic dose and 1. Prevalence/Etiology: 4. Antibiotics:
- IV Antibiotics frequency: - Fecal matter - TMP/SMX
• TMP/SMX (140-age) X IBW (0.85 if female) - Sexual intercourse - Fluoroquinolones
• Fluoroquinolones
(72 X SCr) 2. Pathogens: - Azithromycin or
• Aminoglycoside +/- Ampicillin doxycycline for
• Aminoglycoside +/- Broad spectrum cephalosporin
- E. coli
- Staph spp. chlamydia treatment
• Beta lactamase inhibitors (i.e. Amp/Sulb, Tic/Clav, Pip/Taz)
- Chlamydia trachomatis 5. Duration of Therapy:
- PO Antibiotics - Short Course
• TMP/SMX - Gardnerella vaginalis
• Fluoroquinolones - Neisseria
5. Duration of Therapy: 3. Clinical Presentation:
- Stop IV therapy after 3 day-treatment and patient - (+) dysuria, pyuria and
clinical improvement, then start PO therapy X 2 weeks urine culture less than
105 bacteria/mL

Asymptomatic Bacteriuria Men UTI’s

1. Prevalence/Etiology: 1. Prevalence/Etiology:
– Most common in children, pregnant women, and elderly - Complicated - ↑ elderly patients
patients
– Relapse and reinfection rates are high - Instrumentation
2. Pathogens: - Lack of circumcision
– E. coli
3. Clinical Presentation: - Sexual activity
– No symptoms 2. Pathogens:
– Urine culture ≥ 105 bacteria/mL X 2 specimens
4. Antibiotics: - May vary when compare to women pathogens
– Controversial in elderly patients 3. Clinical Presentation:
– Children and pregnant women SHOULD BE TREATED
- Combination of lower and upper UTI symptoms

UTI’s During Pregnancy

Men UTI’s (cont’d)
4. Antibiotics: 1. Etiology:
- Urine culture – Urinary stasis, ↓ defenses against bacteria reflux and ↑
[urine nutrients]
- Gram (-) coverage: TMP/SMX and fluoroquinolones
(caution- ↑ risk for tendon rupture in those > age of 60, – Asymptomatic bacteriuria occurs in 4 to 7% of pregnant
patients. Of these, 20 % - 40 % develop acute
kidney, lung and ♥ transplant recipients and with symptomatic pyelonephritis.
concomitant steroid therapy)
2. Pathogens:
– E. coli
5. Duration of Therapy:
- Conventional ( 10 - 14 days)- Slightly longer than 3. Screening:
female conventional therapy – Recommended at initial prenatal visit and 28 wks
gestation
- Short-course is CONTRAINDICATED
- 2 week vs. 6 week therapy 4. Antibiotics:
– Amoxicillin, amox/clav, cephalosporins or nitrofurantoin X
- F/U cultures 7 days
– Do not treat with TCN, sulfonamides, fluoroquinolones
– F/U culture in 1 – 2 weeks
 Catheterized UTI’s
Risk Factors:
• Duration of
catheterization (> 30 days
= ↑ risk)
• Catheter system (closed
drainage preferred)
• Inappropriate care
• Poor aseptic technique
for catheter insertion
• Patient susceptibility
Treatment Approach:
• Asymptomatic patient-
Remove catheter
• Symptomatic patient-
Remove catheter +
conventional therapy
• Prophylactic use of
antibiotic for short-term
catheter X 4 – 7 days
• Bladder irrigation
Recurrent UTI’s
• Mostly re-infections (different pathogen)
but also include relapses (same pathogen)
• Relapse cases should be treated longer
and follow up cultures are recommended
• Classification: 2 infections/6 months, < 3
infections/year and ≥ 3 infections/year
• Etiology
• Sexual intercourse
• Diaphragm and spermicide use

Recurrent UTI’s Treatment Adjunctive UTI Management and

• Postmenopausal women- topical estrogen
• Antibiotic self-administration:
Prevention
• Postcoital (low-dose prophylaxis)- single dose of • Hydration
TMP/SMX, nitrofurantoin, cephalexin, or • Cranberry juice (i.e. extract tablets 300 to
fluoroquinolone
• Continued low-dose (long-term, low-dose 400 mg BID, CranMax 500 mg daily)
prophylaxis)
– < 3 infections/year:
• Lactobacillus
• Short course therapy per episode • Topical estrogen
– ≥ 3 infections/year:
• Treat each episode conventionally first • UT analgesics
• Prophylactic therapy second to prevent symptomatic • phenazopyridine
infections X 6-12 months)
• TMP/SMX, nitrofurantoin, fluoroquinolone (limit use
secondary to ↑ drug resistance, adverse events, drug-
interactions and cost)

Adjunctive UTI Management and UTI UTI Assessment, Treatment & Prevention Checklist
Prevention
• Assessment:
• Shower instead of bathing – Past medical history
• Age related changes, co-morbidities, pregnancy, UT
• Avoid using any feminine hygiene sprays abnormalities, history of UTI or recurrent UTIs, medication
and scented douches allergies, urine culture susceptibility interpretation (if
applicable)
• Avoid long intervals between urination • Current list of medications

• After urination, wipe from front to back – Personal and social history
• Catheter placement, home arrangement, shower vs. bathing
• Empty your bladder after sexual – Review of systems (physical exam):
intercourse • General appearance (skin, hydration)
• Vitals
• Signs and symptoms of lower UTI vs. upper UTI
• Metal status changes (key presentation in elder patients)
 UTI Assessment, Treatment & Prevention UTI Assessment, Treatment & Prevention
Checklist Checklist

• Assessment: • Treatment:
– Urinalysis: – Establish treatment goals based on diagnosis
• (+/-) pyuria, bacteriuria, nitrites, leukocyte esterase and presentation
– Others (for acutely ill patients): – Select antibiotic dose and therapy duration:
• Lab. urinalysis w/ microscopic exam • Consider renal function, drug interactions, urine
• Urine C&S C&S, medication compliance and cost
• CBC with diff. – Assess the need to treat fever, pain &
• Blood chemistry dehydration
• Blood culture – Educate patient about UTI prevention

Prostatitis Prevalence

• ~ 60,000 ambulatory care visits by men

over the age of 18 in the U.S./year
• Young to middle age men
A. Acute
• Symptoms include pain (testicles, penis,
B. Chronic Bacterial lower abdomen) bladder irritation, bladder
obstruction, blood in semen and
impotence

NIH Classification of Prostatitis

• Category I
– Acute Bacterial Prostatitis
• Category II
– Chronic Bacterial Prostatitis
• Category III
– Chronic Pelvic Pain Syndrome
• Category IV
– Asymptomatic Inflammation
 Acute Prostatitis Acute Prostatitis
• Microorganism way of • Presentation:
entry – urethra –
–
Spiking fever
Chills • Pathogens: • Diagnosis:
• Risk factors: – Malaise – Gram (-), specially E. – Edematous and tender
– Dysuria prostate at digital
– Trauma
– Pelvic or perineal pain coli and Proteus spp.
– Dehydration exam
– Sexual abstinence – Cloudy urine
– Chronic indwelling – Obstructive symptoms – – Urine gram stain
bladder catheters dribbling and hesitancy to
anuria – Blood cultures
• Complications:
– Bacterimia and sepsis – Leukocytosis
– Sacroiliac infection – ↑ Serum prostate
– Epididymitis
– Prostatic abscess antigen (PSA) levels
– Chronic bacterial prostatitis

Acute Prostatitis Treatment Acute Prostatitis Treatment

• Gram (+) pathogens: • Gram (-) pathogens:
• Non protein bound, lipophilic antibiotics – Cocci in chains – Oral – TMP/SMX one
(ideal but not required) (enterococcal) – DS q12h;
• Oral – amox. 500 mg q8h fluoroquinolone
• NSAIDs to relieve pain, inflammation, and • IV – amp. 2 g q6h (ciprofloxacin 500 mg
liquefy prostatic secreations – Cocci in clusters q12h and levofloxacin
(staphylococcus) – 500 mg daily)
• Parental therapy can be switched to oral • Oral – cephalexin 500 mg – IV – aminoglycosides
antibiotics alone after the patient has been q6h; dicloxacillin 500 mg (gentamicin or
afebrile for 24 to 48 hours q6h
• IV – cefazolin 1g q8h;
tobramycin 5 mg/kg
q24h) PLUS
• Duration of therapy: 4-6 weeks nafcillin 2 g q6h;
ciprofloxacin or
vancomycin 1 g q12h
(MRSA/PCN allergy) levofloxacin

Chronic Bacterial Prostatitis Chronic Bacterial Prostatitis

• Presentation include dysuria and frequency, • Chlamydia infection: • Treatment duration:
urgency, perineal discomfort, low-grade
fever, (+/-) prostate edema, and recurrent – Involve the epididymis 6 to 12 weeks
UTI in the absence of bladder and urethra • Fluoroquinolones
catheterization – Can reside in the and TMP-SMX reach
• Gram (-) rods are the most common prostate tissue rather [therapeutic] in
pathogens except for enterococci, than invasion of prostate tissue
Chlamydiae, and Mycobacterium urethral contaminants
tuberculosis
• Diagnosis can be made by analyzing
specimens obtained following prostatic
massage for leukocytes and bacteria
 Chronic Bacterial Prostatitis Patient Cases
Treatment
• For first and recurrent • For Chlamydia
episodes, infection,
ciprofloxacin 500 mg azithromycin 500 mg “Yearning and Burning”
q12h or levofloxacin daily vs. 1 g once
500 mg daily

Patient Case JM Clinical Presentation

• PMH: • ROS: (-) vaginal
discharge, bleeding,
UTI 6 mo ago treated
JM is a 21 y.o. woman who presents to fever, or chills. (+)
with TMP/SMX for
the University Health Center with pain during urination
which she developed a
dysuria. She reports having increased rash after finishing tx. • Med ALL: TMP/SMX
• SH: Smokes ½ ppd, • Current Meds:
urgency and frequency of urination that
(+) marijuana use, – Ortho-Novum 7/7/7- 1
began the night before. po QD
social ETOH, sexually
active (multiple – Phenazopyridine-
partners). 100 mg po prn

Patient Case : UA Results 1. What type of UTI this pt has?

Parameter Finding A. Complicated, upper, recurrent,
Appearance Cloudy, red/orange
asymptomatic UTI
B. Complicated, lower, recurrent
pH 5
symptomatic UTI
Protein 10 mg/dL
C. Uncomplicated, upper, recurrent,
Nitrite Positive
asymptomatic UTI
Leukocyte esterase Negative
D. Uncomplicated, lower, recurrent,
RBC 1 – 5 cells/hpf symptomatic UTI
WBC 10 – 15 cells/hpf

Bacteria Many
2. Which of the following is a 3. Which of the following antibiotics
potential pathogen? could be considered for treatment?

A. S. aureus A. Ciprofloxacin
B. P. aeruginosa B. Amoxicillin
C. E. coli C. TMP/SMX
D. C. trachomatis

4. What should be the therapy 5. At this point in time, should

this patient receive prophylactic antibiotic
duration? therapy?
A. 1 day
B. 3 days A. YES
C. 14 days (2 weeks) B. NO
D. 21 days (3 weeks)

6. What could include a future treatment 7. Should a urine culture be obtained from
approach for multiple recurrent UTIs? this patient experiencing her 2nd episode of
cystitis?
A. Self antibiotic administration
A. YES
B. Postcoital antibiotic administration
B. NO
C. Continued low-dose antibiotic therapy
D. All of the above
 Case # 2
Case # 2
• What additional information do we need
A medical resident calls the ambulatory care pharmacist
from this patient?
regarding the use of a fluoroquinolone in a 24 y.o. semi
professional soccer player with an apparent UTI. She has
complained of dysuria and frequency for the last 24 hours.
Her UA is positive for bacteria using a nitrate dipstick and
WBC’s using a dipstick esterase test. Her past medical
history is significant for DM.
She has no allergies and other than her diabetes there has
been no other significant medical problems.

Case # 2 Case # 2
• What type of UTI this is? • Patient education:
• Is a fluoroquinolone agent a good
option for this patient?

• What are other antibiotic alternatives?

Case # 3 Case # 3
A consultant pharmacist is contacted about a
72 y.o. woman nursing home patient. She
recently was treated for 10 days with ceftriaxone
• How should this patient be
and azithromycin for presumed CAP. During her
managed?
hospitalization a foley catheter was placed. She is
currently afebrile and asymptomatic of any UTI
symptoms but a culture of her urine at the end of
her antibiotic therapy had a significant growth of
yeast. How should she be managed?
 Acute and Chronic Prostatitis:
Review
• Pathogen
• Recommended therapy
• Duration of therapy
References
• Potoski BA. Urinary Tract Infection. In
Chrisholm-Burns MA, Wells BG, et al, eds.
Pharmacotherapy: Principles and Practice. New
York, NY:McGraw Hill; 2008:1151-1158.
• Urinary Tract Infection. In Dipiro JT, Talbert RL,
Yee GC, et al, eds. Pharmacotherapy, A
pathophysiologic Approach. 6th ed. New York,
NY:McGraw Hill; 2006:2087.