Medina, Miguel Andrei C.
2016-00448
UTI Assignment
Case 1
1. Based on the PSMID Clinical Practice
Guidelines for UTI (2015), a diagnosis of
recurrent urinary tract infection may be
made. On history, the patient, otherwise
healthy and not pregnant, reported three
episodes of acute uncomplicated cystitis
documented by urine culture within the past
12 months, justifying this diagnosis.
2. Screening for urologic abnormalities is not
recommended in this patient because of the
absence of risk factors as detailed in the
PSMID CPG for UTI Update (2015). Instead, in
addition to a complete history and PE, post-
void residual urine should be measured. A
urine culture may also be obtained to guide
treatment.
3. Any of the antibiotics used to treat acute
uncomplicated cystitis may be used to treat
recurrent UTI. Antibiotics such as
nitrofurantoin macrocrystals and fosfomycin
trometamol are primary antibiotics used in
the treatment of individual episodes of
recurrent UTI. Prophylaxis may be indicated if
the patient is not satisfied with her quality of
life and if her recurrent UTI is interfering with
her activities of daily living.
4. Behavioral measures such as cleansing
antero-posteriorly post-defecation,
douching/urinating post-coitus, and
encouraging liberal fluid intake after
intercourse may help prevent recurrences of
UTI. Antibiotic prophylaxis may be given to
women in whom non-antimicrobial strategies
have proven ineffective. In patients placed on
long-term antibiotic prophylaxis therapy,
cranberry products may be taken to avoid
antimicrobial resistance. Methenamine
hippurate may be used as an alternative to
antibiotics for short-term prophylaxis in
women without any urologic abnormalities.
Immunoprophylaxis or acupuncture may also
be done.
5. “Wala pa pong ebidensya na nagpapakita
na epektibong gamitin ang cranberry juice
bilang lunas para sa UTI. Nirerekomenda lang
po ito sa mga pasyente na binibigyan ng
antibiotics nang matagalan upang siguraduhin
na mananatiling epektibo ang gamot. Pero
kung gusto lang po ninyong uminom, wala*
naman pong masama doon.”
*Findings by Li et al. (2009) “do not support a clinically relevant
interaction between β-lactam antibiotics and cranberry juice at
the amounts regularly consumed.”
Case 2
1. A diagnosis of asymptomatic bacteriuria
may be made because the patient is
asymptomatic and presents with a urine
specimen in which E. coli has been isolated in
a quantitative count ≥ 100,000 cfu/mL, as
explained in the PSMID CPG for UTI Update
(2015).
2. Because the patient will undergo
cystoscopy, treatment is indicated.
3. A seven-day regimen is recommended.
Case 3
1. A diagnosis of acute uncomplicated cystitis
may be made because the patient is
premenopausal presenting with acute dysuria
and urgency without discharge as explained in
the PSMID CPG for UTI Update (2013).
2. Most UTIs involve bacteria establishing
infection by ascending from the urethra up to
the bladder (HPIM 20th ed.). In women, risk for
UTI is increased because of the close
proximity of the anus to the urethral opening,
which may increase the likelihood for
bacterial entry.
3. There are no recommended tests.
According to the PSMID CPG for UTI (2013),
pre-treatment urine culture and sensitivity is
NOT recommended. Urine microscopy and
dipstick leukocyte esterase (LE) and nitrite
tests are NOT prerequisites to treatment. A
pregnancy test should be done to be sure the
cystitis is uncomplicated, however.
4. Based on the PSMID CPG for UTI Update
(2013), nitrofurantoin macrocrystal
formulation 100 mg, QID for 5 days PO, is
recommended as first-line treatment.
Fosfomycin (3g single dose PO) and beta-
lactam agents like Co-Amoxiclav (625mg BID,
7 days PO) may also be used.
Case 4
1. A diagnosis of acute uncomplicated
pyelonephritis may be made because the
patient presented with fever, right flank pain,
vomiting, R CVA tenderness, hypogastric pain,
and with lower UTI symptoms (dysuria), in line
with the PSMID CPG on UTI (2013).
2. Like in the pathogenesis of lower UTIs,
bacteria may enter the urinary tract through
the urethra, causing symptoms. In
pyelonephritis, the bacteria reaches up from
the bladder into the ureter/s and infects the
kidney/s. Pyelonephritis may also be caused
by bacteria in the blood. (HPIM 20th edition)
3. One single test which could confirm the
diagnosis is a urinalysis, which would show
pyuria (>5 WBC/HPF of centrifuged urine).
4. In patients not requiring hospitalization
quinolones can be given as first-line
treatment. (This patient does not require
hospitalization and thus this is the
recommended management).
For patients requiring hospitalization,
ceftriaxone, fluoroquinolones, or
aminoglycosides are indicated as empiric first-
line treatment.
Treatment should be given for 14 days, and
selected fluoroquinolones can be given for 7-
10 days. Urine C/S may be done to facilitate
cost-effective and proper antimicrobial use.
5. Admission is not indicated for this patient.
Indications for admission include the inability
to take oral meds, compliance issues, the
presence of complicating conditions, or severe
illness with high fever/severe pain/marked
disability/signs of sepsis.
Case 5
1. According to the PSMID CPG for UTI (2013),
the patient may be diagnosed with a
complicated UTI because of the presence of a
symptomatic bacteriuria in the setting of a
urinary tract obstruction secondary to benign
prostatic hyperplasia.
2. A post-void residual volume measurement
is recommended by the American Urological
Association (AUA). Prostate imaging to
estimate prostate volume, while unnecessary
for diagnosis, may help indicate if surgery will
be recommended. Urine gram staining and
C/S will be important for initiation of
treatment of the UTI. (UpToDate; PSMID CPG
for UTI (2013).
3. Oral fluoroquinolones such as ciprofloxacin
(500-750 mg BID x 7-14 days) or Co-Amoxiclav
(875/125mg BID x 7-14 days) may be given to
manage the complicated UTI. Kidney function
must be monitored as these meds are given.
The BPH can be managed by Alpha-1
adrenergic antagonists such as
tamsulosin/terazosin or by 5-alpha-reductase
inhibitors such as finasteride.
4. DM may now have catheter-associated
asymptomatic bacteriuria because of the
presence of significant (>50,000 cfu/mL) E.
coli bacteriuria without clinical symptoms in
the setting of having an indwelling Foley
catheter.
5. Screening and treatment of patients with
catheter-associated asymptomatic bacteriuria
is not recommended routinely, and is only
done in patients who will be undergoing
urologic procedures.
References
Harrison’s Principles of Internal Medicine, 20th Edition
UpToDate
Philippine Clinical Practice Guidelines on the Diagnosis and
Management of Urinary Tract Infections in Adults
Li, M., Andrew, M. A., Wang, J., Salinger, D. H., Vicini, P., Grady,
R. W., Phillips, B., Shen, D. D., & Anderson, G. D. (2009). Effects
of cranberry juice on pharmacokinetics of beta-lactam
antibiotics following oral administration. Antimicrobial agents
and chemotherapy, 53(7), 2725–2732.
https://doi.org/10.1128/AAC.00774-08