Clinical Case Studies

Case 1

HA., a 20-year old woman with no previous history of UTI, complains of burning on urination, frequent
urination of a small amount, and bladder pain. She has no fever. A clean-catch midstream urine sample
shows Gram-negative rods on Gram stain. A culture and sensitivity test are ordered. Based on these
findings, HV is presumed to have a lower UTI.

Lower UTI

UTI – Urinary Tract Infection is a collective term for infection involving any part of the urinary tract
– kidneys, ureters, bladder and urethra.
The urinary tract can be divided into upper (kidneys and ureters) and lower tract (bladder and
urethra).
Lower UTI – infection in bladder and urethra is one of the most commonly treated infections.

Symptoms

Dysuria – Discomfort associated with urination.

Bladder fullness, Increased frequency and urgency of urination of small amounts.
Bladder/Pelvic pain
Bacterial species responsible for Lower UTI

Common bacterial species causing lower UTI are Escherichia coli and Klebsiella pnuemoniae.
Other species are Staphylococcus epidermidis, Pseudomonas aeruginosa and Enterococcus spp.

Escherichia coli
Klebsiella pnuemoniae
 Family: Enterobacteriaceae, Genus: Escherichia
 Gram Negative  Family: Enterobacteriaceae, Genus: Klebsiella

 Facultative Anaerobe  Gram Negative

 Rod-shaped  Facultative Anaerobe

 Constitute 0.1% of gut microbiota  Rod-shaped

 Found in normal flora of mouth, skin, intestine
Questions:

1. What should be the goals of the treatment plan at this time?

 The main goal of the treatment plan would be to cure the UTI first.
 It is important to prevent the infection from spreading to other parts of the urinary tract and prevent
the gram-negative species from travelling into the blood.
 The treatment to be provided should cause minimal side effects.
2. What treatment duration options are available for HA?
Ans. Since urine sample shows the presence of Gram-Negative rods on gram stain, the antibiotics to be
used:
CLASS EXAMPLES
Folate antagonist Trimethoprim/Sulfonamide
β-lactam antibiotics Penicillin (Preferably semi
(2nd Line Therapy) synthetic – Methicillin)
Cephalosporins (Preferably
Cefuroxime)
Carbapenems (active against
gram -ve aerobes only. Last
resort only. Expensive)
Monobactams (Aztreonam)
REASONS
 When risk of resistance is low, it is
commonly used to treat UTI caused by E.
coli and Klebsiella pneumoniae.
 Penicillin and Cephalosporins are widely
used for treatment of UTIs.
 Since they may show bacterial resistance,
they can be given with β-lactamase
inhibitors (Clavulanic Acid, Tazobactam).
 Methicillin and Cefuroxime are less
susceptible to inactivation.
 Aztreonam is effective against E.coli and is
 safe to use for treatment of UTI.
Aminoglycosides Gentamicin  Though mainly used against aerobic gram-
(2nd Line Therapy) Tobramycin negative bacilli, it is potent against E. coli.
Amikacin  Side effects – Serious injury to inner ear and
kidney.
Quinolones st
1 Gen – Nalidixic Acid  Deep-tissue and cell penetration makes it
(2nd Line Therapy) useful for UTI. Also have minimal toxicity.
nd
2 Gen - Ciprofloxacin  Nalidixic acid is effective in treatment of
UTI caused by E.coli, Klebsiella etc.
rd
3 Gen – Levofloxacin
 Ciprofloxacin is most potent against gram
-ve bacilli (E. coli)
 Levofloxacin can be used to treat UTI,
effective against gram -ve bacilli.
Case 2

L.B. is a 48-year-old female, who presents with a community-acquired UTI. She has experienced a rash
with Bactrim (Combination of sulfamethoxazole and trimethoprim) and developed acute shortness of
breath while taking penicillin.

Bactrim – Sulfamethoxazole and Trimethoprim, is a combination of two anti-folate antibiotics commonly

used to treat UTIs. One of its serious side effects includes severe skin rashes

Penicillin – A β-lactam antibiotic is also used to treat UTIs. One of the adverse reactions to Penicillin is
Hypersensitivity – which is presented by acute shortness of breath.

Questions:

1. What should be the goals of the treatment plan at this time?

 Goals of the treatment plan should be to withdraw the antibiotics prescribed.
 Since the patient exhibited adverse reactions from Bactrim and Penicillin, the patient can be
prescribed the follow medications. The patient should be observed closely for other reactions.
 Other β -lactam antibiotics – Cephalosporins (Cefuroxime), Monobactam (Aztreonam)
 Aminoglycosides (Gentamicin)
 Quinolones (Ciprofloxacin, Levofloxacin) – Minimal side effects