Urinary Tract Infection Overview

Urinary Tract Infection:
Overview
Ab u lrah man M. Alsh amm ar i, Ph arm.D.
PGY1 Clin ical Ph armacy Resid ent
Kin g Salman Sp eciali st Hosp ital (KSSH)
Hail Health Clu ster
1
Outlines
2 3 4 5
1
Introduction Epidemiology Clinical Risk Treatment

and and Presentation Factors and and
Definition Pathophysiology and Etiology Diagnosis Prophylaxis
2
Introduction
According to the Centers for Disease Control and Prevention (CDC), Urinary
Tract Infection (UTI) is the most common bacterial infection requiring medical
care, resulting in 8.6 million ambulatory care visits in 2007.
The economic burden of using the ED for the treatment of UTIs is estimated
at $2 billion (7.5 billion SAR) annually.
UTIs rank as the No. 1 infection that leads to an antibiotic prescription after a
physician’s visit.
Applied Therapeutics : the Clinical Use of Drugs. Philadelphia :Lippincott Williams & Wilkins, 2020.
3
Introduction, Cont..
Catheter-associated UTIs (CA-UTIs) are the most common type of health care–
associated infections reported to the National Healthcare Safety Network,
making up two-thirds of hospital-acquired UTIs.
The symptoms of UTIs are generally mild, and inappropriate use of antibiotics
can lead to antibiotic resistance; therefore, it is important to establish the
appropriate criteria for treatment using narrow-spectrum antibiotics for the
optimal duration.
4
Anatomy of Urinary System
Adapted from Johns Hopkins Medicine
5
Definition
Urinary tract infection (UTI) is an acute or chronic infection, usually bacterial
in origin, that may affect any part of the upper or lower urinary system.
Infections of the bladder are referred to as Cystitis, and infections involving

the parenchyma of the kidneys are known as Pyelonephritis.
6
Urinary Tract Infection Types
• Uncomplicated UTI
• Complicated UTI
• Catheter-associated Urinary Tract Infections (CA-UTI)
• Asymptomatic bacteriuria (ASB)
7
Urinary Tract Infection Types, Cont..
Uncomplicated UTI
• Lower urinary symptoms (dysuria, frequency, and urgency) in otherwise healthy
non-pregnant women.
Complicated UTI
• Pregnant women, men, obstruction, immunosuppression, renal failure, renal
transplantation, urinary retention from neurologic disease.
• Health care associated.
8
Urinary Tract Infection Types, Cont..
Catheter-Associated UTI
• Presence of indwelling urinary catheters with signs and symptoms of UTI
and no other source of infection.
• Presence of ≥ 103 CFU/mL in a single catheter urine specimen or in a
midstream urine, despite removal of urinary catheter in the previous 48 hr.
Asymptomatic Bacteriuria
• Women: Two consecutive voided urine specimens with isolation of the
same bacteria at ≥ 105 CFU/mL.
• Men: Voided urine specimen with 1 bacteria isolated 105 CFU/mL.
9
Epidemiology
Up to 60% of women have at least one symptomatic UTI during their lifetime.
Around 10% of women in the United States have one or more episodes of
symptomatic UTIs each year.
The prevalence of UTIs in men is significantly lower than in women.
10
Pathophysiology (Lower UTIs)
• Cystitis is a urinary tract infection (UTI) that affects the bladder.
Periurethral Followed by Migration by the

contamination by colonization of flagella and pili
a uropathogen the urethra to the bladder
11
Pathophysiology (Upper UTIs)
• Pyelonephritis is a bacterial infection one or both kidneys.
Bacteria reach the bladder through the urethra and

ascend to the kidney.
Urinary tract obstruction (e.g. Urinary stones,

tumors, and prostatic hypertrophy) is another cause.
Staphylococcus aureus bacteremia or endocarditis

can lead to hematogenous seeding of the bacteria to
the kidneys.
12
Cystitis Clinical Presentation
Dysuria
Frequent Urination
Cystitis Hematuria
Back Pain
Pain or burning
while urinating
13
PyelonephritisClinical Presentation
14
Etiology
Content of an education
Documentation
15
Community and Health Care Acquired
Community-Acquired
• Escherichia coli cause 75% to 95% of community-acquired.
• Coagulase-negative staphylococci (e.g., Staphylococcus saprophyticus)
account for another 5% to 20% of UTIs in younger women.
Health Care–Associated
• E. coli remains the most common pathogen in hospital acquired or other
complicated UTI, but it is responsible for only 20% to 30% of these infections.
• Other gram-negative organisms, such as Pseudomonas aeruginosa, Klebsiella,
Proteus, Enterobacter, and Acinetobacter.
• Candida involved in 20% to 30% of cases.
16
Uropathogens by Type of UTIs
17
Predisposing Factors
Urinary Tract
Age Catheterization or
Obstruction
Female Sex Pregnancy
Sexual Activity Renal•renal disease

Disease
•previous
Previous
Use of Contraception antimicrobial
Antimicrobial Use use
18
Diagnosis
Documentation
19
Urinalysis
Urinalysis (UA) is a series of laboratory tests commonly performed in patients
suspected of having a UTI.
Microscopic examination of urine sediment in patients with documented

UTI reveals many bacteria (usually >20 per high-power field [HPF]).
Bacteriuria alone is not a disease and usually does not necessitate treatment.
20
Urine Culture
The gold-standard criterion for the diagnosis of UTI.
Greater than 105 colonies of bacteria/mL cultured from a midstream

urine specimen confirms a UTI.
Urine culture is not recommended for managing acute uncomplicated cystitis.
21
Urine Culture, Cont..
The urine culture should be obtained before empiric therapy.
Of note, gram-positive organisms and fungi may not reach 105 CFU/mL.
22
Diagnosis in Special Population
• Screening for Asymptomatic bacteriuria (ASB) is necessary for select patients:
Special Population Pregnant Women
Individuals Undergoing Invasive

Urological Procedures
•Renal Transplant Recipients
23
Complications of UTIs
Complications
Sepsis
Acute Renal Failure
Shock
Multiple-Organ Failure
24
Treatment
Documentation
25
General Treatment Considerations
The first step in treating UTIs is to classify the type of infection, such as:
• Acute uncomplicated cystitis or pyelonephritis.
• Acute complicated cystitis or pyelonephritis.
• Catheter-associated Urinary Tract Infections (CA-UTI).
• Asymptomatic bacteriuria (ASB).
• Prostatitis.
26
Goals of Therapy
Symptomatic relief is a high priority in patients with UTIs.
With appropriate antibiotic therapy, clinical response occurs within

24 hours for cystitis and within 48–72 hours for pyelonephritis.
Patients should receive treatment with agents that are low in toxicity
and that have low potential of changing the normal bowel flora.
27
Non-Pharmacological
Treatment
Documentation
28
Hydration
During UTI management, hydration dilutes the uropathogen and removes
infected urine by frequent bladder emptying.
However, the bacterial count returns to the Pre-hydration level after

hydration is discontinued.
Although hydration removes the infected urine, there is no clear evidence

that hydration improves the outcomes of UTI.
29
Cranberry
Cranberry blocks the adherence of bacterial.
However, a meta-analysis of 24 studies showed that cranberry products

did not significantly reduce the occurrence of symptomatic UTIs.
Cranberry capsules are an option in pregnant women to prevent ASB.
30
Probiotics
Probiotics protect the vagina from bacterial colonization by blocking attachment
and producing hydrogen peroxide that is microbicidal.
In a study of postmenopausal women, Probiotics administration was compared

with trimethoprim/sulfamethoxazole prophylaxis over 1 year.
The mean time to the first UTI was 3 and 6 months for Probiotics
and trimethoprim/sulfamethoxazole, respectively.
31
Estrogen
Topical estrogen therapy normalizes the vaginal flora and has been shown to
reduce the risk of recurrent UTI.
Use of 0.5 mg of estriol vaginal cream at night for 2 weeks followed by twice-
weekly administration for 8 months significantly reduced the incidence of UTIs
compared with placebo.
32
Pharmacological
Treatment
Documentation
33
Antibiotic Selection Overview
Most uncomplicated UTIs are treated in the outpatient setting.
Initial therapy is based on the local susceptibility.
34
Antibiotic Resistance
The Study for Monitoring Antimicrobial Resistance Trends reported that among 3498 E. coli
isolates from hospitals in Canada and the United States, extended-spectrum β-lactamase
(ESBL) rates increased from 7.8% in 2010 to 18.3% in 2014.
The percent susceptibilities of E. coli isolates collected in 2014 in the United States
Ceftriaxone 80.5%
Cefepime 83.4%
Ciprofloxacin 64,7%
Levofloxacin 65.3%
Piperacillin/ tazobactam 96.2%
Amikacin 99.4%
35
Empiric Regimens
• Be guided by the local susceptibility,
particularly to E. coli.
Uncomplicated • Trimethoprim/sulfamethoxazole if the local
resistance rate is less than 20%
UTIs • Fluoroquinolones if the resistance rate is
less than 10%
• Should also be guided by local susceptibility

Complicated trends of uropathogens, and definitive
regimens should be tailored according to
UTIs susceptibility results, when available.
36
Acute Uncomplicated Cystitis
Antibiotics Dose Therapy Duration
Nitrofurantoin 100 mg PO BID 5 days
Trimethoprim/sulfamethoxazole 160/800 mg PO BID 3 days
Trimethoprim 100 mg PO BID 3 days
Fosfomycin 3 g PO once Once
Alternative Agents
Amoxicillin/clavulanate 500/125 mg PO q8hr 5–7 days
Cefpodoxime 100 mg PO BID 5–7 days
Cefdinir 300 mg PO BID 5–7 days
Cephalexin 500 mg PO BID 5–7 days
Ciprofloxacin 250 mg PO BID 3 days
Levofloxacin 250–500 mg PO daily 3 days
37
Acute Uncomplicated Pyelonephritis
Ciprofloxacin 500 mg PO BID 7 days
Levofloxacin 750 mg PO daily 5 days
Alternatives or Definitive Therapy after susceptibility is confirmed
Trimethoprim/sulfamethoxazole 160/800 mg PO BID 14 days
Amoxicillin/clavulanate 500 mg PO TID 10–14 days
Inpatient management or in those unable to take oral medications
Ciprofloxacin 400 mg IV q12hr 7 days
Levofloxacin 500 mg IV q24hr 7 days
Ceftriaxone 1–2 g IV q12hr 14 days
Cefepime 500 mg PO TID 14 days
Piperacillin/tazobactam 3.375 g IV q6hr 14 days
38
ACC or CA-UTI
Ciprofloxacin 500 mg PO BID 5–7 days
Levofloxacin 750 mg PO daily 5–7 days
Ampicillin/sulbactam 1.5–3 g IV q6hr 5–7 days
Ceftriaxone 1 g IV q24hr 5–7 days
Gentamicin/tobramycin 3–5 mg/kg IV once 5–7 days
Pathogen-Specific Treatment (ESBL E. coli)
Nitrofurantoin 100 mg PO BID 7 days
Fosfomycin 3 g PO once 7 days
ACC = Acute Complicated Cystitis, CA-UTI = Catheter-associated Urinary Tract Infections
39
ACP or CA-UTI or Urosepsis
Recommended Empiric Therapy for inpatient, Severely ill
Ceftriaxone 1 g IV q24hr 14 days
Ceftazidime 1–2 g IV q8hr 14 days
Cefepime 1 g IV q12hr 14 days
Piperacillin/tazobactam 3.375–4.5 g IV q6hr 14 days
Aztreonam 1–2 g IV q8hr 14 days
Meropenem 1 g IV q8hr 14 days
Ertapenem 1 g IV q24hr 14 days
Doripenem 500 mg IV q8hr 14 days
* Empiric Therapy: Add aminoglycoside initially (i.e., gentamicin 5–7 mg/kg once daily).
* Antibiotic-resistant (e.g., CRE or Acinetobacter spp: Add Colistin Loading dose, then maintenance dose.
ACP = Acute Complicated Pyelonephritis
40
ASB in Pregnancy
Nitrofurantoin * 100 mg PO BID 5-7 days
Trimethoprim/sulfamethoxazole * 160/800 mg PO BID 3 days
Amoxicillin 500 mg PO TID 3–7 days
Amoxicillin/clavulanate 500 mg PO TID 3–7 days
Cephalexin 500 mg PO QID 3–7 days
Cefpodoxime 100 mg PO BID 3–7 days
Fosfomycin 3 g PO once Once
* Note: Except during first trimester or near term.
ASB = Asymptomatic Bacteriuria
Edited by Mary Anne Koda-Kimble, Lloyd Yee Young ; assistant editors, Wayne A. Kradjan, B. Joseph Guglielmo. Applied Therapeutics : the Clinical Use of Drugs. Philadelphia :Lippincott Williams & Wilkins, 2020. 41
Acute and Chronic Bacterial Prostatitis
Ceftriaxone 1–2 g IV q24hr 24 to 48 hours
Acute Ciprofloxacin
Levofloxacin
400 mg IV q12hr
500 mg IV q24hr
24 to 48 hours
24 to 48 hours
Follow by PO FQs for 2–4 wk.

Ciprofloxacin 500 mg PO BID 4–6 wk
Levofloxacin 500 mg PO daily 4–6 wk
Chronic Trimethoprim 100 mg PO BID 4–12 wk
Doxycycline 100 mg PO BID 4 wk
2020.
42
Candidiasis
Fluconazole 200 mg (or 3 mg/kg) PO 2 weeks
Fluconazole-Resistant Species (eg, Candida krusei, Candida glabrata)
Amphotericin B 0.3 to 0.6 mg/kg/day IV 1 to 7 days
43
Recurrent UTIs
Recurrent UTI is defined as at least two infections within 6 months, or at least three
infections within 1 year.
The recurrence of a UTI may be:

Relapse (i.e., caused by the same uropathogen) or Reinfection (i.e., caused by
different uropathogens).
44
Antibiotic Prophylaxis
Antibiotic prophylaxis should be considered a last resort after behavioral changes.
Behavioral changes (e.g., avoiding spermicide-containing products, early postcoital

voiding, and liberal fluid intake).
45
Prevention of UTIs
Antibiotics Dose
Nitrofurantoin 50 mg PO qhs
Trimethoprim/sulfamethoxazole 40/200 mg PO daily
46
MOH initiative
47
Pharmacist Role
Improve the antimicrobial regimen selection to prevent antimicrobial resistance.
Patient education about self-care skills.
Improve the antimicrobial use for UTIs by increasing patient knowledge.
Improve the antimicrobial regimen selection based on the cost and availability.
48
Thank You
49

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Urinary Tract Infection:

Introduction Epidemiology Clinical Risk Treatment

Adapted from Johns Hopkins Medicine

Infections of the bladder are referred to as Cystitis, and infections involving

The prevalence of UTIs in men is significantly lower than in women.

Periurethral Followed by Migration by the

Bacteria reach the bladder through the urethra and

Urinary tract obstruction (e.g. Urinary stones,

Staphylococcus aureus bacteremia or endocarditis

Female Sex Pregnancy

Sexual Activity Renal•renal disease

Microscopic examination of urine sediment in patients with documented

Greater than 105 colonies of bacteria/mL cultured from a midstream

Urine culture is not recommended for managing acute uncomplicated cystitis.

The urine culture should be obtained before empiric therapy.

Special Population Pregnant Women

Individuals Undergoing Invasive

•Renal Transplant Recipients

Acute Renal Failure

With appropriate antibiotic therapy, clinical response occurs within

However, the bacterial count returns to the Pre-hydration level after

Although hydration removes the infected urine, there is no clear evidence

However, a meta-analysis of 24 studies showed that cranberry products

Cranberry capsules are an option in pregnant women to prevent ASB.

In a study of postmenopausal women, Probiotics administration was compared

Initial therapy is based on the local susceptibility.

• Should also be guided by local susceptibility

ACC = Acute Complicated Cystitis, CA-UTI = Catheter-associated Urinary Tract Infections

* Note: Except during first trimester or near term.

ASB = Asymptomatic Bacteriuria

Antibiotics Dose Therapy Duration

The recurrence of a UTI may be:

Behavioral changes (e.g., avoiding spermicide-containing products, early postcoital

Patient education about self-care skills.

Improve the antimicrobial use for UTIs by increasing patient knowledge.

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