Lower Urinary Tract Infection
What clinical and laboratory features are consistent with the diagnosis of an acute uncomplicated lower UTI (cystitis) in this patient?
Dysuria and frequency of urination and urgency to urinate
How does one differentiate cystitis from urethritis (caused by Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes simplex virus) or vaginitis (caused by candida or trichomonas species)?
To differentiate cystitis from urethritis, the major symptoms will be dysuria and urethral discharge. The discharge can be whitish, purulent, or mucoid. Moreover, its onset is usually sudden and it is characterized by urgency, frequency, and painful or burning voiding of urine in small volumes. Other systemic symptoms include nausea, sweats, chills, and fever.
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How should a patient experiencing her fourth episode of cystitis and not responding to treatment be managed? Should a urine culture and sensitivity test be performed?
Urine culture should be done since it is the standard criterion in the diagnosis of urinary tract infections, however, urine must be properly collected and quickly cultured or refrigerated (Nickel, 2005).
What are the most likely pathogens and frequency of occurrence causing this patient’s infection?
The most likely pathogens include Staphylococcus saprophyticus, Enterobacteriaceae (Klebsiella pneumonia, Proteus mirabilis), and Escherichia coli and their frequency is 75-95% (Seattle STD/HIV, 2015).
What factors can increase the risk of developing a UTI?
- Female gender– UTIs are very common amongst women because they have shorter urethra compared to men, and this cuts down the traveling distance for the bacteria to reach the urethra
- Being sexually active– people who are active sexually tend to have more UTIs
- Using particular types of birth control such as the diaphragm and spermicidal agents increases the risks (UTI, 2013).
- Completing menopause– UTIs are more common in post-menopause women because of lack of estrogen which causes urinary tract changes making it more vulnerable to infection
- Having abnormalities in the urinary tract– abnormal urinary tracts which cause back up of urine in the urethra or do not allow the urine to leave body normally have an increased UTIs risks
- Having urinary tract blockages– enlarged prostate or kidney stones can trap urine in the bladder thus increases UTIs risks (UTI, 2013).
- Having an immune system that is suppressed– diabetes and other diseases impairing the immune system can increase UTIs risks
- Using a catheter in urinating– people who use a catheter for urination because they cannot urinate have an increase in UTIs risks. This also include hospitalized patients with neurological problems which makes it difficult for the patients to control their urinating ability and individuals who are paralyzed (UTI, 2013)
List potential reasons that this patient may not be responding to treatment?
- Re-infection with the same bacteria
- Functional or anatomic abnormalities of the urinary tract
- Frequent sexual intercourse
- The patient might be having comorbid conditions or even other predisposing factors (Kodner & Thomas, 2010)
Because this is her fourth episode of an uncomplicated UTI this year, should she receive prophylactic antibiotics to prevent further episodes?
Yes, since postcoital or continuous prophylactic antibiotics are used in treating women with recurrent urinary tract symptoms.
What are the goals of pharmacotherapy in this case?
Is to make the patient free of the symptoms, eradicate the infection and prevent complications
What are the desirable characteristics of an anti-infective agent selected for the treatment of this uncomplicated UTI?
- They should promote improved compliance
- Low costs
- Lower frequency of leading to adverse reactions (Wagenlehner & Naber, 2001).
- The spectrum of the agent
- Pharmacokinetics that favor wider intervals of dosing effect on the vaginal and fecal flora
- Adequate urinary levels of antimicrobial duration
- Potential for undesirable side effects (Rafalsky, Andreeva & Rjabkova, 2006).
What feasible pharmacotherapeutic alternatives are available for empiric first-line and second-line treatment of an uncomplicated UTI?
Other feasible pharmacotherapeutic options of treatments include cranberry products, and self-started antibiotics (Kodner & Thomas, 2010).
What nonpharmacologic therapies may be useful in preventing uncomplicated UTIs?
Other feasible nonpharmacologic therapies include behavioral modifications. Renal imaging can also be done if structural abnormalities of the urinary tract are suspected (Kodner & Thomas, 2010).
What drug, dosage form, dose, schedule, and duration of therapy are best for this patient?
For this patient, Quinolones is good because of its good actions against E.coli, have minimal effect on the protective flora of the natural vagina, and achieve high urinary concentrations. Once or twice daily dose of regimens can be used in administering Quinolones. Moreover, seven-, three- day, or single-dose schedules can be applied (Rafalsky, Andreeva & Rjabkova, 2006).
What clinical and laboratory parameters are necessary to evaluate the therapy for the achievement of the desired therapeutic outcome and to detect or prevent adverse effects?
Dipstick method in Routine analysis can be used as a clinical and laboratory parameter in the evaluation of the therapy for the achievement of the desired therapeutic outcome and also detect or prevent adverse effects. Moreover, antimicrobial susceptibility testing and repeat urine culture testing, a renal scan, or renal ultrasound.
What information should be provided to the patient to enhance compliance, ensure successful therapy, and minimize adverse effects?
The patient should be informed about simple measures such as taking the prescribed medications. Moreover, to ensure maximum compliance, health professionals should provide information on possible adverse effects and the influence of drugs on treatment continuity. Moreover, to enhance understanding of the patients, the given direction should be given in straightforward and simple language, simple directions and accompanied always by a written version
What are the safety and efficacy of a single dose, 3 days, and 7-day antimicrobial therapy for the treatment of acute uncomplicated bacterial cystitis?
The 7-day antimicrobial therapy has a greater potential of resulting in side effects, has not shown to have a therapeutic effect that is improved, and is even more expensive. The3-day antimicrobial therapy is a short course and has the best combination of efficacy in addition to having decreased toxicity and side effects (Rafalsky, Andreeva & Rjabkova, 2006).
Obtain information on the rates of resistance of E. coli to TMP-SMX and fluoroquinolone antibiotics. How do these rates compare to those reported at your institution?
The prevalence of resistance of E. coli to TMP-SMX antibiotics among patients suffering from uncomplicated pyelonephritis is less than 20% in many regions of the United States. Rates of resistance or E. coli to fluoroquinolone were less than 15.8% (Talan et al, 2008).
Provide assessment and recommendation on the role of phenazopyridine in the treatment of UTIs
For some patients who are suffering from cystitis, phenazopyridine which is a urinary analgesic three times a day as prescribed is useful in relieving discomfort because of severe dysuria. Moreover, a two-day course is normally sufficient to allow time for antimicrobial therapy symptomatic response and minimization of inflammation. In fact, within a few hours, dysuria is usually diminished after the commencement of the therapy. However, this agent should not be chronically used since it may mask the clinical symptoms that are required for clinical evaluation (Klimberg et al, 2005).
Klimberg, I., Shockey, G., Ellison, H., Fuller-Jonap, F., Colgan, R., Song, J., Keating, K., … Cyrus, P. (January 01, 2005). Time to symptom relief for uncomplicated urinary tract infection treated with extended-release ciprofloxacin: a prospective, open-label, uncontrolled primary care study. Current Medical Research & Opinion, 21, 8, 1241-1250.
Kodner, C. M., & Thomas, G. E. K. (January 01, 2010). Recurrent urinary tract infections in women: diagnosis and management. American Family Physician, 82, 6, 638-43. Retrieved from http://www.aafp.org/afp/2010/0915/p638.html
Nickel, J. C. (January 01, 2005). Practical management of recurrent urinary tract infections in premenopausal women. Reviews in Urology, 7, 1, 11-7.
Rafalsky, V., Andreeva, I., & Rjabkova, E. (January 01, 2006). Quinolones for uncomplicated acute cystitis in women. The Cochrane Database of Systematic Reviews, 3.
Seattle STD/HIV. (2015). Chapter 5: Urethritis & Cystitis in Females.
Talan, D. A., Krishnadasan, A., Abrahamian, F. M., Stamm, W. E., Moran, G. J., & EMERGEncy ID NET Study Group. (January 01, 2008). Prevalence and risk factor analysis of trimethoprim-sulfamethoxazole- and fluoroquinolone-resistant Escherichia coli infection among emergency department patients with pyelonephritis. Clinical Infectious Diseases: an Official Publication of the Infectious Diseases Society of America, 47, 9, 1150-8.
Urology Care Foundation. (2013). The Official Foundation of the American Urological Association. (n.d.).
Urinary tract infection (UTI). (2013). Retrieved April 2, 2015, from http://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/basics/risk-factors/con-20037892
Wagenlehner, F. M., & Naber, K. G. (January 01, 2001). Uncomplicated urinary tract infections in women. Current Opinion in Urology, 11, 1, 49-53. Retrieved from http://www.antimicrobe.org/e4a.asp
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