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Chapter 89

Drug Therapy of Urinary


Tract Infections

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Urinary Tract Infections (UTIs)


Second most common infection
Sexually active young women

Older adult women in nursing homes

25% to 35% develop at least one UTI a year


30% to 50% have bacteria at any given time

Less frequent in males

Occurrence likely associated with


complications (for example, septicemia,
pyelonephritis)

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Urinary Tract Infections (UTIs)


Complicated and uncomplicated UTIs
Upper (kidney)

Lower (bladder and urethra)

Acute pyelonephritis
Acute bacterial prostatitis
Acute cystitis
Acute urethral syndrome

Recurrent urinary tract infections

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Organisms That Cause UTIs


80% of uncomplicated, communityacquired UTIs: Escherichia coli
Hospital-acquired UTIs: Frequently
caused by Klebsiella, Proteus,
Enterobacter, Pseudomonas,
staphylococci, enterococci, and E. coli

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Drug Therapy of UTIs

Trimethoprim/sulfamethoxazole
(TMP/SMZ) and nitrofurantoin:
Frequently the treatment of choice for
oral therapy of UTIs

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Acute Cystitis

Symptoms

Dysuria, urinary urgency, urinary frequency,


suprapubic discomfort, pyuria, bacteriuria
(subclinical pyelonephritis)

Single-dose therapy
Short-course therapy (3 days)
Conventional therapy (7 days)

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Acute Uncomplicated Pyelonephritis

Common in young children, older adults,


women of childbearing age

Fever, chills, severe flank pain, dysuria,


urinary frequency, urinary urgency, pyuria,
and usually bacteriuria

E. coli: Causative organism in 90% of


community-acquired infections

Mild pyelonephritis: Moderate infection


(treatment at home with oral antibiotics)
Severe pyelonephritis: Requires
hospitalization and IV antibiotics
Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Complicated UTI

Female and male patients with


structural or functional abnormality of
the urinary tract

Prostatic hyperplasia, renal calculi,


nephrocalcinosis, renal or bladder tumors,
ureteric stricture, or indwelling catheter

Symptoms range from mild to severe

Patient may develop systemic illness


manifesting as fever, bacteremia, and septic
shock

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Recurrent UTI

Relapse

20% recolonization with the original


infecting organism
Suggests structural abnormality of urinary
tract, involvement of kidneys, or chronic
bacterial prostatitis

Reinfection

80% of recurrent UTIs in females


Usually involves lower urinary tract and may
be related to sexual intercourse

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Acute Bacterial Prostatitis

Inflammation of the prostate caused by


local bacterial infection

High fever, chills, malaise, myalgia,


localized pain, dysuria, nocturia, urinary
urgency, urinary frequency, urinary
retention
80% of cases caused by E. coli
Frequently associated with indwelling
urethral catheter, urethral instrumentation,
transurethral prostatic resection
Responds well to antimicrobial therapy
Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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Urinary Tract Antiseptics


Nitrofurantoin
Methenamine

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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Nitrofurantoin [Furadantin,
Macrodantin, Macrobid]
Low concentrations: Bacteriostatic
High concentrations: Bactericidal
Uses: Lower UTIs, prophylaxis, recurrent
lower UTIs

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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Nitrofurantoin [Furadantin]

Adverse effects

Gastrointestinal effects
Pulmonary reactions: Acute and subacute
Hematologic effects
Peripheral neuropathy: Demyelinization and
nerve degeneration can occur and may be
irreversible
Hepatotoxicity
Birth defects
Other

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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Methenamine [Mandelamine]
Decomposes into ammonia and
formaldehyde, which denature bacterial
proteins
Therapeutic uses

Chronic lower UTIs (TMP/SMZ is the


preferred drug)

Adverse effects

Relatively safe and generally well tolerated


Contraindicated in renal and liver failure

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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Methenamine [Mandelamine]

Drug interactions

Urinary alkalinizers
Sulfonamides

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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Question 1
Which patient does the nurse identify as most likely to
need treatment with trimethoprim/sulfamethoxazole
[Bactrim] for a period of 6 months?
A. A female patient with acute pyelonephritis
B. A male patient with acute prostatitis
C. A female patient with recurring acute urinary tract
infections
D. A male patient with acute cystitis

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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Question 2
Which patient would most likely need intravenous
antibiotic therapy to treat a urinary tract infection?
A. A patient with an uncomplicated urinary tract infection
caused by Escherichia coli
B. A patient with pyelonephritis with symptoms of high
fever, chills, and severe flank pain
C. A patient with acute cystitis who complains of dysuria,
frequency, and urgency
D. A patient with acute bacterial prostatitis with a mild
fever, chills, and nocturia

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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Question 3
Which drug does the nurse identify as a urinary tract
antiseptic?
A.
B.
C.
D.

Ciprofloxacin
Ceftriaxone
Nitrofurantoin
Ceftazidime

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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